NEAR DROWNING

Jeffrey W.Parker EMT-P

Jeremy Beck EMT-P
&
INTRODUCTION
 Drowning is an unexpected
tragedy where previously healthy
persons are exposed to severe
hypoxia leading to death, or in the
case of near-drowning, at potential
for permanent brain injury and/or
neurologic dysfunction.
EPIDEMIOLOGY

 Males>Females
 Although exact number is
uncertain, many more individuals
survive serious near-drowning
episodes
 Peak Ages
 1-2 years old

 15-19 years old

EPIDEMIOLOGY
 Freshwater drowning is more
common than saltwater drowning,
even in coastal areas
 Places:lakes/rivers/canals/pools
 Toddlers:
 Any container of water can be

responsible:
Buckets/fish tanks/washing

machine/toilets/bathtub
EPIDEMIOLOGY
 Toddlers drown primarily in
swimming pools and account for
75%-90% of all drownings.
 Child deaths are not generally
from gross neglect, but from
momentary lapses in adult
supervision
 Risk climbs again in the elderly
from bathtub drowning
Associated Risk Factors
 Intoxication with drugs/alcohol
 Venomous stings from aquatic animals
 Head/spinal injuries (Diving accidents)
 Hyperventilation syndrome (Breath
Holding) which suppresses the physiologic
response to increased CO2
 Pre-existing medical conditions:
Seizures/DM/ Syncopal episodes
Associated Risk Factors
 MI/pre-existing cardiac disease
 Hypothermia
 Physical exhaustion
 Suicide
 Non-accidental trauma (NAT)
EVENTS

 For many years , drowning was considered

a “Fight for Survival”
 Typical scenario of a person screaming for
help, arms flailing, struggling to remain on
the surface of the water.
 This scene is rarely reported by persons at
the scene of of drownings
Common Scenarios
 Last seen in the home or yard
around the pool
 Playing alone: Parents occupied by
chores (answering the telephone
most common)
 Typically - no splash heard, if
barriers where in place they where
circumvented
 In the northern states - bucket
drowning commonly occurs
Common Scenarios
 Witnesses report individual was:
 Floating on the surface and suddenly

becomes motionless
 Swimming underwater and stopped

 Dove into water and never surfaced

 Horsing around underwater and then

appeared to play “Possum”

 Just quietly disappeared in the water
DEFINITIONS

 Drowning = Death within 24 hours

after submersion and suffocation in a
liquid medium. Cause is asphyxia from
airway obstruction, laryngospasm, or
aspiration of liquids
 Near drowning = Submersion episode
with temporary suffocation and loss of
consciousness that results in survival
(full or partial recovery), or temporary
survival that ultimately leads to death
after a period of at least 24 hours.
DEFINITIONS
 Secondary drowning= Implies that
the patient is initially resuscitated,
but death occurs minutes to days
(generally 24 hours) after the
initial resuscitation. Also known as
Delayed death to near-drowning or
Post immersion syndrome.
syndrome Death
frequently due to the delayed
onset of respiratory insufficiency.
DEFINITIONS
 Immersion syndrome=
Drowning that may be caused by a
vagally induced arrhythmia
secondary to exposure to cold
water (68 F) Enhanced
predisposition with the use of
alcohol/drugs
DEFINITIONS
 Wet Drowning= Where a certain
amount of water has been
aspirated into the lungs. (Amount
variable)
 Dry Drowning= Laryngospasm
which occurs after all spontaneous
respiratory efforts cease
MISUNDERSTOOD
FACTS
 Despite “Hype” regarding the differences
between salt and fresh water, it is not
generally apparent clinically
 Severe E’lyte changes are seen in rare
setting after ingestion of large amounts of
water
 Not generally enough fluid aspiration to
change the total blood volume or E’lyte
concentration (Seen only with aspiration of
> 22ml/kg
MISUNDERSTOOD
FACTS
 On autopsy, lungs of patients who died in
water had various quantities of water in
their lungs.
 Supports premise that Active respiration
and not Passive flow of water determines
the volume of water aspirated
 Hematologic and renal function usually
normal and not impaired
 Steroids do not alter course
MISUNDERSTOOD
FACTS

 The problem is HYPOXEMIA

from pulmonary injury whether
from fresh or salt water.
MISUNDERSTOOD
FACTS
 Alldefinitions are esoteric, and
all patients should be
resuscitated unless there is
gross injury, or documented
submersion times greater than
1 hour!
PATHOPHYSIOLOGY
Pathophysiology
 Wet drowning - Water aspiration
after aborted laryngospasm 85%
 Dry drowning - Anoxia due to
laryngospasm 15%
 Whatever the mechanism, the final
common pathway is profound
hypoxemia.
Fresh Water Vs. Salt
Water
 No difference in electrolytes and
hematocrit
 Average drowning victim aspirates
3-4 ml/kg
 No electrolyte or blood volume
changes seen until 22 ml/kg and
11ml/kg respectively
Fresh Water Aspiration
 Fresh water produces an increase
in airway resistance due to reflex
mechanisms
 Pathway:
 Alveoli surfactant is washed out

causing atelectasis
 V/Q Mismatch

 Alveolar membrane breakdown

 Onset of pulmonary edema

Fresh Water Aspiration

 Acute respiratory failure

 This process can be abrupt or can
occur over several hours.
 Salt Water Aspiration

 Salt water has three (3) to four (4) times the

tonicity of plasma
 Fills alveoli with fluid

 Osmolar gradient gives alveoli ability to

draw in fluid
 Pulls protein-rich fluid into the alveoli
Salt Water Aspiration
 Blood volume decreases
 Leads to hypovolemic shock

 Causes intrapulmonary shunt leading to

hypoxia
 E’lytes concentrate (Extracellular)
 With large volumes of aspirated fluids

 Both types of fluid combine within the

alveoli:
 Results in Acute Pulmonary Edema
QUESTIONS?