Drowning is the 3rd leading cause of unintentional injury death worldwide, accounting for 7% of all injury related deaths. Low- and middle-income countries account for 95% of unintentional drowning deaths Children, males and individuals with increased access to water are most at risk of drowning. Children under 5 years of age have the highest drowning mortality rates worldwide
PACIFIC PARTNERSHIP Drowning: Risk Factors
Age: Children under 5 years of age have the highest drowning mortality rates worldwide Gender: Males twice as likely than females to be hospitalized than females for non-fatal drowning. Access to water: Occupations involving water (fishing), children who live near open water sources Other risk factors: lower socioeconomic status, lack of higher education, ethnic minority, rural population infants left unsupervised or alone with another child around water; unsafe or overcrowded transportation vessels lacking flotation devices; alcohol use medical conditions, such as epilepsy; tourists unfamiliar with local water risks and features; floods and other cataclysmic events like tsunamis.
PACIFIC PARTNERSHIP Pre-Hospital Care
Optimal pre-hospital care is a significant determinant of outcome. Victim should be removed from the water at the earliest opportunity Bystanders should call for emergency help immediately. Transport patient to hospital quickly Start rescue breaths (while still in water) Ensuring adequacy of the airway, breathing, and circulation (ABCs). C-spine precautions
Why are C-spine precautions important for drowning victims? PACIFIC PARTNERSHIP Emergency Department Care
Initial management of near drowning should place emphasis on immediate resuscitation and treatment of respiratory failure. Manage airway Supplemental oxygen, 100% by mask as soon as available. Monitor oxygen saturation (SpO2) If the patient remains dyspneic on 100% oxygen or has a low oxygen saturation, use continuous positive airway pressure (CPAP) if available Frequent neurologic assessment should occur: the Glasgow Coma Scale is one modality that has been effectively used PACIFIC PARTNERSHIP Treatment of Volume Depletion and Acidosis
Intravascular volume depletion is common secondary to pulmonary edema and intracompartmental fluid shifts, regardless of the type of fluid aspirated. Rapid volume expansion may be indicated using isotonic crystalloid (20 mL/kg) or colloid. Inotropic support may be required using dopamine and/or dobutamine. Most acidosis is restored after correction of volume depletion and oxygenation. Hypothermia may also be present and exacerbate bradycardia, acidosis, and hypoxemia. PACIFIC PARTNERSHIP Other Interventions
Nasogastric tube placement can be used for removal of swallowed water and debris. Use the orogastric route if head or facial trauma is suggested. Bronchoscopy may be needed to remove foreign material, such as aspirated debris or vomitus plugs from the airway. Appropriate management of hypoglycemia and other electrolyte imbalances, seizures, bronchospasm and cold-induced bronchorrhea, dysrhythmias, and hypotension may be necessary in the drowning patient. PACIFIC PARTNERSHIP Patient Discharge
Patients can be safely discharged from the ED after 6-8 hours of observation if they meet the following criteria: Able to relay a good history of minor immersion injury No evidence of significant injury No change in mental status or behavior No evidence of bronchospasm or tachypnea/dyspnea No evidence of inadequate oxygenation (by ABG analysis and pulse oximetry) Tell discharged patients to return immediately if they develop dyspnea, cough, and/or fever.
Observe victims for a more prolonged period of time if they experienced mild to moderately severe submersion and only have mild symptoms that improve during observation and have no abnormalities on ABG analysis or pulse oximetry and chest radiograph
PACIFIC PARTNERSHIP Complications to watch for
Look for evidence of: acute respiratory distress syndrome (ARDS) multiple organ system failure nosocomial infection, especially pneumonia; hyperglycemia [ gastric stress ulceration.
Begin aggressive rehabilitation early (as soon as tolerated) to prevent disuse injury and promote functional improvement.
PACIFIC PARTNERSHIP Emergencies and other complications
Inform provider immediately if patients exhibit signs of any of the following: Acute Respiratory Distress Syndrome (ARDS) Significant hypoxia that requires intubation Worsening dyspnea with the potential for intubation Evidence of hypoxic cerebral injury Evidence of renal insufficiency Evidence of hemolysis Severe hypothermia requiring cardiopulmonary bypass
Notes to Nurses: The patients must be monitored for any of these symptoms, as early detection and treatment improves chances for survival
Also, consider: nosocomial infection, especially pneumonia Begin aggressive rehabilitation early (as soon as tolerated) to prevent disuse injury and promote functional improvement.
PACIFIC PARTNERSHIP Prevention
Drowning prevention strategies start with community education: Increase individual, family and community awareness of risk and to aid in response if a drowning occurs
What are some things nurses can do to educate communities about preventing drowning? PACIFIC PARTNERSHIP Prevention
Other community level efforts to prevent drowning: Engineering methods to remove the hazard Legislation to enforce prevention and assure decreased exposure Research and public health initiatives to further define the burden of drowning worldwide and explore prevention interventions.
Where can nurses go to to learn about best practices and research for nursing care? PACIFIC PARTNERSHIP
Nursing care: Teamwork
It takes excellent teamwork to provide care for patients experiencing near-drowning Nurses, doctors, laboratory, public health, hospital administrators, the community, etc. all must come together. Good communication between the team members is essential For those with less experience, the team should support that person, and provide guidance as needed The patients deserve the best, and that can only be provided with a team effort. PACIFIC PARTNERSHIP
Summary Drowning incidences are a serious problem worldwide, especially for children. Prevention is one strategy to address, but unfortunately, this is not always possible Effective management of near-drowning patients requires a good working health care team. Nurses are important members of the health care team