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Drowning: an Update 2012

Gary Williams
Mini PAC Conference ,
Melbourne
16-17 November 2012

Plan

Definitions
Guidelines
Epidemiology
Pathophysiology
Management
Outcome prediction

Definition
2002, World Congress on Drowning,
Amsterdam: respiratory embarrassment
from submersion / immersion in a liquid
medium
near drowning
dry or wet drowning
secondary drowning
delayed onset respiratory distress

Drowning: Aust Resus


Council
Victim rolled to side during initial
checking, airway clearance and initial
breathing check
Begin EAR in water if immediate exit
not possible
If hypothermic, attempt resuscitation
even after possibly prolonged
immersion
Last updated Feb
2005

Drowning: ERC 2010 Update


More research comparing OHCA due to drowning
with primary cardiac OHCA needed
In-water EAR if victim unresponsive, 10-15 breaths
in 1 minute then decide based on est time to shore
< 5 mins continue EAR while towing
> 5 mins give 1 more minute EAR then head off
uninterrupted

Early intubation with cuffed ETT, not LMA or Guedel


Use ECG, ET CO2 or echo to confirm arrest. Be wary
to discontinue resus efforts in the field
Core temp < 30C : limit defib to x3 and withold
drugs till core temp > 30C
Recommends rewarming hypothermic patient to
32-34C and avoid temps >37C during subsequent
intensive care course

Drowning: AHA / ILCOR


2010

Mouth to nose EAR by swimmer while retrieving


When ALS commenced traditional A-B-C sequence
used
In hypothermic patient value of deferring subsequent
defib attempts or resuscitation drugs controversial
and reasonable to consider. according to standard
algorithmconcurrent with rewarming strategies
Use ETCO2 to monitor effectiveness, ROSC and avoid
hyperventilation
32-34C may be considered for children who remain
comatose after ROSC
Avoid rewarming faster than 0.5C per 2 hours and
treat fever (>38C) aggressively with antipyretics and
cooling devices

Age-standardised Disability-Adjusted Life Year (DALY) rates from Drownings by


country (per 100,000 inhabitants)

< 100

350-400

100150

400-450

150200

450-500

200250

500-600

National Drowning Report, RLSA, 2011

National Drowning Report, RLSA, 2011

National Drowning Report, RLSA, 2011

ANZPIC Registry

PICU Admissions, Drowning, 2000-2011

ANZPIC Registry

PICU Admissions, Drowning by Age Category 2000-2011

ANZPIC Registry

National Drowning Report, RLSA, 2011

National Drowning Report, RLSA, 2011

National Drowning Report, RLSA, 2011

PICU Admissions Deaths Drowning, 2000-2011

ANZPIC Registry

Predictors of Death or Severe Neur Impairment


After Submersion
At site of submersion
Immersion duration > 10
Delay in commencement of CPR
In the ED
Asystole on arrival or CPR duration > 25
Fixed and dilated pupils and GCS < 5
Fixed and dilated pupils and arterial pH < 7
In the ICU
No spontaneous purposeful movements and
abnormal brainstem function 24h after
immersion
Abnormal CT scan within 36h of submersion
Ohs Intensive Care Manual, 6th Ed 2009

Could water temperature be


protective?

Animal data that brain cooling before HI


event neuronal injury
Diving Reflex: HR, SVR, Qskin Qmuscle
Qgut Qkidney Qmyocardial with CBF preserved
maybe even by evolving hypercarbia
Colder the water more profound is reflex
No evidence stronger in the young

Immersion-induced apnoea: prevents heat


exchange through the lungs before hypoxia
intervenes

Could water temperature be


protective?
Q: How cool has deep brain got to be and how
quickly while hypoxia is developing?
A: Unknown
Animal data (rat) suggests 33C in <5, probably 30C
in <10

Mathematical model of human hippocampus temp on exposure to water at 2C

A proposed decision making rule for search, rescue


and resuscitation of submersion victims
Tipton and Golden, Resuscitation, 2011

Submersions > 4 min, age, water temp, deep body temp, duration of submersion
and good neurologic outcome
43 cases, all with water temp documented
Submersion time in 40/43
37/43 initial deep body temp available: < 30C in30/37 (80%)

A proposed decision making rule for search, rescue


and resuscitation of submersion victims
Tipton and Golden, Resuscitation, 2011

Submersion Duration & Risk of Death or Severe Neur Impairment

Quan et al, Peds, Oct 1990

Christensen et al, Peds, May 1997

Impact of age, submersion time and


water temp on outcome in near
drowning
Suominen et al, Resuscitation 2002

Finland regional survey most drownings occur in


cold water
61 admissions to ICU Helsinki over 12 y: water
temp, rectal temp, and estimated submersion time
Median water temp 17C (range 0-33)lower in
survivors but much cross over
80% admission temp < 35C (no diff S & NS)
Est submersion time only independent predictor of
survival (5 V 16) but no clear cut off could be
defined

Seasonal River Temperatures around


Sydney

ED Prediction of outcome ?
Even fixed and dilated pupils, low
GCS, need for CPR in ED have proven
unreliable in individual cases
Christensen et al (Peds, 1997):
composite score based on ED
physical exam (apnoea, coma) +
need for CPR + lowest pH ..best
available but even this 93%
accurate in their hands

ED Prediction of outcome ?

ICU Prediction of Outcome ?


PE: GCS 6 or purposeful movement +
intact brainstem reflexes v likely good
outcome
SEPS: absent SEPS 100% predictive of poor
outcome
Imaging:
Early (8h) abnormal CT strongly predictive for
bad outcome; normal CT uninformative
MRI more specific but need 3-4 days to avoid
inappropriate optimism

Drowning: PICU
Management

Ventilation: normocapnia, optimise oxygenation,


minimise VILI
Circulation: fluids, inotropes, monitoring to optimise
haemodynamics, perfusion
Prophylactic anticonvulsants? No evidence
Continuous EEG monitoring of unconscious pt
Glucocorticoids? No evidence (Foex, ADC, 2002) ?
infection, ?? role later if ARDS
Prophylactic antibiotics? No evidence (Wood, ADC,
2010) even with CXR changesselects resistant
bugs
Therapeutic Hypotherrmia Cooling ?

Moler et al, CCM, 2011

THAPCA

32-34C for 48h then 36-37.5C for 3d

Paed
OHCA

Within 6h
of ROSC
36-37.5C for 5d

* Drowning victims with core temp <32C on arrival specifically excluded

Reasons to be
circumspect
1. Fever common, bad for injured brain, often not
controlled to normothermia in control arms
2. TH does have risks
3. Two large retrospective studies in paed cardiac
arrest (Pittsburgh n=181, CCTG n=222) have not
shown benefit
4. Data on early prophylactic use of TH in TBI in
children suggesting a worse outcome

Hutchinson et al, NEJM, June 2008

Summary
Drowning remains a major cause
death and disability
Accurate outcome prediction in field
and ED problematic
Cold water protection theoretically
feasible but little evidence to support
Therapeutic hypothermia still waiting
for good evidence to support

Questions ?

Drowning by Ken Done

Drowning Pathophysiology: Pulmonary


Aspirate small amounts, usu ,22ml/kg
Fluid shifts
Aspiration of debris
Infection (rare)
Surfactant depletion

Pulmonary oedema, pneumonia (2550%), ARDS < 10%


Neurogenic
Altered capillary permeability
Forced inspiration against a closed glottis
Surfactant dysfunction

Pathophysiology: Cardiac
Potential role of molecular autopsy in
unexplained drownings ?cardiac
channelopathy
Mayo Clinic 2011: 35 unexplained drownings,
average age 17y, 23 male 12 female
putative pathogenic mutation in 1/3: 3 LQT S,
6 CPVT
More common in females with 5/8
unexplained swimming-related drownings in
females having mutation
< 10% of drownings, implications for family
In retrospect 50% had warning sign on history

Presentation and outcome of water-related events in children with LQT syndrome


Albertella et al, ADC, Aug 2011

OHCA Drowning V Primary Cardiac


Claesson et al, Resuscitation, 2008

OHCA Drowning Vs Primary Cardiac


Grmec et al, Int J Emerg Med 2009