DROWNING Dr.Özgül Keskin Yeditepe University School of Medicine Department of Anesthesiology and Reanimation

> 500 000 deaths/year due to drowning Mostly 5-14 years of age 4th frequent cause of death in the same age More frequent in pediatric age group Fresh water drowning > salt water drowning (?) ( Boğulma vakalarında suyun tuz içeriği sonucu etkilememektedir) Especially in <5 y age group drowning in bathtubs are frequent Drowning affects healthy people in young and productive age group

Statistical Risk Factors Age: Pediatric age Location: Pools, bathtubs, lakes, rivers Sex: Male 3:1 Time of year: Warm months

Definitions Drowning: Near-drowning:?? Drowning is defined as death resulting from suffocation within 24 hours of submersion in a liquid medium 2005 DSÖ **(Sıvı ortama batma/dalma sonucu gelişen solunumsal bozulma) Near-drowning:?? Near-drowning, as survival of (even with severe medical thrapy) at least 24 hours after an episode of suffocation caused by submersion in a liquid medium

Definitions Dry-drowning:?? Wet-drowning:?? Secondary drowning: Due to a sudden immersion into water, largyngospasm leading to asphyxia resulting with alveoli without water Wet-drowning:?? Drowning due to water in the alveoli Secondary drowning: Any secondary disease (Heart disease, epilepsy, alcohol use etc) leading to loss of consciousness in water, thereby drowning

Definitions Immersion Syndrome: The immersion syndrome is syncope provoked by bradycardia, tachycardia, or arrhythmia precipitated by sudden contact with water at a temperature of at least 5°C less than body temperature. It can happen, therefore, in water as warm as 31°C

Chain of events Immersion in water Breath holding voluntarily and with panic Struggle of the victim Unvoluntarily point of cession (vazgeçme noktası) Aspiration of water and/or laryngospasm Cardiac arrest due to on-going hypoxia Hypoxic damage of brain Cytotoxic cerebral odema Increased intracranial pressure, decreased cerebral blood flow Herniation and death

Pulmonary hypertension Pathophysiology (Pulmonary) Immersion in water Breath holding Aspiration of water Laryngospasm Alveolar hypoxia & hypercapnia ARDS Surfactant loss Left ventricular afterload Pulmonary hypertension Pulmonary edema Systemic hypoxemia and hypercapnia Cardiac depression Asistoli

HİPOKSİ HİPOTERMİ ASİDOZ

Fresh Water Aspiration Hypotonic pass into capillary easily Hemolysis Pulmonary surfactant dissolution Alveolar collaps Atelectasis V/Q mismatch HYPOXEMIA

pass into alveoli easily Salt Water Aspiration Salt water aspiration Water Hypotonic pass into alveoli easily Hemoconsantration Water in the alveoli HYPOXEMIA

Electrolyte imbalance Consequences of Aspiration 2.2 cc/kg Hypoxia 11 cc/kg Blood volume changes 22 cc/kg Electrolyte changes Average aspiration is only 2-4 cc/kg

Cold water has more survivors and WARM WATER drownings are different Cold water has more survivors

they are WARM and DEAD (30 C) Submersion victims aren’t dead until they are WARM and DEAD (30 C)

Drown not thyself to save a drowning man Treatment Drown not thyself to save a drowning man

Treatment Resuscitation in the setting of accident A-B-C should be applied Mouth –to-mouth breathing should be started in water No need for cardiac massage in water, loss of time Heimlich and Patric maneuvers (?) Subdiaphragmatic pressure may be effective for draining water from the lungs They may both aspirate and drink water in to stomach also. Pressure may cause more aspiration Manual and mechanical ventilation with ETT Standart CPR SpO2 should tried to be kept at 90% Cervical injury (%0.5)

Vakayı getiren ekibe sormamız gerekenler! Su altında kalma süresi Suyun ısısı ve temizliği hakkında bilgi Travma hikayesi/şüphesi varmı? Alanda CPR uygulandı mı? Süresi ve kim tarafından? Kazazedenin vücut ısısı? Boğulma sebebi? (İlaç veya alkol intoksikasyonu, kardiyak arrest, uzun QT sendromu, suisid, pediatrik vakalarda istismar ve ihmal olasılığı düşünülmelidir)

Treatment in ER & ICU Respiratory System Hafif semptomu olan bazı hastalar hızla kötüleşebilir Artmış solunum hızı, ronküs, ral ve wheezing; solunumsal kötüleşme açısından uyarıcı olmalıdır Gastrik içeriğin aspirasyonu (ARDS, enfeksiyon) Nörolojik açıdan (değişken), KIBAS bulguları geç ortaya çıkabilir ETT and mechanical ventilation if needed Aim is to make SpO2 >90% NG tube

TETKİK Kardiak monitorizasyon ve EKG Pulse oksimetre, kapnografi, arter kan gazı Kan glukozu, kreatinin, elektrolitler Rektal vücut ısısı Tam kan sayımı (Lökositoz dışında normaldir) Toksikoloji paneli Böbrek ve karaciğer fonksiyon testleri (koagülasyon testleri) Akciğer grafisi, travma varlığında CT

Treatment in ER & ICU Cardiovascular System Thermoregulation Fluid replacement with appropriate solution Inotropic support Treat hypoglycemia and hypocalcemia to treat mycardial depression Thermoregulation Wet clothes should be removed Especially in children heat loss is very fast Heat the patient slowly with blankets and light IV fluids should be heated to 36-40 ̊C O2 should be heated and humidified (HMEF-Heated humidifiers) (Komatöz hasta 34 derecenin üzerinde ısıtılmamalıdır)

Treatment in ER & ICU Neurological System GCS <8 should be intubated and mechanically ventilated Increased ICP leads to bad prognosis and can not be treated if occured CPR vücut sıcaklığı 32-35 C olana dek devam etmelidir

TABURCULUK GKS 15, spontan solunumu olan, vitalleri ve saturasyonu normal, hipotermisi olmayan hastalar, destek oksijen tedavisi ve sürekli monitorizasyon ile 4-6 saat gözlemlenerek taburcu edilebilir. Taburcu edilen hasta ve yakını gecikmiş pulmoner komplikasyonlar konusunda bilgilendirilmelidir. Semptomatik hastalar yatırılmalıdır. Apne, hipoksi veya bilinç kaybı öyküsü olanlar, ritim bozukluğu saptanan ve anormal akciğer grafi bulgusu olanlar yatış gerektirir.

Prognosis Factors for good prognosis Factors for poor prognosis Duration of stay in water <5 min Immediate CPR CPR duration <10 min Spontaneous ECG rhytm on ER admission GCS >5 on ER admission Spontaneous movement and heathy brain stem function in 24 hours Factors for poor prognosis Duration of stay in water >10 min CPR start > 10 min Cardiotonic drug need on ER admission GCS <5 No spontaneous movement after 24 hours