Drowning

Drowning

Posted by Sara Fazio • May 31st, 2012

NOW@NEJM

In many areas of the world, drowning is a leading cause of death, especially among young children. The latest review in our Current Concepts series describes the pathophysiology of drowning and summarizes the principles of resuscitation, prehospital treatment, and intensive care.

According to the World Health Organization, 0.7% of all deaths worldwide — or more than 500,000 deaths each year — are due to unintentional drowning. Since all cases of fatal drowning are not classified as such according to the codes of the International Classification of Disease, this number underestimates the real figures, even for high-income countries, and does not include drownings that occur as a result of floods, tsunamis, and boating accidents.

Clinical Pearls

• What are the risk factors for drowning?

Key risk factors for drowning are male sex, age of less than 14 years, alcohol use, low income, poor education, rural residency, ethnic group, aquatic exposure, risky behavior, and lack of supervision. For people with epilepsy, the risk of drowning is 15 to 19 times as high as the risk for those who do not have epilepsy. Drowning is a leading cause of death worldwide among boys 5 to 14 years of age. In the United States, drowning is the second leading cause of injury-related death among children 1 to 4 years of age, with a death rate of 3 per 100,000.

• What is the pathophysiology of drowning?

If the individual is rescued alive, the clinical picture is determined predominantly by the amount of water that has been aspirated and its effects. The combined effects of fluids in the lungs, loss of surfactant, and increased permeability of the alveolar-capillary membrane (alveolitis) result in decreased lung compliance, increased right-to-left shunting in the lungs, atelectasis, and bronchospasm. If the individual is not rescued, aspiration of water continues, and hypoxemia quickly leads to loss of consciousness and apnea. The sequence of cardiac rhythm deterioration is usually tachycardia followed by bradycardia, pulseless electrical activity, and, finally, asystole. The whole drowning process, from submersion to cardiac arrest, usually occurs in seconds to a few minutes.

Morning Report Questions

Q: What are the key elements of rescue and resuscitation?

A: Attempts at chest compression are futile as long as the rescuer and drowning person are in deep water, so assessment for a pulse does not serve any purpose. Drowning persons with only respiratory arrest usually respond after a few rescue breaths. If there is no response, the person should be assumed to be in cardiac arrest and be taken as quickly as possible to dry land, where effective CPR can be initiated. The European Resuscitation Council recommends five initial rescue breaths instead of two because the initial ventilations can be more difficult to achieve, since water in the airways can interfere with effective alveolar expansion. Once on land, the person who has drowned should be placed in a supine position, with the trunk and head at the same level, and the standard checks for responsiveness and breathing should be carried out. If the person is unconscious but breathing, the recovery position (lateral decubitus) should be used. If the person is not breathing, rescue ventilation is essential.

Q: What are the important aspects of emergency department care for a drowning victim?

A: Once the airway has been secured, oxygenation has been optimized, the circulation has been stabilized, and a gastric tube has been inserted, thermal insulation of the patient should be instituted. This is followed by physical examination, chest radiography, and measurement of arterial blood gases. Metabolic acidosis occurs in the majority of patients and should be corrected by increasing minute ventilation. Routine use of sodium bicarbonate is not recommended. The recorded history of events surrounding the drowning incident should include information on the rescue and resuscitation activities and any current or previous illness. Drowning is sometimes precipitated by an injury or medical condition (e.g., trauma, seizure, or cardiac arrhythmia) and such conditions affect treatment decisions. If the person remains unresponsive without an obvious cause, a toxicologic investigation and computed tomography of the head and neck should be considered. Measurements of electrolytes, blood urea nitrogen, creatinine, and hematocrit are rarely helpful; abnormalities are unusual.

How do I perform CPR ?

Dok , I saw someone who almost drowned in the beach yesterday, how do i perform CPR ?

Cardiopulmonary resuscitation (CPR) is a lifesaving technique useful in many emergencies, including heart attack or near drowning, in which someone's breathing or heartbeat has stopped. CPR involves a combination of chest compression and mouth-to-mouth rescue breathing that keeps oxygenated blood flowing to the brain and other vital organs until more definitive medical treatment can restore a normal heart rhythm. When the heart stops, the absence of oxygenated blood can cause irreparable brain damage in only a few minutes. Death will occur within eight to 10 minutes. Time is critical when you're helping an unconscious person who isn't breathing. To learn CPR properly, take an accredited first-aid training course, including CPR and how to use an automatic external defibrillator (AED). Before you beginAssess the situation before starting CPR: Is the person conscious or unconscious? If the person appears unconscious, tap or shake his or her shoulder and ask loudly, "Are you OK?" If the person doesn't respond and two people are available, one should call 911 or the local emergency number and one should begin CPR. If you are alone and have immediate access to a telephone, call 911 before beginning CPR — unless you think the person has become unresponsive because of suffocation (such as from drowning). In this special case, begin CPR for one minute and then call 911. If an AED is immediately available, deliver one shock if advised by the device, then begin CPR. Remember the ABCs Think ABC — Airway, Breathing and Circulation — to remember the steps explained below. Move quickly through Airway and Breathing to begin chest compressions. AIRWAY: Clear the airway Put the person on his or her back on a firm surface. Kneel next to the person's neck and shoulders. Open the person's airway using the head-tilt, chin-lift maneuver. Put your palm on the person's forehead and gently tilt the head back. Then with the other hand, gently lift the chin forward to open the airway. Check for normal breathing, taking no more than five or 10 seconds: Look for chest motion, listen for breath sounds, and feel for the person's breath on your cheek and ear. Gasping is not considered to be normal breathing. If the person isn't breathing normally and you are trained in CPR, begin mouth-to-mouth breathing. If you believe the person is unconscious from a heart attack and you haven't been trained in emergency procedures, skip mouth-to-mouth rescue breathing and proceed directly to chest compression. BREATHING: Breathe for the personRescue breathing can be mouth-to-mouth breathing or mouth-to-nose breathing if the mouth is seriously injured or can't be opened. With the airway open (using the head-tilt, chin-lift maneuver) pinch the nostrils shut for mouth-to-mouth breathing and cover the person's mouth with yours, making a seal. Prepare to give two rescue breaths. Give the first rescue breath — lasting one second — and watch to see if the chest rises. If it does rise, give the second breath. If the chest doesn't rise, repeat the head-tilt, chin-lift maneuver and then give the second breath. Begin chest compressions to restore circulation. CIRCULATION: Restore blood circulation with chest compressions Place the heel of one hand over the center of the person's chest, between the nipples. Place your other hand on top of the first hand. Keep your elbows straight and position your shoulders directly above your hands. Use your upper body weight (not just your arms) as you push straight down on (compress) the chest 2 inches (approximately 5 centimeters). Push hard and push fast — give two compressions per second, or about 120 compressions per minute. After 30 compressions, tilt the head back and lift the chin up to open the airway. Prepare to give two rescue breaths. Pinch the nose shut and breathe into the mouth for one second. If the chest rises, give a second rescue breath. If the chest doesn't rise, repeat the head-tilt, chin-lift maneuver and then give the second rescue breath. That's one cycle. If someone else is available, ask that person to give two breaths after you do 30 compressions. If the person has not begun moving after five cycles (about two minutes) and an automatic external defibrillator (AED) is available, apply it and follow the prompts. The American Heart Association recommends administering one shock, then resuming CPR — starting with chest compressions — for two more minutes before administering a second shock. If you're not trained to use an AED, a 911 operator may be able to guide you in its use. Trained staff at many public places are also able to provide and use an AED. Use pediatric pads, if available, for children ages 1 to 8. Do not use an AED for infants younger than age 1. If an AED isn't available, go to No. 5 below. Continue CPR until there are signs of movement or until emergency medical personnel take over. To perform CPR on a child: The procedure for giving CPR to a child age 1 through 8 is essentially the same as that for an adult. The differences are as follows: If you're alone, perform five cycles of compressions and breaths on the child — this should take about two minutes — before calling 911 or your local emergency number or using an AED. Use only one hand to perform heart compressions. Breathe more gently. Use the same compression-breath rate as is used for adults: 30 compressions followed by two breaths. This is one cycle. Following the two breaths, immediately begin the next cycle of compressions and breaths. After five cycles (about two minutes) of CPR, if there is no response and an AED is available, apply it and follow the prompts. Use pediatric pads if available. If pediatric pads aren't available, use adult pads. Continue until the child moves or help arrives. To perform CPR on a baby: Most cardiac arrests in infants occur from lack of oxygen, such as from drowning or choking. If you know the infant has an airway obstruction, perform first aid for choking. If you don't know why the infant isn't breathing, perform CPR. To begin, assess the situation. Stroke the baby and watch for a response, such as movement, but don't shake the child. If there's no response, follow the ABC procedures below and time the call for help as follows: If you're the only rescuer and CPR is needed, do CPR for two minutes — about five cycles — before calling 911 or your local emergency number. If another person is available, have that person call for help immediately while you attend to the baby. AIRWAY: Clear the airway Place the baby on his or her back on a firm, flat surface, such as a table. The floor or ground also will do. Gently tip the head back by lifting the chin with one hand and pushing down on the forehead with the other hand. In no more than 10 seconds, put your ear near the baby's mouth and check for breathing: Look for chest motion, listen for breath sounds, and feel for breath on your cheek and ear. If the infant isn't breathing, begin mouth-to-mouth breathing immediately. BREATHING: Breathe for the infant Cover the baby's mouth and nose with your mouth. Prepare to give two rescue breaths. Use the strength of your cheeks to deliver gentle puffs of air (instead of deep breaths from your lungs) to slowly breathe into the baby's mouth one time, taking one second for the breath. Watch to see if the baby's chest rises. If it does, give a second rescue breath. If the chest does not rise, repeat the head-tilt, chin-lift maneuver and then give the second breath. If the chest still doesn't rise, examine the mouth to make sure no foreign material is inside. If the object is seen, sweep it out with your finger. If the airway seems blocked, perform first aid for a choking infant. Begin chest compressions to restore circulation. CIRCULATION: Restore blood circulation Imagine a horizontal line drawn between the baby's nipples. Place two fingers of one hand just below this line, in the center of the chest. Gently compress the chest to about one-third to one-half the depth of the chest. Count aloud as you pump in a fairly rapid rhythm. You should pump at a rate of about 100 to 120 pumps a minute. Give two breaths after every 30 chest compressions. Perform CPR for about two minutes before calling for help unless someone else can make the call while you attend to the baby. Continue CPR until you see signs of life or until a professional relieves you.