Drowning: Management

by Julianna Jung, MD, FACEP

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    00:01 For drowning victims who present in cardiac arrest, the major determinant of outcome is the time it takes to initiate CPR.

    00:10 So CPR should almost always be attempted in all drowning cases, and it should be attempted as soon as possible after getting the patient out of the water.

    00:18 Another important thing to think about with cardiac arrest patients is that hypothermia is a common phenomenon that’s observed in drowning patients.

    00:27 You lose a lot more heat in the water than you do in the air, and it’s quite common that patients will come in with lower body temperatures.

    00:33 So one, you need to rewarm the patient in order to stabilize them from a cardiac arrest standpoint and interestingly, prognosis are actually favorable for cardiac arrest victims who are hypothermic.

    00:48 Hypothermia is neuroprotective and actually decreases the neurologic damage associated with cardiac arrest.

    00:55 So patients who come in hypothermic in cardiac arrest after a drowning incident might actually have better outcomes than patients who come in at normal body temperatures.

    01:07 One thing that’s really important to emphasize about cardiac arrest in drowning is that hands only CPR or the CPR that’s recommended for lay people where you just do chest compressions and don’t do any kind of rescue breathing, that’s not appropriate for drowning.

    01:23 Rescue breathing should always be attempted on the scene and the reason for that is that the cause of cardiac arrest in drowning is not a heart attack, it’s not a primary cardiac etiology.

    01:36 It’s asphyxia from aspirating water.

    01:40 So unless you provide the patient with respiratory support, get some of the water out of their lungs, replace it with some air, you’re not gonna be able to get them back from their cardiac arrest.

    01:51 So this is a situation where we really shouldn’t be focusing on hands only CPR.

    01:56 We should actually be performing mouth to mouth rescue breathing if necessary in order to attempt to resuscitate the victim on-scene.

    02:03 Clearly, once the medical team arrives, respiratory support should be provided with either bag valve mask ventilation or intubation.

    02:12 For drowning victims, we always wanna give supplemental oxygen and we’re generally gonna titrate our oxygen to keep the saturation above 90%.

    02:22 It’s not always gonna be possible to obtain normal oxygen saturations in patients with drowning because they’ve got a fluid in their lungs and until you get that fluid out, they’re not gonna be able to oxygenate and ventilate normally.

    02:36 So we just want adequate oxygenation, not necessarily perfect oxygenation.

    02:42 A really useful adjunct to supplemental oxygen is noninvasive positive pressure ventilation by which I mean CPAP or BiPAP.

    02:51 So for patients who are hypoxic despite high flow oxygen, you can use a little bit of positive pressure and what that does is it helps extravagate water out of the lungs and replace some of that water with air to help improve oxygenation and ventilation.

    03:11 Any patient who has inability to protect their airway, significant respiratory distress, inadequate oxygenation despite use of CPAP or BiPAP, or is significantly a hypercarbic should be intubated.

    03:28 So you don’t need to intubate everybody with drowning but basically, if your patient isn’t responding to more conservative measures, or if they have significant distress or other physiologic derangements, you wanna get another tracheal tube into them and mechanically ventilate them.

    03:43 A really important thing not just with drowning but really, with all critical illness is to frequently reassess.

    03:50 Patients with drowning often have symptoms that evolve over time and they might come in looking pretty good but as aspiration, pneumonitis begins to blossom as they develop ARDS, their respiratory status can actually deteriorate and these are common complications of drowning.

    04:08 So just because the patients looks good on initial presentation, doesn’t mean that they’re gonna continue to do well over time, and you really wanna make sure that you are keeping close tabs on their clinical status and responding accordingly.

    04:21 So other than airway and respiratory support, most of the care that we provide for drowning patients is really gonna be supportive.

    04:27 Generally, we allow hypothermic drowning patients to remain somewhat hypothermic.

    04:34 We let their body temperatures normalize gradually over time because hypothermia’s actually associated with better neurologic outcomes.

    04:42 So there’s no need to aggressively rewarm these patients unless they’re in – have severe hypothermia that we think is contributing to cardiac arrest.

    04:50 A lot of drugs have been tried for drowning and there’s actually no proven benefit of any pharmacologic intervention.

    04:57 So steroids, antibiotics, diuretics, a number of things have been looked at and none of them have been shown to change outcomes.

    05:05 So really, there’s no pharmacologic therapy that’s necessary.

    05:08 Ultimately, the disposition of your drowning patient is gonna be based on their clinical status and how much respiratory support they need.

    05:15 So clearly, if they require intubation and mechanical ventilation, they’re gonna be in the intensive care unit.

    05:21 Whereas, if they remain stable over a 6 to 8 hour observation period and they don’t have any evidence of hypoxia or worsening respiratory distress, they might be able to go home.

    05:33 So you’re really gonna tailor your ultimate disposition of the patient based on how sick they are and how much support they need.

    05:42 So bottom-line on drowning is it’s very common and it’s unfortunately a very common cause of death.

    05:48 Aspiration of water into the lungs is the primary cause of morbidity and mortality.

    05:53 You always wanna think not just about what happened in the drowning incident itself but why the patient drowned in the first place.

    06:02 So always consider the underlying cause of the drowning.

    06:06 You wanna provide respiratory support for patients in cardiac arrest.

    06:10 So no hands only CPR.

    06:12 We wanna make sure all of these patients get rescue breathing.

    06:15 We wanna optimize their oxygenation and ventilation while they’re in the Emergency Department and that might involve supplemental oxygen, noninvasive ventilation or intubation depending on the severity of their symptoms.

    06:30 Thank you very much.

    About the Lecture

    The lecture Drowning: Management by Julianna Jung, MD, FACEP is from the course Toxicologic and Environmental Emergencies.

    Included Quiz Questions

    1. Time interval to CPR
    2. Quality of CPR
    3. Number of CPR cycles
    4. Number of chest compressions
    5. Water composition where the patient drowned
    1. Hands-only CPR is appropriate if there is cardiac arrest.
    2. Permissive hypothermia may be acceptable.
    3. Aspiration, pneumonia and ARDS are common complications.
    4. Favorable outcomes are possible even with prolonged arrest times when there is associated hypothermia.
    5. Oxygen supplementation must be given to maintain oxygen saturation above 90%.
    1. Allowing a low body temperature to normalize on its own ("permissive hypothermia")
    2. Steroid use
    3. Early antibiotic coverage
    4. Early hands-only CPR in cardiac arrest cases
    5. Passive rewarming

    Author of lecture Drowning: Management

     Julianna Jung, MD, FACEP

    Julianna Jung, MD, FACEP

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