TABLE 1932 Hospital Care of Near Drowning Victims

Although patient survival in a persistent vegetative state is a concern, substantial numbers of patients, predominantly children, requiring CPR on emergency department arrival have survived with good outcomes, and physicians should err on the side of providing resuscitation. 45 and 6 The physician should gather sufficient history to allow an estimate of prognosis and gauge the patient's response to resuscitative efforts.

On the victim's arrival in the emergency department, adequate oxygenation should be ensured, the integrity of the patient's spine should be confirmed if necessary, and associated injuries should be sought. Pulmonary insufficiency may be indicated by dyspnea, tachypnea, or use of accessory muscles of respiration. Physical examination may reveal wheezing, rales, or rhonchi, although the chest may be normal to auscultation after aspiration.

All patients should receive supplemental oxygen during evaluation, and those with more than mild symptoms should be on 100% oxygen until adequate oxygenation is documented. If high-flow oxygen (40% to 50%) cannot maintain the arterial P o2 greater than 60 mmHg in adults or 80 mmHg in children, the patient should be intubated and mechanical ventilation used.

Intubated patients generally require positive end-expiratory pressure (PEEP) or continuous positive airway pressure (CPAP). Occasionally, a patient may require only increased oxygenation and CPAP without mechanical ventilation. Only patients who are alert and unlikely to vomit are candidates for mask or nasal CPAP or other noninvasive ventilation.

All patients need an accurate temperature that reflects core temperature, since resuscitation may be impossible until hypothermia is treated. Hypothermia can immobilize a swimmer, resulting in drowning, may cause ventricular fibrillation, or may be responsible for a variety of adverse metabolic effects. Hypothermic patients have body temperatures less than 30°C (86°F), after submersion in water less than 20°C (68°F). Severe hypothermia often indicates prolonged submersion and is a bad prognostic sign. Despite this, individuals have survived after prolonged submersion (more than 60 min) in cold or icy water. Aspiration of cold water in concert with intact circulation for several minutes rapidly cools the body to low temperatures.7 The nature of the protective effect of hypothermia is unclear. It is most likely generalized slowing of metabolism, but preferential shunting of blood to the brain, heart, and lungs (diving reflex) may play some role. Hypothermic near-drowning victims in whom resuscitation is attempted should be warmed to at least 30 to 32.5°C (86°-90.5°F) before resuscitation efforts are abandoned. In selected cases of submersion in extremely cold water, extracorporeal rewarming may be helpful.8

Appropriate laboratory data should be obtained (see TableJQ^-^). Direct measurement of oxygenation and acid-base status by arterial blood gas analysis and pulse oximetry guide pulmonary therapy and the need for sodium bicarbonate.

Roentgenograms of the chest may be normal after a significant near-drowning incident or may show generalized pulmonary edema ( Fig 193-1), perihilar infiltrates, or other patterns. Chest films do not necessarily correlate with arterial Pa o2, making direct measurement of oxygen saturation important, although many patients with significantly abnormal films will require intubation.

FIG. 193-1. Chest roentgenogram of near-drowning patient demonstrating diffuse noncardiogenic pulmonary edema.

Standard treatment of hypothermia, hypotension and hypovolemia, bronchospasm, electrolyte imbalance (including hypoglycemia), seizures, and arrhythmias should be undertaken. Some patients may need fluid resuscitation in the face of noncardiogenic pulmonary edema. To avoid inducing arrhythmias, central venous catheters, if used, should not enter the heart in hypothermic patients. A nasogastric tube will empty the stomach and help prevent vomiting, and a Foley catheter will help to monitor urine output. Neither antibiotics nor steroids alter the course of aspiration pneumonia or pulmonary edema in drowning, and they should not be given prophylactically.

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