Near drowning
Near drowning: Excerpt from Professional Guide to Diseases (Eighth Edition)
Near drowning refers to surviving — temporarily, at least — the physiologic effects of hypoxemia and acidosis that result from submersion in fluid. Hypoxemia and acidosis are the primary problems in victims of near drowning.
Near drowning occurs in three forms: “dry,” in which the victim doesn’t aspirate fluid, but suffers respiratory obstruction or asphyxia (10% to 15% of patients); “wet,” in which the victim aspirates fluid and suffers from asphyxia or secondary changes due to fluid aspiration (about 85% of patients); and “secondary,” in which the victim suffers a recurrence of respiratory distress (usually aspiration pneumonia or pulmonary edema) within minutes or 1 to 2 days after a near-drowning incident.
Causes and incidence
Near drowning results from an inability to swim or, in swimmers, from panic, a boating accident, a heart attack or blow to the head while in the water, a fall through ice, heavy drinking prior to swimming, or a suicide attempt. Children can also suffer near drowning from swimming accidents, bathing, or falling into a container of water such as a bucket or a body of water such as a pond.
Regardless of the tonicity of the fluid aspirated, hypoxemia is the most serious consequence of near drowning, followed by metabolic acidosis. Other consequences depend on the kind of water aspirated. If the water is contaminated, such as water from a stagnant pool or contaminated stream, bacteria, fungus, or algae may be aspirated as well, causing infection or sepsis. After fresh water aspiration, changes in lung surfactant character result in exudation of protein-rich plasma into the alveoli. This, plus increased capillary permeability, leads to pulmonary edema and hypoxemia.
After saltwater aspiration, the hypertonicity of seawater exerts an osmotic force, which pulls fluid from pulmonary capillaries into the alveoli. The resulting intrapulmonary shunt causes hypoxemia. Also, the pulmonary capillary membrane may be injured and induce pulmonary edema. In both kinds of near drowning, pulmonary edema and hypoxemia occur secondary to aspiration.
In the United States, drowning claims nearly 6,500 lives annually. No statistics are available for near-drowning incidents.
Signs and symptoms
Near-drowning victims can display a host of clinical problems: apnea, shallow or gasping respirations, substernal chest pain, asystole, tachycardia, bradycardia, restlessness, irritability, lethargy, fever, confusion, unconsciousness, vomiting, abdominal distention, and a cough that produces a pink, frothy fluid.
Diagnosis
Diagnosis requires a history of near drowning, including the type of water aspirated along with characteristic features and auscultation of crackles and rhonchi if respirations are present or if the patient is being ventilated.
Arterial blood gas (ABG) analysis shows decreased oxygen content, low bicarbonate levels, and low pH. Electrolyte levels may be elevated or decreased, depending on the type of water aspirated. Leukocytosis may occur. Electrocardiogram shows arrhythmias and waveform changes.
Treatment
Emergency treatment begins with cardiopulmonary resuscitation (CPR) and administration of 100% oxygen.
❑ Stabilize the patient’s neck in case he has a cervical injury.
❑ When the patient arrives at the hospital, assess for a patent airway. Establish one if necessary. Continue CPR, intubate the patient, and provide respiratory assistance such as mechanical ventilation with positive end-expiratory pressure, if needed.
❑ Assess ABG and pulse oximetry values.
❑ If the patient’s abdomen is distended, insert a nasogastric tube. (Intubate the patient first if he’s unconscious.)
❑ Start I.V. lines and insert an indwelling urinary catheter.
❑ Drug treatment for near drowning may include sodium bicarbonate for documented acidosis, corticosteroids and osmotic diuretics for cerebral edema, antibiotics to prevent infections, and bronchodilators to ease bronchospasms.
Special considerations
❑ Remember that all near-drowning victims should be admitted for an observation period of 24 to 48 hours because of the possibility of developing delayed drowning symptoms.
❑ Observe for pulmonary complications and signs of delayed drowning (confusion, substernal pain, adventitious breath sounds). Suction often. Pulmonary artery catheters may be useful in assessing cardiopulmonary status.
❑ Monitor vital signs, intake and output, and peripheral pulses. Check for skin perfusion and watch for signs of infection.
❑ To facilitate breathing, raise the bed’s head slightly.
❑ To prevent near drowning, advise swimmers to avoid drinking alcohol before swimming, to observe water safety rules, and to take a water safety course sponsored by the Red Cross or YMCA.
Book Source Details
- Book Title: Professional Guide to Diseases (Eighth Edition)
- Author(s): Springhouse
- Year of Publication: 2005
- Copyright Details: Professional Guide to Diseases (Eighth Edition), Copyright © 2005 Lippincott Williams & Wilkins.
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