Drowning in the Literature

Drownings

In this blog, I want to discuss with you drownings, whether it be a near-drowning or a drowning. Despite the weather some of us sitting by the pool, lake, river, ocean, or even waterpark, however, never rule out the dangers of wells, buckets, bathtubs, and hot tubs in months not associated with swimming. Being around water comes many risks, and the most significant threat is the potential for drowning. As a paramedic, previously in a dedicated 911 service and before that a medic working within footsteps of the Atlantic Ocean, I know the risks associated with water. Furthermore, when I hear the tones drop, and it’s a ‘drowning,’ my heart sinks, figuratively, and with it, a massive adrenaline dump occurs. Drownings, to be honest, are scary, and treating the patient is not something we practice on a routine basis.

Objective and Background

In this blog, I would like to discuss what we as emergency medical services (EMS), helicopter EMS (HEMS), and critical care transport (CCT) providers should do if dispatched on one of these unfortunate events. Globally, drownings account for 360,000 – 500,000 deaths annually, depending on what literature you read (Cerland et al., 2017; Veetil, Parambath, Rajanbabu, & Suresh, 2017). Furthermore, it is one of the leading causes of death in children and older children (Cunnigham, Walton, & Carter, 2018). Throughout this blog, I plan to cover the finer points of pre-hospital management and a few CCT interventions so that you, as the provider, are familiarized with what to do, when to, and how to do it.

Patient Care

Whether or not your patient is breathing and alert or apneic and pulseless, effective management must be provided, and this includes transport to an appropriate hospital. Early interventions improve outcomes, rescue, and immediate resuscitation of a person who has been involved in a drowning incident are paramount and for apparent reasons (Venema, Groothoff, & Bierens, 2010). Moreover, rescue and resuscitation do not need a trained professional to make an impact. The key is rescue and beginning resuscitation (Venema, Groothoff, & Bierens, 2010).

That said, I need to mention that safety is a critical component, and any rescuer (civilian or professional) should take the proper precautions. I wanted to be sure that we are keenly aware that early interventions (rescue and resuscitation)improve patient outcomes despite who the rescuer is, however, safety is critical.

Scene Management and the Primary Survey

Our role as EMS and HEMS providers is effective scene management and control of the patient’s airway, breathing, and circulation (ABC’s); the medic, the nurse, or whomever the first responder provider to arrive? From experience, I would argue that, first and foremost, managing the scene effectively is critical to focused patient care. Scenes tend to be chaotic and ensuring that we remain calm, have a commanding presence, show compassion, and choreograph like a champ are just a few methods to create a suitable patient care environment (Grayson, 2014). If you need to utilize other assets, do so, fire, police, and even your partners are great resources to assist you with crowd control.

Airway (This is Important)

Once the scene is controlled, manage the patient’s (ABC’s). But how do we do this? First things first, if your patient is not protecting his or her airway, you need to be considering a means of managing this, one method is rapid sequence induction (RSI) and endotracheal (ET) intubation. Conversely, patients who are protecting their airway can be treated with bi-level positive airway pressure (BLPap) (if available), or continuous positive airway pressure (CPAP) / non-invasive positive pressure ventilation (NIPPV) (Heikal & Berry; Schwerin & Goldstein, 2019). If none of these adjuncts are available, the use of high-flow oxygen is also a consideration and has shown benefit in a case report (Soumaya, Nawfal, Abderrahim, Brahim, & Nabil, 2018). However, patients who cannot protect their airways need an alternative means of control, and this cannot be overlooked.

Airway control is not only a HEMS or CCT function; it must be the first arriving basic life support crew’s primary objective. Remember to use your adjuncts for airway protection e.g., oropharyngeal airways (OPAs) and nasopharyngeal airways (NPAs) and bag valve masks (BVMs) (Lloyd, 2004; Layon & Modell, 2009).

Supraglottic airways are an alternative, these devices are less adequate in ventilating patients who have been involved in a drowning incident; yes, they are easy to use, but if they are not able to do the job for the patient, their use will delay interventions that have the potential to improve patient outcomes, however, in at least one literature review they were discussed as an intervention, if ET placement is not possible (Baker & Webber, 2011; Baker & Webber, 2014; Layon & Modell, 2009). What I take away from this is cost versus benefit, if the only tool you have is a supraglottic airway and it does not delay care, use it, but remember the risk associated.

Breathing (So is this)

Monitor respiratory rate and always to listen to breath sounds, do not just assume breath sounds are “wet,” there are cases where drowning victims have not aspirated any water, highly unlikely but this is an essential aspect of your patient assessment (Szpilman et al., 2018). You will likely need an ALS intercept if your patient is deteriorating if ALS intercept is going to take a long time, consider your distance to a hospital and begin transport or call for a medevac. If there is a concern for c-spine trauma, a modified jaw thrust can be used for airway patency if c-spine precautions have been ruled out using the head-tilt-chin lift technique  (Schmidt, 2012). This is all dependent on your patient, and you must assess these patients, however, never get ahead of yourself, stay calm, and utilize in-depth but efficient assessments, critical thinking, and education to make informed decisions.

Circulation (and this too)

Finally, circulation, a wet patient can become a cold patient, and this is something easily rectified. Remove wet clothing and keep your patient warm. It is always wise to carry towels, blankets, and sheets with you for this type of incident. I have, on more than one occasion, been required to remove wet clothing from near-drowning and drowning patients and replace their soaked clothing with dry sheets, towels, and blankets. If a thermometer is available to use one and monitor for temperatures, try for a goal above 33 degrees Celcius (91.4 degrees Fahrenheit), if not work toward keeping your patient warm (Chandy, Danzl, & Grayzel, 2019). Hypothermia has the potential to lead to arrhythmias and other complicating factors that will worsen the patient’s condition. It also makes pulse oximetry challenging to assess. Our goal is to prevent further heat loss (Harries, 2003).

The Heimlich Maneuver

Contraindicated, please do not perform the Heimlich maneuver in an attempt to remove fluid from the airway (Rosen, Soto, & Harley, 1995). However, according to Rosen, Soto, and Harley (1995), the Heimlich maneuver is an excellent technique for the removal of solid foreign bodies. Still, there is no research to support its use during aspiration from fluids. I know the citation is dated, but I verified its accuracy with more up-to-date evidence e.g., Layon and Modell (2009).

Cervical-Spine Protection?

Cervical spine protection is routinely considered among these patients due to their likelihood of trauma associated mechanism. However, according to at least one cohort study, researchers found that out of 2244 “submersion” patients, only 11 had c-spine injuries, moreover, all with “obvious” signs (Walton, Cummings, Quan, Bratton, & Weiss, 2001). That said, if your patient is unconscious, it is probably best to err on the side of caution and use c-spine techniques per protocols.

Keep in mind that rigid collars lack the evidence to support their routine use, head blocks and towel rolls appear to be an effective means of mobilizing the patient that are commonly available and do not require sizing (Sundstrom, Asbjornsen, Habiba, Sunde, & Wester, 2014). Also, this will likely make it less complicated if a definitive airway is required.

CPR?

Delaying cardiopulmonary resuscitation (CPR) has the ability to compromise end-organ tissue due to hypoxia, neurological function, and increased intracranial pressure, pulmonary, renal, and acid-base imbalances (although this is rare) (Sarnail, Preston, Lieh-Lai, & Eisenbary, 1985; Bierens, Knape, & Gelissen, 2002; Yagil, Stalnkowicz, Michaeli, & Mogle, 1985; Bonnor, Siddiqui, & Ahuja, 1999;). A recent article suggests that CPR is performed no differently than you would if the patient were having a cardiac event in their living room or a hospital bed (Suloviv et al., 2018). My only suggestion and this comes via the American Heart Association (AHA), is to quickly dry the patient off so that the pads stick better and provide better defibrillation if needed (Emergency Cardiovascular Care, 2015). Be prepared for vomiting. The AHA states in a study in Australia showed that 86% of drowning patient who is receiving compressions vomited (Emergency Cardiovascular Care, 2015).

Transport and Secondary Survey

Once you have completed your primary survey, you must transport these patients to a hospital that can assess them further. Do not forget a secondary assessment. This should include exposing the patient to examine for injuries associated with the drowning, possible medical conditions that may have caused the individual to become unconscious, always consider drugs and alcohol as an underlying cause, and never rule out anything until you have a definitive tool for doing so.

For instance, check blood glucose levels (if low, administer dextrose per protocol), looks for a history of seizures (administer reversal agents if indicated), assess for signs of illicit drug or alcohol use (if reasonable, administer Narcan), perform an electrocardiograph (ECG), and monitor end-tidal CO2 (Topijan et al., 2012; Suloviv, et al., 2018).

Head of Bed Elevation

Elevating the head of the bed/cot to 30 degrees is suggested if you suspect a neurological injury, and have excluded c-spine injury (Topijan et al., 2012). According to Topijan et al., (2012) elevating the bed to 30 degrees has the most significant impact on reducing intracranial pressure (ICP) while still allowing for adequate cerebral perfusion pressure, be careful to not elevate beyond 30 degrees as this has shown to have negative consequences concerning cerebral perfusion pressure. Beyond this intervention, we in the pre-hospital environment must be vigilant in our assessment of neurological function. Other interventions can be used as well and will be discussed in the following paragraphs. These interventions include strict glucose monitoring and preventing hypoxia, hypoxemia, and seizure activity (Topijan et al., 2012).

Intubation and Gastric Distention Relief

If you elect to intubate based on your assessment, take into consideration the use of an orogastric tube. If your patient is conscious and you have the tools to perform RSI or delayed sequence induction, intubate for airway protection and of course, positive pressure and increased fractions of inspired oxygen. Individuals who are undergoing intubation will have likely swallowed a lot of water-based on the facts surrounding the events. Introducing an OG tube will relieve the stomach contents and may assist you with providing better ventilation; in turn, this has the potential to offer improved outcomes (Layon & Modell, 2009).

Arterial Blood Gases

For providers who have access to arterial blood gas sampling, utilize this tool, but do not delay your priorities, especially if the individual is showing signs of altered mental status and is protecting his or her airway. However, if you have the time to check a blood gas, evidence suggests that if your patient is unable to maintain a PaO2 “above 60 mmHg, an O2 saturation above 90” with supplemental oxygen being administered, or a PaCO2 of 50 or higher he or she should be intubated (Chandy, Danzl, & Grayzel, 2019). Be mindful and “do no harm,” trying to use all your fancy tools.

Non-Invasive Positive Pressure Ventilation

Let us not beat this subject too much. However, if you or your team can provide a patient with NIPPV, please use it. Research subjects that the use of NIPPV improves lung compliance, alveolar recruitment, and “improves ventilation-perfusion mismatches” (Schwerin & Goldstein, 2019). In essence, it moves fluid out of the alveoli and improves perfusion, which is an excellent thing for people who happen to have fluid-filled lungs.  Layon and Modell (2009) suggest pressure support starting at 10 cm H2O for CPAP and then trending up to what works best for the patient.

Mechanical Ventilation

If you are an advanced provider and have access to a ventilator and your patient is intubated, it is essential to set your ventilator to ensure that “Pao2/Fio2 ratios (PFRs) are above 300 and the Fio2 is below .5 to prevent oxygen toxicity (Layon & Modell, 2009). It is best to manage the patient according to ABGs; however, assuring that they are ventilating and oxygenating is critical.

Antibiotics and Steroids

According to Layon and Modell (2009), steroids have shown to be ineffective and may cause worse outcomes. That said if you suspect the patient has aspirated contaminated water consider the use of broad-spectrum antibiotics. This can be beneficial even prior to obtaining blood cultures (Layon & Modell, 2009). Remember to prioritize treatment, ABCs, CPR, and then take care of your secondary interventions.

Albuterol

            A patient who has a constricted airway may benefit from the use of nebulized albuterol, many of these are capable of being placed in-line with other adjuncts such as ET intubation and mechanical ventilators (Layon & Modell, 2009). In the awake patient, asking him or her to hold a handheld nebulizer seems appropriate.

Hypertonic Fluids, Not yet!

I researched the use of hypertonic saline for neurological issues such as swelling and increased ICP, but was unable to find data supporting its use in humans (Layon & Modell, 2009). I am not promoting its use. Instead, I am merely relaying the information. Research in animal subjects has shown that hypertonic saline reduces ICP (Layon & Modell, 2009). My advice, call for medical direction before proceeding with this intervention.

Summary

  • What we learned, first, and one of the most critical takeaways from this article is that it is beneficial for you and your patient, if you remain calm, cool, and collected. Focus on maintaining control of the scene and ensure you have space to work.
  • Rescue is a critical component to the survival of a person involved in a drowning incident. You do not have to be the initial responder to make an impact, but if you are safe.
  • Resuscitation needs to begin as soon as you are able. Once the patient is safe, and you can perform interventions, do so. Earlier, the better.
  • Airway, breathing, and circulation. It is as basic as it gets. Do you have a patent airway? Yes, move to breathing. Is your patient breathing effectively? Yes, now to circulation, remove wet clothing and assess for hemodynamic stability and maintain homeostasis by ensuring your patient is warm and dry.
  • C-spine, not likely a factor, however, if it is, utilize proper techniques for inline mobilization. Remember, if a person is altered or has distracting injuries, consider placing a collar.
  • CPR, do it if you the patient needs it. Pads will not be as effective if the patient is wet, so dry him or her off. Do good compressions, and if your patient vomits, suction and get back on the chest.

Secondary Summary and Interventions

If your patient is awake and breathing great, transport him or her to the nearest appropriate facility. If they are not going through the steps previously mentioned. With that being said, there are other interventions to consider if you have the time. For example,

  • Perform a thorough assessment to include a head to toe, glucose monitor, and look for signs of potentially reversible causes, such as opiate overdose.
  • Raise the head of the bed to protect neurological function and decrease ICP.
  • You may elect to use NIPPV. Peep will assist with moving water out of the airway and provide you with better oxygenation and ventilation. If you are unable to protect the patient’s airway and choose to intubate, utilize PEEP of at least 10.
  • Obtain an ABG if possible and use it to your advantage with ventilator management.
  • Antibiotics can be beneficial for patients who have aspirated contaminated water. However, avoid the use of steroids in these patients.
  • Albuterol works, if you have it and it is indicated, administer it.
  • Hypertonic saline is currently not suggested, so avoid its use in these patients.
  • Finally, stay calm and do good work.

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