Drowning: emergency treatment for drowning

Drowning is death from asphyxia due to immersion in water. Drowning is most often associated with a cervical spine injury (especially the fifth cervical vertebra) sustained while diving, and alcohol or drug intoxication is also a common cause of drowning.

There is also partial drowning - survival after asphyxia due to immersion in liquid. Most often, death from drowning is recorded in adolescence and youth, as well as in children in the first years of life.

Risk factors for drowning also include:

• Children's games by the water.
• Accidents resulting from diving, exposure to poisons (such as pesticides or toxic gases) near bodies of water or in rural mud.

In the pathogenesis of drowning in fresh water, two factors are important: washing out of surfactant from the pulmonary alveoli and rapid absorption of hypotonic water from the alveoli into the vascular bed (hypervolemia), which leads to microatelectasis, hypoxia, pulmonary edema, and in the post-resuscitation period - to acute renal failure and hemolysis. With prolonged exposure to warm water, energy depletion, collapse, hyposystole and bradycardia develop. Long-term exposure to cold water leads to peripheral vascular spasm, muscle rigor mortis, ventricular fibrillation. The more water is aspirated, the greater the likelihood of fibrillation. Drowning in sea water is accompanied by similar disorders, but with water sweating into the lumen of the alveoli and the development of hypovolemia, arterial hypotension after rescue. In case of “dry” drowning, i.e. as a result of laryngospasm, acute asphyxia and hypoxia, fibrillation also develops.

[ 1 ], [ 2 ], [ 3 ], [ 4 ]

How to recognize drowning?

The following signs help to recognize drowning: a history of immersion in liquid with respiratory arrest or cardiac arrest. Profound hypothermia is possible. Neck and spinal injuries are common.

What should be used for differential diagnosis?

• Diving accidents with head injury.
• Exposure to toxic waste and chemicals in water.
• Poisoning.
• Intentional harm (non-accidental damage).

First aid for drowning in children

Assistance to a conscious drowning victim without impaired hemodynamics and breathing is limited to warming and taking valocordin, 1 drop per year of life.

If the victim develops tachypnea, bradycardia, impaired consciousness and seizures, assistance consists of clearing the oropharynx from mucus and maintaining airway patency after removing water from the lungs and stomach. The victim should be laid on his side and pressed with the palm of the hand on the upper part of the abdomen or placed face down and, clasping the body with the hands in the abdominal area, lift up, squeezing out the water. Then oxygen therapy is carried out through a mask, starting with the introduction of pure oxygen (100%). Convulsions are stopped by intramuscular or intravenous administration of a 0.5% solution of diazepam (seduxen) at a dose of 0.3-0.5 mg per 1 kg of body weight or midazolam at a dose of 0.1-0.15 mg per 1 kg of body weight. In case of bradycardia, a 0.1% atropine solution is administered intramuscularly at a dose of 0.1 ml per year of life or 10-15 mcg per 1 kg of body weight in case of emergency tracheal intubation (along with diazepam). The stomach contents must be removed using a tube to prevent aspiration. A nasogastric tube is left in the stomach for decompression. It is necessary to exclude cervical spine injury, the characteristic signs of which may be paradoxical breathing, lethargy, arterial hypotension, bradycardia.

If spontaneous breathing is maintained, ventilation is performed through a mask under constant positive pressure in the respiratory tract, using pure oxygen (100%). If breathing stops, tracheal intubation is provided, artificial ventilation with a positive end-expiratory pressure of 4-6 cm H2O. Then, a 1% solution of furosemide (lasix) is administered intravenously by jet stream at the rate of 0.5-1 mg per 1 kg of body weight, repeatedly, and a 2.4% solution of aminophylline (euphyllin) at a dose of 2-3 mg to 4-6 mg per 1 kg of body weight intravenously by jet stream or drip. Inhalation is performed with 100% oxygen passed through a 33% ethanol solution.

For victims with hypothermia, assistance consists of cardiopulmonary resuscitation in parallel with measures to warm the patient to a body temperature of over 32°C.

In cases of true drowning, after cardiopulmonary resuscitation, children experience cyanosis, swelling of the veins of the neck and extremities, discharge of foamy masses (sometimes pink) from the mouth and nasal passages, arterial hypertension, ventricular fibrillation, and pulmonary edema.

In asphyxial (dry) drowning, the skin is pale, the pupils are dilated, and reflex cardiac arrest or fibrillation occurs quickly. Foaming does not occur.

In case of rescue, children may not have residual neurological disorders. This is due to the rapid development of hypothermia, which contributes to greater resistance of the central nervous system to hypoxia, with the preservation of a certain volume of air in the respiratory tract and lungs, due to which gas exchange can continue during laryngospasm with the development of reflex bradycardia and increased blood flow in the brain and heart.

[ 5 ], [ 6 ] First aid for drowning Assess the condition of the cervical spine. The neck must be linearly immobilized. Begin basic resuscitation. If resuscitation equipment is available, give oxygen via bag/valve/mask. There is a high risk of aspiration of gastric contents. Intubate as soon as possible - in this situation, drugs are often not needed. If drugs are available - rapid sequence induction. Insert a gastric decompression tube. The stomach can also be washed through it. [ 7 ] Advanced drowning care If the internal temperature is less than 30°C, refuse adrenaline and other resuscitation drugs. Above 30 °C - the lowest recommended doses with a doubling of the interval between administrations. If VF is present, administer three shocks initially, but further attempts at defibrillation should be withheld until the core temperature rises to 30°C. [ 8 ], [ 9 ] Active warming First aid for drowning is unlikely to be successful unless the internal temperature can be raised above 32°C. Establish rectal or (preferably) esophageal temperature monitoring. Remove all wet clothing and dry the patient thoroughly. Use a warming blanket with a blower of warm air, warm all fluids before intravenous administration. If possible, heat the breathing circuit of the respirator or use a circulation system with a carbon dioxide absorber and low gas flow with warming of the inhaled gas mixture (NB during hypothermia, CO2 production is reduced). Rinse the stomach and bladder with saline solution warmed to 40-42 °C. Rinse the abdominal cavity with potassium-free Analytical solution, warmed to 40-42 CC, 20 ml/kg/15 min per cycle. Extracorporeal circuit with blood warming. Complete examination for other injuries. [ 10 ], [ 11 ] Further management Supportive care in the intensive care unit. Regular tracheal hygiene, aspirate culture. A course of antibiotic therapy. Physiotherapy and chest X-ray in dynamics.

What you need to know about drowning?

• Three-quarters of people who suffer from near drowning recover without sequelae if they receive basic care immediately after being removed from the water.
• The duration of the dive reduces the chance of survival. Diving for more than 8 minutes is most often fatal.
• Rapid restoration of spontaneous breathing (several minutes) after the start of first aid for drowning is a good prognostic sign.
• Deep hypothermia (after cold water immersion) may protect vital functions but predisposes to ventricular fibrillation, which may remain refractory to treatment until the temperature rises above 32°C.
• The myocardium does not respond to drugs at temperatures below 30°C, so if the temperature is below 30°C, adrenaline and other drugs should be discontinued. When drugs are administered at standard extended resuscitation intervals, they accumulate in the periphery, so at 30°C the lowest recommended doses should be used with a doubling of the interval between administrations.
• Drowning initially causes apnea and bradycardia due to vagal stimulation (diving reflex). Continued apnea leads to hypoxia and reflex tachycardia. Continued hypoxia produces severe acidosis. Eventually breathing resumes (tipping point) and fluid is inhaled, causing immediate laryngospasm. This spasm weakens with increasing hypoxia; water and its contents rush into the lungs. Increasing hypoxia and acidosis lead to bradycardia and arrhythmia, eventually leading to cardiac arrest.