Near Drowning: Follow-up ?>

Near Drowning: Follow-up

Near Drowning: Follow-up

Follow-up
Further Inpatient Care
The primary goal in the management of a submersion injury is preservation of CNS perfusion and function. Cerebral edema and intracranial hypertension secondary to hypoxic neuronal injury are frequently observed, but studies have shown that invasive monitoring of intracranial pressure is neither useful nor necessary in near-drowning incidents.
Maintain adequate oxygenation and ventilation. Prophylactic hyperventilation has no role.
Avoid hypotension, hypoglycemia, and hyperthermia.
Monitor and maintain intravascular volume and blood pressure. Arterial and central venous pressure (CVP) monitoring is useful in patients requiring intensive care.
The early use of supplemental oxygen with high levels of positive end-expiratory pressure (PEEP) is helpful in reversing hypoxemia. High-frequency ventilation or extracorporeal membrane oxygenation may be needed for patients who are refractory to conventional ventilation.
Monitor closely for bacterial and fungal infection. Evidence is insufficient to support the use of prophylactic antibiotics.
Begin aggressive rehabilitation early (as soon as tolerated) to prevent disuse injury and promote functional improvement.
Further Outpatient Care
Outpatient care dictated by nature and degree of residual functional impairment at discharge.
Transfer
Patients with severe neurologic impairment may benefit from transfer to inpatient rehabilitation institutions.
Deterrence/Prevention
In most instances, drowning and near drowning can be prevented with simple safety measures and common sense. Most children younger than 5 years enter a swimming pool directly adjacent to their home or one with inadequate fencing or unlatched gates or doors. Most children are found silently floating with no screaming or splashing noted, were last seen in the home, and were out of sight for only moments.
Adult supervision is essential in the prevention of drowning. Because lapses of supervision are inevitable, other safety precautions must be in place.
The use of adequate fencing around swimming pools has decreased the number of immersion injuries significantly (to less than one half). The enclosure may be a wall or fence that completely surrounds a pool on all 4 sides, isolating the pool from the remainder of the property. The enclosure must be at least 4 ft tall with no more than 4 in between openings in the fence. A house or building wall may serve as part of the enclosure only if it does not have any doors or windows through which a child may pass. Doors and gates to the pool should be self-closing and self-latching.
Pool alarms and covers have not been shown to prevent drowning.
The use of personal flotation devices approved by the US Coast Guard may reduce the incidence of drowning among children when playing in natural bodies of water or when boating. However, these devices must not be used as a substitute for appropriate adult supervision.
Pool owners should be instructed on basic life support.
Children and adults should be instructed never to swim alone or unsupervised.
Submersion injuries may occur in toilets and water buckets. Appropriate measures must be taken to ensure that children are never unsupervised in bathrooms, and water buckets must be emptied when not in use.
Infant swimming or water-adjustment programs do not prevent submersion injuries and are potentially hazardous, providing parents with a false sense of security if they perceive their infant can swim.
Refraining from alcohol use while boating.
The American Academy of Pediatrics have established guidelines for the prevention of drowning in infants, children, and adolescents.2
Complications
Immediate complications are secondary to hypoxia and acidosis. The immediate threats are the effects on the central nervous and cardiovascular systems. CNS effects depend on the severity and duration of hypoxia. Posthypoxic cerebral hypoperfusion may occur. Long-term effects of cerebral hypoxia, including vegetative survival, are the most devastating.
Hypoxia and acidosis may lead to cardiac dysrhythmias, including ventricular fibrillation and asystole. Myocardial damage may lead to cardiogenic shock. Capillary leak and neurologic injury can predispose submersion victims to hypovolemia and hypotension.
Aspiration of freshwater or salt water alters the function of surfactant, causing injury to the alveoli and pulmonary capillaries. Increased capillary permeability can worsen the hypoxia and impair ventilation.
Near-drowning patients may develop pneumonia, although it is less common than chemical pneumonitis, especially if the submersion occurs in a chlorinated pool or in a bucket containing a cleaning product.
Nonpulmonary infections, including brain abscesses, osteomyelitis, and soft tissue infections with unusual fungal, amebic, and bacterial pathogens, may present after initial recovery.3,4,5,6 Because the causative organisms for these infections are rarely seen in other clinical settings, a high index of suspicion must be maintained in patients after acute or subacute injury. Surgical consultation may be required because many of these infections do not respond to antimicrobial therapy alone.
Prognosis
The prognosis is directly related to the duration and magnitude of hypoxia.
The most significant impact on morbidity and mortality occurs before the patient arrives at the hospital.
Poor survival is associated with the need for continued cardiopulmonary resuscitation efforts on arrival to the hospital.
Of these patients, 35-60% die in the ED.
Of the survivors, 60-100% have long-term neurologic sequelae.
Of the patients who recover from the pulmonary effects of the submersion, those who were fully awake on arrival to the hospital generally do very well.
The neuroprotective effects of cold-water drowning are poorly understood.
Hypothermia profoundly decreases the cerebral metabolic rate.
Neuroprotective effects seem to occur only if the hypothermia occurs at the time of submersion and only if very rapid cooling occurs in water with a temperature of less than 5°C. Helpful general rule to consider is if the child broke through ice on the surface, indicates potential for cold water event.
Intact survival of comatose patients after cold-water submersion injuries is still quite uncommon.
Patient Education
Prevention is the best approach to minimize the risk of morbidity and mortality associated with submersion injuries.
Children should never swim alone or unsupervised.
Toddlers should not be near bathrooms or buckets of water outside of immediate adult supervision.
Families with swimming pools should ensure that all safety concerns are addressed, especially appropriate barriers.
Families with swimming pools should learn basic life support.
Alcohol and drugs should not be used when operating or riding in motorized watercraft.
For excellent patient education resources, visit eMedicine’s Public Health Center and Environmental Exposures and Injuries Center. Also, see eMedicine’s patient education articles Cardiopulmonary Resuscitation (CPR) and Drowning (CPR).
Miscellaneous
Medicolegal Pitfalls
The degree of hypoxemia is often underrecognized. Administer 100% oxygen. Oxygenation should be monitored closely via pulse oximetry, blood gas analysis, or both. Patients who remain hypoxic warrant endotracheal intubation with an appropriate level of positive end-expiratory pressure (PEEP).
Secondary causes of drowning should always be considered. Child neglect and abuse, including sexual abuse and Munchausen syndrome by proxy, may result in submersion injury.
Cervical spine injuries may be present in any near-drowning episode. Unless a clear history rules out the possibility of such injuries, a cervical collar should be used until a proper evaluation is made.

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