Tuesday 20 October 2020
Drowning and near-drowning

Drowning and near-drowning

The accidents by immersion in water with all the consequences that may have health and even life itself the victim of direct interest to the Greek society, given the close relationship with the sea. The purpose of this article is to describe what these accidents, what can result, what should be done and how we can avoid.

Definition

The term "drowning" is defined as death due to suffocation during immersion in a liquid medium, usually water, or within 24 hours of immersion. A 'near miss drowning' is defined as an episode of immersion in water capable of severity to require medical attention and which can lead to morbidity and death (after 24 hours of the incident).

Epidemiology

International

Annually about 140,000 recorded deaths due to drowning worldwide.

For the near-drowning no precise statistics. However, it is estimated that the impact of near-drowning is 20-500 times the incidence of drowning.

In the U.S.:

Every year there are 6500 deaths from drowning, and about 48,000 cases of near-drowning. Drowning is the fifth leading cause of accidental death among all age groups, with average annual incidence of approximately 2.5-3.5 per 100,000 inhabitants, while for children aged 1 month to 14 years for young adults is the second cause of injury and death by accident. 80% of accidents involve males. Many near-drowning victims develop severe morbidity, which can lead to permanent health damage or death. In children aged 1 month to 14 years morbidity occurs in 12-27% of survivors. It is estimated that children 35% of episodes are fatal sinking, 33% leading to a degree of neurological impairment and 11% in severe neurological sequelae.

Greece

Data included for the Greek area were unable to find, the Greek Statistical Sites on the Internet. However, they may be cited as probably representative data for the prefecture of Corfu, according to an epidemiological survey conducted by the Medicine Hospital of Corfu for the years 1900-2003. All in all, there were 160 cases of drowning, that is 12.3 cases per year. These data, if traced back to the people of Corfu is approximately 100,000 residents and tourists during the summer, giving an annual incidence of drowning more than 10 serious incidents and 5 near-drowning per 100,000 residents annually. The effect is much greater than at international level and about four times the U.S., which indicates the severity of the problem.

Causes and risk factors for drowning

* Existence of various diseases
*
o Epilepsy
o mental retardation
o Convulsions
o Myocardial infarction or syncope
o poor neuromuscular control, as seen in severe arthritis, Parkinson, or other neurological disorders
o Major depression / suicide
o disorder anxiety / panic
o Diabetes, hypoglycemia


* Consumption of alcohol and to a lesser extent, other psychotropic drugs in swimming and sailing / boats use
* Lack of appropriate education profile
* Failure to use personal flotation devices
* Dives in shallow water or water with rocks, the head trauma and / or cervical spine
Risks of water sports
* Poor education and substance abuse (alcohol or other psychoactive drugs).
* Failure of cervical spine-cervical spine and head injury associated with surfing, water skiing, and jet skiing.

Place where accident

In the U.S., the most frequent sites of accidents is the tub for children younger than 1 year, family pools for preschool children, while the lakes, rivers and seas are typically the location of drowning for young adults. The fact that many family pools in our country have no physical barrier between the pool and house, or if there is a fence, the entrance gate is always open.

In Corfu sites drownings were identified in order of frequency: the sea (131), wells (12), swimming (7), river (1).

Pathophysiological disorders

The main physiological consequence of failure is precipitated by prolonged hypoxia. The target organ damage from precipitation is the lungs. Damage to other systems is largely secondary to hypoxia and acidosis.

The morbidity and mortality from sinking due primarily to a lack of oxygen and the harmful effects on the brain, heart and other organic systems. After an initial desperate attempt to breathe, and possibly aspiration, the immersion causes a variable degree and duration of reflex spasm of the larynx and closure of the epiglottis (defense mechanism to prevent the ingress of water into the lungs). This leads to hypoxaemia. Suffocation leads to relaxation of the airway, which allows many victims to fill the lungs with liquid medium in which the precipitation ( "wet drowning"). However, 10-20% of victims maintain the laryngospasmo until cardiac arrest occurred and stop the inhalation effort. The victims are not eisrofoun any liquid ( "dry drowning"). In wet drowning in the development of hypoxaemia and other mechanisms contribute. The eisrofithen liquid into the lungs causes pulmonary vasoconstriction via the vagus and hypertension. Fresh water moving rapidly through the membrane kypselidotrichoeidikis within the microcirculation. The surfactant in the alveoli is destroyed, causing instability of the alveoli, atelectasis, and decreased yielding to serious disruption of the relationship ventilation / perfusion (V / Q). Up to 75% of blood flow may circulate through ypoaerizomenon parts of the lung (shunt). At the same time endangering kypselidotrichoeidiki membrane resulting liquid is rich in protein to exudes rapidly within the cells and the median tissue and yielding reduced (Non-cardiogenic pulmonary edema). The disorder leads to the further development of severe hypoxia. Bronchospasm caused by the liquid may also contribute to hypoxia. In a smaller proportion of patients, vomiting, aspiration, and foreign materials may cause bronchial obstruction, bronchospasm, pneumonia, abscess formation, and inflammatory damage to the cell-capillary membrane. Post-obstructive pulmonary edema sequent spasm of the larynx and hypoxic neuronal injury with subsequent neurogenic pulmonary edema may also play a role.

If in the early stages of the accident there was no help, the hypoxaemia leads to severe lactic acidosis and ischemia of the central nervous system (CNS), resulting in unconsciousness, and heart, resulting in cardiac arrest and ultimately death. Additional damage to the CNS can be caused by co-escort-injury trauma of the head and spine.

It should be noted that victims who develop hypothermia may appear dead with no apparent heartbeat or brain function. However, the experience of immersion in cold water that supports full resuscitation efforts can and should be continued until the temperature of the body become almost normal.

Clinical classification

An accident victim immersion can be classified into one of the following 4 groups:

* Asymptomatic

* Symptomatic

* Changes in vital signs (eg hypothermia, tachycardia, bradycardia)

* Anxiety appearance

* Tachypnea, dyspnea, or hypoxia. If shortness of breath, no matter how small it is, the patient is symptomatic.

* Metabolic acidosis (may be even in asymptomatic patients)
* Change in level of consciousness, neurological impairment

* Cardio opposition - Cardiopulmonary arrest

* Apnea

* Shamelessly (55%), ventricular tachycardia / fibrillation (29%), bradycardia (16%)

* Manifest dead
*
o Normothermikos with brazen

* Apnea

* Occult central nervous system function

Treatment

Pre-hospital Care: The pre-hospital care focuses on the following important points:

* Correcting arterial blood gases, with particular attention to the earliest possible and ensure supply of adequate airway, oxygenation and ventilation

* In patients with impaired mental status, the airway should be checked for foreign material and vomiting
* Ask the patient immediately to 100% oxygen through a mask. If the patient remains dyspnoikos in of 100% oxygen shows a low oxygen saturation, use continuous positive airway pressure (CPAP) if available. If not available, consider quick intubation, with appropriate use of positive end-expiratory pressure (PEEP).

* Immobilizing the neck if the patient has trauma to the face or scalp, if not in a position to give an adequate history, or has engaged in a diving accident

* Began reheating

Emergency Department: The initial response of near-drowning should emphasize the immediate resuscitation and treatment of respiratory failure.

* It took time attendant injuries, cervical spine injury and spinal cord may complicate handling aeraragogon.
* Ensure all victims providing supplemental oxygen during all these considerations
* Intratracheal Pipe: Pipe may be required to ensure adequate oxygenation in a patient who is unable to maintain a PO2 greater than 60-70 mm Hg (> 80 mm Hg in children) in 100% oxygen through a face mask.
*
o The patient has a level of consciousness and cooperative, provided noninvasive positive pressure ventilation (BiPAP) / CPAP), if available, to ensure adequate oxygenation before the implementation of intubation.
o Other criteria intratracheal intubation include the following:

* Change in level of consciousness and inability to protect the airway or removal of secretions
* High blood-cell difference (Aa) oxygen
* Respiratory Insufficiency - PaCO2> 45 mm Hg
* Deterioration of arterial blood gases

* The diasolinomena victims of near-drowning may require the application of PEEP during mechanical ventilation to maintain adequate oxygenation. The PEEP has been shown to improve ways of ventilating lung in the non-soft in many ways, including (1) water slope of the median area within the pulmonary capillary (2) increase in lung tumor growth by preventing the expiratory airway occlusion, (3) ensuring improved alveolar ventilation and reduction in alveolar blood flow, and (4) increase the diameter of both small and large airways to improve distribution of ventilation.

* Reheating: Ypothermikoi patients who have suffered sudden, rapid precipitation, may show slowing of metabolism with preferred slope of blood to the heart, brain and lungs, which can exert a protective effect during subduction. However, this is not the norm with most victims of subduction, which have done gradually and hypothermia are at risk for ventricular fibrillation and neurological damage. Therefore, fast xanathermane ypothermikous patients until normothermia.
* Place a nasogastric tube to assist in efforts to boost and ourokathetira for assessment of urine output.
* Try to provide a central vein with caution in these patients to avoid irritation of the vaginal hypothermia and subsequent dysregulation
* Do not stop the resuscitation of a victim of near-drowning until the patient is warm to a minimum of 30 ° C.
* Appropriate therapy electrolyte disorders, seizures, bronchospasm, and vronchorroias caused by cold, dysrhythmia, and hypotension if necessary.

Exit from the Hospital

* The time of patient exit from the hospital depends on the background, this session failures and the extent of damage from the dip.

* Patients able to describe a good record of failure by a small dip, with no evidence of significant harm and without evidence of bronchospasm, tachypnea / dyspnea, or insufficient oxygenation (based on arterial blood gases and pulse oxymetry) may leave the Emergency Department after 6 -8 hours of monitoring.
* Victims of mild to moderately severe dip, which have only slightly improved symptoms during the follow-up and have no disturbance in arterial blood gases and chest radiography, may leave after 6-8 hours, monitoring the Emergency Department.
* Victims of serious immersion, with only slight symptoms and no findings on arterial blood gases, the pulse oximetry, and chest radiograph, need to be monitored for longer.
* Some patients may have a slightly to moderately severe hypoxaemia which was corrected easily with oxygen. He introduced these patients in the hospital for observation. They leave the hospital after the fall of hypoxaemia if they do not have further complications.
* Introduced in ICU patients requiring intubation and mechanical ventilation. Varying degrees of neurological and pulmonary events usually epiplekoun their course.

Weather in near-drowning

The prognosis depends largely on the extent and duration of hypoxia episode. Moreover, the average temperature of immersion, the availability and timely implementation of specific treatment, and the coexistence of medical illness or injury is often severe determinants of outcome. Overall, patients who have consciousness and have normal x-ray upon arrival at the hospital can be expected to recover fully. Those who are able to dormancy but to wake up and have normal breathing almost good prognosis. However, two thirds of those requiring cardio-respiratory and revive those who are admitted in a coma or die remain with severe neurological impairment.

The fact that a proportion of these patients to recover fully may require the need for extensive and intensive efforts to revitalize-recovery in all cases near-drowning.

The neurological disorders is a serious proportion of near-drowning will improve gradually and subside over several months. However, 5-20% of patients will have lasting consequences, many of which would eventually prove fatal.

Prevention - Prevention

Deterrence is the key to treatment and education of society is the key to prevention. Parents should be aware of their obligations, and limits the possibilities of bathing their children. We must constantly supervise their children when they are near water, even in the tub, whether the babies. Instant removal of attention is likely to result in an accident.

All (family) swimming pools and other areas containing water (eg reservoirs) should have a fence, and the door is locked when no supervision from adults. Parents who have a family pool must take serious account to be trained in cardio-pulmonary resuscitation, in case you will need to apply for their child. Children should understand the capabilities and limitations on swimming and not allowed to play dangerous in or around water.

People should avoid using alcohol or other psychoactive substances during swimming or participating in other water sports, carefully check the water depth and a possible dangerous items (eg rocks) when attempting dives. Adequate lifesaving equipment of vessels to be used, including personal life-and everyone on board vessels must be swimmers and be able to understand the weather and water conditions.

Persons with underlying disease that might expose them to danger in swimming, like epilepsy, seizures, diabetes mellitus, significant coronary artery disease, severe arthritis and neuromuscular disorders operation, swim only under the supervision of another adult who is able to save if any event. Finally, a great help offered by the presence of trained lifeguards on crowded beaches and the beaches at risk.

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