<臨床情境>
一位14歲男性海水溺水,被救起時意識不清,經急救後恢復意識
Drowsy, dyspnea, headache
檢傷Vital signs: T/P/R: 37.5/94/20, BP: 121/70, E4V5M6 SpO2: 91%
理學檢查: Clear conscious; Bilateral crackles
過去病史: denied
Lab data:
CXR and EKG:
Oxygen supplement with NRM SpO2 around 95-100%, Empiric abx as Fortum + Doxycycline
Impression:
Impending respiratory failure s/p NRM support
Near-drowning with asphyxia related pulmonary edema
<Drowning>
2005 WHO definition: the process of experiencing respiratory impairment from submersion or immersion in a liquid
Submersion: the airway is below the surface of the liquid
Immersion: the airway is above the surface of the liquid
<Risk factors of drowning>
Inadequate adult supervision
Inability to swim or overestimation of swimming capabilities
Risk-taking behavior
Use of alcohol and illicit drugs
Hypothermia (lead to rapid exhaustion or arrhythmias)
Concomitant trauma/stroke/MI
Seizure disorder or developmental disorders
Undetected primary arrhythmias
Hyperventilation prior to a shallow dive
<Pathophysiology>
Aspiration of water into the lung
Damages surfactant
Disrupts the alveolar capillary membrane
Development of alveolar edema
End organ damage (affected by hypoxemia, metabolic acidosis)
Pulmonary: aspiration, hypoxemia
Neurologic: cerebral edema, IICP
Cardiovascular: arrhythmia secondary to hypothermia and hypoxemia
Electrolytes: seldom
Renal: due to ATN resulting from hypoxemia/shock
Coagulation
<Treatment – prehospital care>
Removal of the victim from water
Rapid resuscitation/CPR (restore ventilation & oxygenation)
Cervical spine injury is rare (neck collar not always necessary)
High-flow oxygen
<Treatment –primary ED treatment>
若有C-spine injury(不常見), amnesia, GCS decline則預後都會較差
<Treatment – secondary treatment>
Extra-corporeal life support:
ECLS with cardiac arrest (poor) V.S. ECLS with respiratory failure (better)
Mechanical ventilation: pneumonia, barotrauma (lung protective strategy)
Non-invasive ventilation - CPAP, HFNC (樣本數極少)
Prophylactic antibiotics: no improvement
Prophylactic steroids: no benefit
Prophylactic diuretics: no benefit
<Prognosis>
Poor in both adult and children
Bystander CPR is very important
[跨領域補充資料 張景泓 (“像一條魚Like A Fish”創辦人)]
溺水時會抬頭仰頭、像是在玩水,但卻是自己一個人在玩
大多溺水時會先跌倒撞到,因此觀察地形避免受傷很重要
必學三招: 仰漂、踩水、抬頭蛙
救援原則: 岸上>入水; 團體>個人; 器材>徒手(可丟保冷冰箱、寶特瓶、防水袋…)
若救援時被溺水者抓住,可以下潛,溺水者便會放開
<Reference>
Bulletin of the World Health Organization (WHO) 2005; 83:853-856
Tintinalli’s Emergency Medicine, 9th edition
Treatment of the lung injury of drowning: a systemic review. Critical Care 2021 25:253
Edited by Chih-Yang, Mao / Mei Cheng
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