溺水 Drowning



<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:

  1. Impending respiratory failure s/p NRM support

  2. 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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