MITCH TAYLOR, 31, is brought to your ED after being rescued from an area lake by the Stevensons-a husband and wife who passed his floating body while out on their boat. When they pulled Mr. Taylor from the water, he was unconscious and didn't appear to be breathing. He also had a large gash on his head. They immediately initiated CPR. By the time they reached the dock, Mr. Taylor had a weak pulse and was breathing on his own. They tell you that they don't know how long Mr. Taylor was in the water before they found him and that they didn't see anyone else at the lake before or after finding him.
Immediate CPR is the factor with the greatest influence on the survival of a person who has nearly drowned. After resuscitation, subsequent hypoxia and acidosis are the primary complications that require immediate intervention in the ED.
Let's take a closer look at near drowning and the care of a patient who has nearly drowned.
A chance for survival
Near drowning is defined as survival for at least 24 hours after submersion that caused a respiratory arrest. An estimated 7,000 drowning and 90,000 near-drowning cases occur yearly in the United States; more than 140,000 cases of near drowning occur worldwide. Factors associated with drowning and near drowning include alcohol ingestion, inability to swim, diving injuries, hypothermia, and exhaustion. Women usually drown in the ocean or bathtub, whereas men usually drown in rivers, lakes, or ditches. Efforts to save a person who has drowned shouldn't be abandoned prematurely; successful resuscitation with full neurologic recovery has occurred in near-drowning patients after prolonged submersion in cold water. This is possible because of a decrease in metabolic demands and the diving reflex (the body's self-preservation technique of slowing its major systems when submerged in water).
What to expect
The near-drowning process involves the onset of hypoxia, hypercapnia, bradycardia, and dysrhythmias. If a violent struggle is associated with the near-drowning episode, exercise-induced acidosis and tachypnea may result in aspiration. Hypoxia and acidosis cause eventual apnea and loss of consciousness. When the person loses consciousness and makes a final effort to breathe, the terminal gasp occurs. Water then moves passively into the airways before death.
Pathophysiologic changes and pulmonary injury depend on the type of fluid (fresh or salt water) and the volume aspirated. Fresh water aspiration results in a loss of surfactant, leading to an inability to expand the lungs. Salt water aspiration leads to pulmonary edema from the osmotic effects of the salt within the lungs. After a person survives submersion, acute respiratory distress syndrome, resulting in hypoxia, hypercapnia, and respiratory or metabolic acidosis, may also occur.
What you'll need to do
Therapeutic goals for a patient who has nearly drowned include maintaining cerebral perfusion and adequate oxygenation to prevent further damage to vital organs and managing hypoxia, acidosis, and hypothermia. Because Mr. Taylor is breathing spontaneously, administer supplemental oxygen by mask. (An endotracheal tube is necessary if the patient isn't breathing spontaneously.) Manage his hypoxia by ensuring an adequate airway, which helps correct respiratory acidosis by improving ventilation and oxygenation. Monitor his arterial blood gas (ABG) values to evaluate oxygen, carbon dioxide, and bicarbonate levels and pH. These parameters determine the type of ventilatory support needed; for example, use of endotracheal intubation with positive end-expiratory pressure improves oxygenation, prevents aspiration, and corrects intrapulmonary shunting and ventilation-perfusion abnormalities caused by water aspiration. Administer intravascular volume expansion and inotropic agents, as ordered, to treat hypotension and impaired tissue perfusion. Nasogastric intubation may be ordered to decompress the stomach and prevent aspiration of gastric contents.
Because of submersion, Mr. Taylor will most likely be hypothermic. Use a rectal probe to determine the degree of hypothermia and start rewarming procedures, such as extracorporeal warming, warmed peritoneal dialysis, inhalation of warm aerosolized oxygen, or torso warming, as ordered. The choice of warming method is determined by the severity and duration of hypothermia and available resources. Hypothermia and accompanying metabolic acidosis may compromise renal function.
After a near-drowning incident, a patient is at risk for complications such as hypoxic or ischemic cerebral injury, acute respiratory distress syndrome, pulmonary damage secondary to aspiration, and life-threatening cardiac arrest. Closely monitor Mr. Taylor's vital signs, ABG values, ECG readings, intracranial pressure assessments, serum electrolyte levels, and intake and output.
A close call
It turns out that Mr. Taylor was fishing by himself, standing shin-deep in the water close to the shore, when he slipped and hit his head on a jagged rock, which caused him to lose consciousness. The water's current pulled him further out into the lake, where the Stevensons found him floating. But thanks to the quick thinking and actions of the Stevensons, he's going to live to tell another story about the big one that got away!!
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