OpenAnesthesia and the APSF: Achieving Safe and Quality Anesthesia Care with Education Innovation

Drowning is defined as a primary respiratory impairment from submersion or immersion in a liquid medium. The process of drowning usually entails a voluntary period of breath-holding (for an average of 87 seconds), possible (but not always) swallowing of water, followed by laryngospasm as water becomes entrained into the larynx. Involuntary ventilatory efforts ensue but are ineffective in the setting of laryngospasm. Survivors report this as being the most traumatic component of the drowning process and the total duration of voluntary and involuntary breath holding lasts 1.5-2 minutes. As arterial saturation declines, laryngospasm eventually abates, at which point the subject begins to breathe in water, after which circulatory arrest quickly occurs. The organ most susceptible to injury during drowning is the brain, with brain damage occurring approximately 3 minutes after PaO2 falls below 30 mm Hg. Exceptions to this rule include trained divers and individuals immersed in cold water. Many subjects who drown do so under direct supervision (lifeguards falsely believe that the victims were "fooling around" or attend to other tasks). No individual should ever be allowed under water without making purposeful movements for more than 10 seconds. Treatment: airway management is of paramount importance and should be initiated in water if a) this is safe and b) removal from water would result in any time delay. Once ventilation has been initiated, attend to the cardiovascular system - not all patients will have systole and profound bradycardia is not uncommon. Abdominal thrusts to "remove water" have not been shown to be helpful. The major sources of morbidity and mortality are related to respiratory and CNS compromise. Post-drowning survivors should be admitted to an ICU and CPAP (or PEEP) applied. Anti-epileptics may be initiated in patients with suspected CNS injury. Infection may be an issue in standing water (Pseudomonas) and empiric antibiotic coverage may be indicated in this setting.