Case of the Month
July 2006

15-year-old male — near drowning

Dispatch

"Aid 92, Medic 2; near drowning"

En route your crew discusses the following considerations:

• Water rescue resources
• Additional land resources
• Head and neck precautions
• Hypothermia issues

Dispatch updates you, reporting that the patient has been removed from the water and is unconscious.

Scene Size-up
Your team arrives in the parking lot of a popular beach park. You are immediately flagged down by a young male in a swimming suit. Your crew, knowing the potential for head and neck injury in drowning scenarios, brings a backboard, c-collar, and straps along with the normal complement of equipment (including a suction device). He leads the team to the dock where you find the patient laying on his back motionless. He appears pale and his body is wet. A number of people are standing and kneeling around the patient: one person is holding the patient’s airway open with the head tilt, chin lift maneuver. Somebody states the patient is now breathing again.

Initial Assessment
You find the patient with wet cool skin that is very pale. The patient is breathing on his own but sounds as if there is fluid in the airway. There is a distinct odor of beer and vomit on the patient’s breath. The patient has a weak radial pulse of 124 and a palpated pressure of 90. The respiratory effort is around 12 and shallow. There is no visible signs of trauma.

Your partner completes an initial assessment:

SICK or NOT SICK?
Based on what you see so far, would you consider this patient SICK or NOT SICK? What steps will you take based on the direction you choose?

• Types of treatment needed for this patient?
• Further steps for evaluation?
• Transport destination?

Initial Treatment
You decide the patient is SICK based on mechanism of injury (MOI), respirations and unconsciousness. The ALS unit is updated and a runner is sent to meet and guide this incoming crew.

One of your crew immediately assumes head and neck stabilization and, with the assistance of bystanders, the patient is rolled onto his side to help alleviate the aspiration issue. When placed onto his side the crew is very careful to maintain head and neck inline stabilization.

A suction device is utilized to remove any excess vomit and/or water from the patient’s airway.

The cervical collar is placed and the patient is then rolled onto the backboard and secured with straps. A bag valve mask is used to assist the patient’s own breathing efforts and early oxygen saturations are increased from an initial reading of 84% up to 96%.

Physical Exam
Your partner gives you the following information:

SAMPLE

Second Set of Vital Signs

The ALS crew arrives and starts an IV line. The patient is intubated with extreme care given to minimize head and neck movement. Your crew finishes packaging the patient on the backboard, then the patient is dried as much as possible and covered with blankets to prevent further heat loss. He is carried to the ALS unit for transport to the regional trauma center.

Drowning and Near-Drowning
Drowning is defined as death secondary to asphyxia while immersed in a liquid, usually water, or within 24 hours of submersion. Near-drowning refers to those victims whose submersion was of sufficient severity to warrant emergency medical evaluation and treatment, but didn’t cause immediate death from the submersion.

The demographics of drowning are frightening. Approximately 8,000 people a year drown in the United States. The highest risk groups are children under 5 and adolescents between 15 and 19. Around 50% of drowning involves small children and swimming pools, even though the vast majority of these children are being supervised by adults. A momentary distraction can prove fatal.

In the case of adolescence, 50% of those drowning involves alcohol or drug use and usually occurs in a natural body of water, such as a lake or river. Male adolescents are 12 times more likely to be drowning victims than females!

Contributing Factors
Drowning frequently is preceded by some sort of traumatic injury or medical condition. When caring for a submersion patient you must consider the possibility that an injury to the head or neck may have led to the patient’s inability to stay safely above water. Diving into shallow water and striking the bottom is one common cause of such trauma. A medical issue such as seizure or heart attack may also be a contributing factor to the patient not being able to continue to swim. Always keep this in mind when caring for the drowning/near drowning patient. Any submersion patient needs to be treated for hypothermia. The cooling ability of water is enormous and any uncontrolled decrease of core temperature can severely compound the effects of shock and increase mortality of the submersion victim, whether or not their airway was ever compromised.

Acute Respiratory Distress Syndrome
Follow up care for the near drowning patient is crucial! Even if the submersion victim is looking good during your initial treatment, several conditions may arise over the next 24 hours. Frequently near drowning patients will develop ARDS or Acute Respiratory Distress Syndrome. In this scenario the patient can develop a life threatening case of pulmonary edema several hours after the rescue take place. Aspiration pneumonia is another potential side effect of near drowning that can develop with time. Lung tissue is very delicate, and any water or vomit that seeps in during submersion or after rescue, can have serious, potentially deadly, consequences. 10% to 15% of all drowning are ‘dry drowning’ meaning they never get any fluid into their lungs. This means the remainders do aspirate some amount of water.

Drowning and near drowning events are complicated situations. Though more seasonal in the northern states, the potential exists year round because of swimming pools bathtubs and hot tubs. When faced with the submersion victim consider all of the possible contributing factors and the potential complications. Also know your resources for rescuing individuals from lakes, rivers, and other large bodies of water.

Most importantly work safely, do not attempt a rescue unless you can do so without endangering yourself. Many potential life savers have become victims themselves when attempting to save a drowning person.