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Case of the Month
July 2008
27-year-old male –possible drowning
Dispatch
Your unit is dispatched to a lake side park for a 27-year-old male, possible drowning.
While en route the dispatcher notifies you that the patient is out of the water next to the dock and is having difficulty breathing.
En route your crew discusses the following considerations:
- Water related trauma
- Aspiration
- Scene hazards
- Resources
Scene Size-up
Your team arrives at the scene and finds a group of people surrounding a young man in a swim suit. He is sitting up and appears conscious. One of the bystanders is patting him on the back gently.
Initial Assessment
As you near the patient you notice he is coughing violently and has a very flushed complexion. He states “I can’t breathe” with difficulty and looks extremely scared. You find that he has a strong, rapid radial pulse and is coughing up a clear, foamy phlegm. Aside from his face color, his skin is somewhat pale and he feels slightly cool to touch. You also note the smell of alcohol on his breath.
Initial Treatment
Your partner takes a quick set of vital signs as you to apply a NRM at 10 liters per minute. You attempt to listen to his lungs however his coughing makes this impractical. Due to respiratory difficulty and mechanism you request an ALS unit for evaluation.
Vital Signs
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Respirations 28
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Pulse 120
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Level of consciousness Alert with good recall of events
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Pulse oximetry 94% on 4 liters per minute
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Blood sugar Not taken
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Blood pressure 110/80
Further Evaluation and Treatment
After a minute or so the coughing subsides and he is able to take in air full breaths. He is still anxious and states “I thought I was going to die.” As you continue to evaluate the patient you detect subtle rales in his lungs but his air exchange is very good. As his breathing improves, so does his oxygen saturation reading, achieving 97%. The ALS unit arrives and performs a brief evaluation. Due to the patient’s presentation they decide to allow a BLS transport of the patient to the local ED.
En route to the hospital the patient has a second coughing fit lasting a few minutes. During this episode his oxygen saturation drops to 91% and his anxiety level greatly increases. You and your crew discuss a possible ALS rendezvous; however, it is decided that you can reach the hospital faster than the medic unit. The coughing subsides again and the rest of the transport is uneventful.
On arrival at the emergency department the staff is concerned that this patient has a higher than normal risk for secondary drowning. He is admitted for observation and further tests.
Secondary Drowning
Secondary drowning is a term used to describe a phenomenon that occurs in about 5% of cases of near-drowning. It can be caused by as little as a tablespoon of water entering the lungs while swimming or in near-drowning emergencies. Often a patient will appear fine after the near-drowning episode, however over the next 48 to 72 hours they are susceptible to secondary drowning. Children are more at risk for this insult than adults however nobody is immune.
The mechanism of secondary drowning is thought to be due to small amounts of water entering the lungs and damaging the surfactant inside the alveoli. This “wash down” of surfactant causes the alveoli to fail to work properly and leads to shortness of breath, coughing, and, potentially, death. Due to this risk in any near-drowning patients, every near-drowning patient must be evaluated immediately at an emergency department and should be observed for several hours after the episode.
Remember that in addition to secondary drowning, near-drowning patients are at risk for a myriad of other insults, including bacterial pneumonia, pulmonary barotraumas, pneumonitis secondary to aspiration of mud, sand, plant life or vomit to name a few.
Secondary drowning in children
British Medical Journal (external website)
Drowning
eMedicine (external website)
Dry Drowning
MSNBC (external website)
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