red flags

A brush with near drowning

MITCH TAYLOR, 31, is brought to your ED ated CPR. By the time they reached the after being rescued from an area lake by dock, Mr. Taylor had a weak pulse and was the Stevensons—a husband and wife who breathing on his own. They tell you that passed his floating body while out on their they don’t know how long Mr. Taylor was boat. When they pulled Mr. Taylor from the in the water before they found him and that water, he was unconscious and didn’t ap- they didn’t see anyone else at the lake be- pear to be breathing. He also had a large fore or after finding him. gash on his head. They immediately initi- Immediate CPR is the factor with the greatest influence on the survival of a person who has nearly drowned. After resuscita- tion, 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 drown- ing occur worldwide. Factors associated with drowning and near drowning include alcohol ingestion, inability to swim, diving injuries, hy- pothermia, 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

34 Nursing made Incredibly Easy! July/August 2008 full neurologic recovery has occurred in support needed; for example, use of endo- near-drowning patients after prolonged tracheal intubation with positive end- submersion in cold water. This is possible expiratory pressure improves oxygenation, because of a decrease in metabolic de- prevents aspiration, and corrects intra- mands and the diving reflex (the body’s pulmonary shunting and ventilation- self-preservation technique of slowing its perfusion abnormalities caused by water major systems when submerged in water). aspiration. Administer intravascular vol- ume expansion and inotropic agents, as What to expect ordered, to treat hypotension and im- The near-drowning process involves the on- paired tissue perfusion. Nasogastric intu- set of hypoxia, hypercapnia, bradycardia, bation may be ordered to decompress the and dysrhythmias. If a violent struggle is stomach and prevent aspiration of gastric associated with the near-drowning episode, contents. exercise-induced acidosis and tachypnea Because of submersion, Mr. Taylor will may result in aspiration. Hypoxia and aci- most likely be hypothermic. Use a rectal dosis cause eventual apnea and loss of con- probe to determine the degree of hypother- sciousness. When the person loses con- mia and start rewarming procedures, such as sciousness and makes a final effort to extracorporeal warming, warmed peritoneal breathe, the terminal gasp occurs. Water dialysis, inhalation of warm aerosolized oxy- then moves passively into the airways be- gen, or torso warming, as ordered. The fore death. choice of warming method is determined by Pathophysiologic changes and pulmonary the severity and duration of hypothermia injury depend on the type of fluid (fresh or and available resources. Hypothermia and salt water) and the volume aspirated. Fresh accompanying metabolic acidosis may com- water aspiration results in a loss of surfac- promise renal function. tant, leading to an inability to expand the After a near-drowning incident, a lungs. Salt water aspiration leads to pul- patient is at risk for complications such as monary edema from the osmotic effects of hypoxic or ischemic cerebral injury, acute the salt within the lungs. After a person sur- respiratory distress syndrome, pulmonary vives submersion, acute respiratory distress damage secondary to aspiration, and life- syndrome, resulting in hypoxia, hypercap- threatening cardiac arrest. Closely monitor nia, and respiratory or metabolic acidosis, Mr. Taylor’s vital signs, ABG values, ECG may also occur. readings, intracranial pressure assess- ments, serum electrolyte levels, and intake What you’ll need to do and output. Therapeutic goals for a patient who has nearly drowned include maintaining cere- A close call bral perfusion and adequate oxygenation It turns out that Mr. Taylor was fishing by to prevent further damage to vital organs himself, standing shin-deep in the water and managing hypoxia, acidosis, and hy- close to the shore, when he slipped and hit pothermia. Because Mr. Taylor is breath- his head on a jagged rock, which caused ing spontaneously, administer supplemen- him to lose consciousness. The water’s cur- tal oxygen by mask. (An endotracheal rent pulled him further out into the lake, tube is necessary if the patient isn’t breath- where the Stevensons found him floating. ing spontaneously.) Manage his hypoxia But thanks to the quick thinking and ac- by ensuring an adequate airway, which tions of the Stevensons, he’s going to live to helps correct respiratory acidosis by im- tell another story about the big one that got proving ventilation and oxygenation. away! I Monitor his arterial blood gas (ABG) val- ues to evaluate oxygen, carbon dioxide, Learn more about it Smeltzer SC, et al. Brunner and Suddarth’s Textbook of and bicarbonate levels and pH. These pa- Medical-Surgical Nursing, 11th edition. Philadelphia, Pa., rameters determine the type of ventilatory Lippincott Williams & Wilkins, 2007:2536-2537.

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