666
RESUSCITATION
AND
TREATMENT
FOLLOWING
SUBMERSION
Joseph S. Redding, M.D.
Department of Anesthesiology, Baltimore City Hospitals, Baltimore, Maryland
INTRODUCTORY Nom : We haee asked Doctor Redding to prepare a brief paper for this month’s Diagnosir and Treatment pages, on the sublect rceiewed in extenso
by Doctors lniburg and Hartney on pages 684-6.98. We iio;e the two contribu-tions together may improve understanding and management of an unfortunately commn condition not always receiving optimal therapy.
T
lIE physiology of non-fatal submersionand its treatment are the subjects of an
extensive review elsewhere in this issue.1 In
response to the Editor’s invitation to
con-sider therapy in brief form for the
Dktg-nosis and Treatment series, I thus need not
refer further to experimental studies but
can proceed at once to presenting an
ap-proach to treatment which has proved
ef-fective in clinical situations in our own ex-perience and that of others.
FIRST AID
It must be remembered that the apparent
duration of submersion is an unreliable
guide to the physiological state of the
vie-tim. As 500fl as a victim is removed from
the water, breathing movements should be
checked. If breathing movements and
coughing are noted, it is likely that hypoxic
damage is slight and that little water has
been aspirated. If no cyanosis is observed
and the patient is conscious he should be
transported to a hospital for physical
ex-amination, chest x-ray, and examination of
blood and urine.
If there are no breathing movements,
time must not be wasted. No attempt
should be made to drain the lungs. The
pharynx should quickly be cleared by the
rescuer’s fingers and exhaled air
resuscita-tion started immediately. Immediately after
the first successful lung inflation, the pulse
in the carotid artery should be checked. If
it is not palpable, closed chest cardiac
mas-sage must be started and continued along
with artificial ventilation of the lungs.
Posi-tive pressure breathing with oxygen should
be substituted for exhaled air as soon as
equipment is available. Both artificial
res-piration and closed chest cardiac massage
must be continued during transportation to
a hospital. Closed chest cardiac massage may be discontinued if there is return of a
palpable spontaneous pulse in the caroti(l
artery. In victims of submersion who have been apneic, positive pressure ventilation
of the lungs should not be discontinued
even if spontaneous breathilig movements
return. In this event, the victim’s inspira-tory efforts should be assisted with positive pressure oxygen.
DEFINITIVE TREATMENT
In the hospital, if a spontaneous pulse is
still not palpable, 1 mg of epinephrine
should be injected into a cardiac ventricle
and artificial respiration and closed chest
cardiac massage continued while
electro-cardiographic examination indicates the
presence or absence of ventricular fibrilla-tion.
It has been our practice to use a dose of
1 mg of epinephrine by intracardiac
injec-tion in all adults and children as young as
18 months of age. The dose should be
re-duced for younger children.
If ventricular fibrillation is present, exter-ADDRESS: 4240 Eastern Avenue, Baltimore, Maryland 21224.
ARTICLES 667
nal electrical defibrillation should be accom-plished. Intracardiac injection of
epineph-rifle may be repeated as needed until
spon-taneous circulation is restored. Every effort
should be made to augment venous return
to the heart during the period of cardiac
ar-rest by elevation of the patient’s legs and
rapid intravenous infusion of fluids.
Following restoration of spontaneous
cir-culation, the patient’s plasma and urine
should be examined, a chest x-ray should
be taken, and an adequate physical
exam-ination should be performed.
If a serious degree of hemolysis has
oc-curred in victims of fresh water
submer-sion, partial exchange transfusion must be considered. Fluid intake must be regulated
to promote urinary output and the
compli-cations of aspiration and pulmonary edema
must be treated.
In cases of sea water submersion,
posi-tive pressure ventilation of the lungs with
oxygen must be continued until a blood
specimen has been checked for hematocrit
and a chest x-ray examined. In the event
that the hematocrit is elevated or there is
x-ray evidence of aspiration or pulmonary
edema, plasma should be given
intraven-ously until the hematocrit is normal. Only
when the lung fields are clear and the
hematocrit is normal should positive pres-sure breathing be discontinued.
In those patients who are known to have
aspirated, appropriate steroid and
antibi-otic therapy should be given, and the lungs
should be examined frequently for several days.
Tracheal intubation or tracheotomy will
facilitate prolonged positive pressure
breathing and removal of secretions. This
should be attempted only by physicians
skilled in these procedures.
Severe metabolic acidosis occurs during
Management of a patient following
re-suscitation from circulatory arrest requires a great deal of attention to the many facets
of comatose patient care. Often the
pa-tient’s reflexes are absent and the vital
functions of respiration and circulation are
in precarious condition requiring constant
support. Obviously it is necessary to
con-tinue artificial respiration in those victims who are not able to breathe for themselves.
Even in those in whom spontaneous
respi-ration returns it is desirable to continue
artificial ventilation, since the degree of
dilatation of the cerebral vasculature
de-pends upon the tension of carbon dioxide
in the arterial blood. Initially, passive
hy-perventilation is usually accomplished
through an endotracheal tube, to prevent
gastric distention and to minimize leakage
of air. If the clinical situation indicates the likelihood that artificial ventilation will be
prolonged beyond 24 to 48 hours, the
endo-tracheal tube should be replaced by a
tra-cheostomy. In either case, constant
atten-tion is necessary to humidification of the
inhaled gases, asepsis during suctioning of
secretions, artificial coughing and sighing,
and frequent changes in the position of the
patient.
Since oxygen consumption and carbon
dioxide production are reduced at low
body temperatures, it is desirable to cool
the patient to about 32#{176}Cbody tempera-ture. During the process of cooling,
shiver-ing must be prevented since this will lead
to increased carbon dioxide production.
Cerebral edema often follows periods of
asphyxia and circulatory arrest. The
result-ing increase in intracranial pressure leads to
further death of cellular substance in the
central nervous system. In addition to
res-piratory alkalalosis achieved by passive
668 SUBMERSION effort. The earlier reflex activity returns,
the more likely is the patient to recover
fully. In addition, steadily progressive
light-ening of consciousness is encouraging
corn-pared to those patients who show
improve-ment followed by plateaus during which no
progress is observed. Progressive
constric-tion of the pupils is an encouraging
prog-nostic sign. Electroencephalographic
ex-amination may reveal evidence of obtunded
cerebral activity or progressively returning function.
SUMMARY
In resuscitation from drowning it must
be remembered that when breathing
move-ments are absent no time must be wasted
in attempts to drain the lungs.
Reoxygena-tion must be started immediately with
ex-haled air. Positive pressure ventilation with
oxygen should be substituted as soon as
possible. It should be continued in victims
of sea water submersion until a blood
specimen can be examined and any plasma
deficiency corrected. In fresh water drown-ing, intermittent positive pressure
ventila-tion combined with closed chest cardiac
massage is a preliminary to external
elec-trical defibrillation. Prevention of delayed
death depends upon the management of
massive hemolysis, hypervolemia,
electro-lyte imbalances, aspiration pneumonitis,
and myocardial failure.
REFERENCE
1. Imburg, J., and Hartney, T. C. : Drowning and the treatment of non-fatal submersion. I. Drowning and non-fatal submersion labara-tory studies and human data. PEDIATRICS,
