A 17-year-old man is pulled from the bottom of a neighbor's swimming pool where he was submerged for an unknown period. Although initially pulseless and in respiratory arrest, his vital signs are now: heart rate 110/min; blood pressure 134/88 mm Hg; respiratory rate 4/min. His Glasgow Coma Score is eyes, 1; verbal, 1 (intubated); motor, 2. His pupils are fixed and dilated. You know that:
Aspirated water significantly interferes with successful ventilation from mechanical obstruction of airways.
Injuries of the cervical spine are uncommon.
A normal chest x-ray excludes significant lung abnormalities.
Application of the Heimlich maneuver will help evacuate his lungs of excess fluid.
Twenty percent of near-drowning patients who are comatose and flaccid with fixed and dilated pupils on arrival in the ED fully recover.
The appearance of a patient after a near-drowning accident cannot reliably predict the outcome. In particular, hypothermic near-drowning patients cannot be declared dead until their body temperature is at least 32.2°C (90°F). Not all patients require admission, but observation is indicated if there is any evidence of significant immersion or breathing abnormalities. Pulmonary complications may take several hours to evolve, and initial normal chest x-rays do not exclude the development of pulmonary edema or hypoxia. These delayed complications may account for past reports of a postimmersion syndrome and death following successful resuscitation. Cervical spine injuries should be suspected in every near-drowning patient. Burst fractures of C1 and injuries of the midcervical spine are common in diving accidents. Aspiration of large quantities of water is uncommon and no special efforts should be made to “pump out” excess water. However, aspiration of water and water-borne contaminants, with secondary loss of surfactant, inflammation, and neurogenic pulmonary edema, contributes to the respiratory insufficiency seen in near-drowning patients. Resuscitative efforts follow standard guidelines in near-drowning patients, with consideration of possible hypothermia and occult cervical trauma or intoxication.