Near-drownings

Near drowning is defined as almost dying from suffocating under water. It is common in children under the age of four and teenagers. Near drowning can cause lung damage and hypoxia; and it may lead to hypoxic encephalopathy. Serious complications include volume shift, electrolyte abnormalities, circulation compromise, hemolysis, rhabdomyolysis, renal failure, and DIC.



Physical examination:

· Monitor vital signs closely, especially for hypotension and hypothermia
· Lungs: RALES (indicates ARDS or pulmonary edema) and DECREASED BREATH SOUNDS (pneumothorax)
· CVS: murmurs, arrhythmia, raised JVP (CHF or pneumothorax)
· Assess for C spine injuries
· Neuro: GCS or AVPU, pupils, focal deficits

Investigations:

· Oxygen saturation
· Bloods: CBC, electrolytes, ABG, creatinine/BUN
· Urinalysis
· ECG
· CXR and cervical spine X-ray

Management:
· DRABC
     o Secure airway and intubate—high flow O2/BiPAP/CPAP ventilation may be adequate but some        may need mechanical ventilation with Positive End-Expiratory Pressure. Pulmonary toilet may be necessary.
     o Always initiate CPR even if patient is hypothermic
     o IV replacement of fluids if hypotension
· Treat underlying trauma, shock, hypothermia
· Control symptoms
    o Bronchodilators for bronchospasms
    o Dysrhythmia usually goes away after correcting hypoxemia, hypothermia, and acidosis
    o O2 or diazepam for convulsions
    o NG tube/suction to avoid aspiration in vomiting

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Bites

I grew up in Australia, home to some of the most poisonous animals; we have poisonous snakes, spiders, jellyfish, octopi, and even the cute looking platypus! Not all bites from venomous animals need anti-venom, and not all bites from nonvenomous animals are innocent. Below are some general guidelines:

·      Take a detailed history

o   Time and circumstances of bite

o   What animal? Some patients keep specimen or photos

o   Symptoms relating to bite

o   Allergies

o   Tetanus immunization status

o   Rabies risk?

o   HIV/hepatitis risk (human bite)

·      Do a thorough physical examination

o   Type of wound: abrasion, laceration, puncture, crush injury

o   Assess for direct tissue damage: skin, bone, tendon, neurovascular status

·      Investigations

o   Bloods: CBC, electrolytes, creatine kinase, coagulation studies, renal function tests, ABG

o   Urine: myoglobin or blood

o   ECG

o   X-rays—check for bony injury or gas in tissue (infection)

o   CT Skull in children with scalp bite wounds to rule out cranial perforation

·      Management

o   DRABC

o   Address anaphylactic shock if applicable

§  Epinephrine (IV over 5 min)

§  Beta-agonist bronchodilator

§  Antihistamines

§  Cimetidine IV/IM/PO

§  Steroids

o   Wound cleansing and copious irrigation

o   Debridement if necessary

o   Swab and culture if there are signs of infection

o   Prophylactic antibiotics (amoxicillin + clavulinic acid 3~5 days) is recommended to all bite wounds to the hand

o   Vascular structures (face/scalp) are less likely to become infected and can be sutured; avascular structures (pretibial regions/hands/feet) are not to be sutured—allow healing by secondary intention

o   Tetanus shot

o   Immunoglobulin therapy for rabies if applicable

For snakebites, consult Provincial Poison Information Center. If envenomation present, administer anti-venom as directed. For Massasauga Rattle Snake ONLY: if not serious tissue damage AND INR is normal six hours after bite, the patient can be discharged.

As usual, your contribution is welcomed in the comments section. This blog post is available in podcast form. Look for "Med On The Go" in iTunes, Googleplay, or Podbean. www.medonthego.podbean.com