ED/ICU CARE

INITIAL ER ASSESSMENT AND INTERVENTIONS

Upon arrival to the Emergency Room (ER), rapidly evaluate the patient and rule out traumatic injury. Perform primary (ABCDE) and secondary assessment with specific focus on the following: secure airway, provide adequate oxygenation, ensure hemodynamic stability, gastric decompression, thermal insulation, and identifying concomitant traumatic injury. 10,11,19,22 Following initial ER resuscitation, specific systems-based interventions may be applied as noted in the ICU Management section. Additional immediate interventions below (does not substitute for ER standards of care):

- Chest X-Ray – regardless of patient’s clinical appearance. Used to establish a baseline.
- Electrocardiogram (EKG)
- Volume resuscitation as appropriate for hemodynamic support. Urinary catheter placement. Invasive monitoring (e.g., arterial line) and central access at the discretion of the treating physician.
- CT head and neck is recommended in the persistently unconscious patient to look for evidence of traumatic injury.
- It is important to note, that in the military setting, particularly during combat or other high risk military operations to look for and rule out traumatic injury and hemorrhage in patients with suspected drowning and hypotension. At a minimum an ultrasound FAST (Focused Assessment Sonography for Trauma) should be performed in all drowning victims without evidence of trauma. In unconscious patients, in addition to a CT head and neck, perform a pelvic X-ray as pelvic fracture can be a significant source of bleeding. In drowning victims with persistent hypotension without evidence of trauma, CT torso (chest, abdomen, and pelvis) should be performed to rule out solid organ injury, retroperitoneal bleeding or other occult traumatic injury.

#### LABS

- Arterial/venous blood gas
- Complete blood count
- Comprehensive metabolic panel
- Glucose
- Troponin I
- Prothrombin time/ partial thromboplastin time
- Urinalysis
- Creatine Kinase
- Urine myoglobin
- Urine drug screen
- Blood alcohol

ER DISPOSITION

Once the patient is stabilized from a respiratory and hemodynamic standpoint, disposition should be determined. Figure 1 below helps to establish guidelines for ICU admission versus observation and safe discharge based drowning mortality risk and drowning grade (Table 3).

Patients with a Grade 2 or lower may safely be observed either in the ER or non-intensive care inpatient observation for 4-6 hours.1

- Patients are responsive to verbal and tactile stimuli (GCS >13).
- May have cough or rales on pulmonary evaluation.
- Able to maintain oxygenation with low-flow oxygen (typically 2L by nasal canula).

Patients with Grades 3-6 should be admitted to the ICU.1

- Unresponsive patients
- Patients with significant pulmonary edema or respiratory failure
- Patients in shock (hypotension or poor perfusion shown by capillary refill, elevated lactate, organ failure)

Appropriate consults should be made at this time and may include critical care (medical and neurological), cardiology, psychology.

Table 3. Drowning Severity Grades
Figure 1. Drowning Disposition and Treatment