HEMOGLOBINURIA FROM NEAR-DROWNING

Current Concepts in the Pathophysiology and Management of Near-Drowning

Approximately 6,500 people drown in the United States each year. Nearly 50,000 of the estimated 500,000 annual near-drowning victims seek medical attention. Near-drowning is most common among children, young adults, blacks, males, and in the southern states. Risk factors for near-drowning include ethanol use, drugs, seizures, boating accidents, water sports, inadequate supervision of children, and voluntary hyperventilation. Alcohol use alone is associated with 37 to 47% of these cases. Although anoxia and hypothermia produce the major pathological changes associated with the morbidity of near-drowning, hypothermia may paradoxically exert a protective effect in some cases and is associated with most of the spectacular long term survivals. There is almost no difference in the clinical presentation of freshwater and saltwater near-drowning. Both situations often involve hypothermia, anoxic injury due to cardiac arrest, and the frequent progression to the adult respiratory distress syndrome. Basic principles of management include the immediate institution of cardiopulmonary resuscitation; aggressive rewarming, preferably with cardiopulmonary bypass; continuation of cardiopulmonary resuscitation at least until the patient has been effectively rewarmed; and appropriate supportive care if the patient develops the adult respiratory distress syndrome. Cerebral salvage techniques have not been proved to be beneficial in these patients.