PENANGANAN KORBAN

TENGGELAM

M. ZUL’IRFAN
 TENGGELAM (DRAWNING)
Menurut WHO, mendefinisikan tenggelam
sebagai proses mengalami penurunan
pernapasan dari terendam dalam cairan.
3
 EPIDEMIOLOGY
Age
• Toddler age <5 yr
•15-19 years old.

• Male predominant in All ages .

• Male/ Female
• 2:1 in toddlers 10:1 in teenager
 Relevant factors:
• Water Tonicity
• Time submersion
• Water Temperature
• symptoms associated injuries .
• Undetected primary cardiac
arrhythmia( long QT)
• Response to initial CPR
 Kejadian Tenggelam ….
PART 1
• Panik, Menahan
napas
• Reflex inspiratory →
aspirasi air dalam
jumlah kecil
• Involuntary
laryngospasm .
• Menelan air dalam
jumlah besar
• Laringospasm mereda
karena hipoxia
• Aspirasi ke paru-pru
PART 2
• P↘ saturasi
• P ↘ cardiac output
• Vasokonstriksi perifer yang
intens
• Hipotermi
• Bradicardi
• Circulatory arrest
• Extravascular fluid shifts,
diuresis
 aspiration
Laryngospasm of
aborted
water (90%)

Tenggelam Aspiration & Terelan

Laryngospasm air
anoxia, seizures
and death
Laryngospasm without
berulang aspiration (10%)

Stage I Stage II Stage III

(0-2 minutes) (1-2 minutes)
 Patofisiologi
 Asfiksia, hipoksemia,
hiperkarbia, &
asidosis metabolik
 Air tawar vs air garam
- sedikit perbedaan
(kecuali untuk
tenggelam dalam air
dengan kandungan
mineral yang sangat
tinggi, seperti Laut
Mati)
 Hipoxemia  Cardiac arrhythmias
 Penyumbatan  Hypoxic
saluran napas oleh encephalopathy
air dah partikel  Renal insufficiency
debris  Pulmonary injury
 Perubahan aktivitas  Global brain anoxia &
surfaktan potential diffuse
 Bronkospasme cerebral edema
 Peningkatan ruang
mati paru fisiologis
 Pathophysiology – Pulmonary Injury

• Aspiration as little as 1-3 cc/kg can cause

significant effect on gas exchange
– Increased permeability
– Exudation of proteinaceous material in alveoli
– Pulmonary edema
– decreased compliance

13
 Pathophysiology – fresh vs. salt
• Kedua-duanya mengganggu surfaktan
– Kerusakan membaran dasar alveoli  pulmonary
edema, ARDS
• Secara teoritis:
– Salt water: hypertonic pulmonary edema
– Fresh water: plasma hypervolemia, hyponatremia
• Humans (most aspirate 3-4cc/kg)
– Aspirate > 20cc/ kg Akan mulai terjadi perubahan
elektolit yang berarti
– Aspirate > 11cc/kg before fluid changes
14
 Pathophysiology

• Hasil autopsy forensik korban tenggelam

– Wet, heavy lungs
– Jumlah edema dan perdarahan paru yg bervariasi
– Kerusakan didnding alveoli
– >70% korban dgn aspirasi muntah, pasir, lumpur
dan debris air.
– Cerebral edema and diffuse neuronal injury
– Acute tubular necrosis

15
 Signs & Symptoms

• Alertness  agitation  coma

• Cyanosis, coughing & pink frothy sputum
(pulm edema)
• Tachypnea, tachycardia
• Low grade fever
• Rales, rhonchi & less often wheezes
• Cari tanda-tanda yang berhuhungan dengan
trauma kepala & leher 16
 PROGNOSIS

• Hasil yang lebih baik terkait dengan CPR dini

• C-spine protection
• Transport
– Continue effective CPR
– Establish airway
– Remove wet clothes
– Hospital evaluation

17
 LABS & TESTS
• EKG
• Min electrolyte changes – Sinus tach, non spec ST-
• Increase WBC segment & T-wave changes
– Resolved within hrs
• Hct & HgB normal initially
– Ominous- vent arrhythmias,
– Fresh water: Hct falls due to
complete heart block
hemolysis
• XRay
– Inc. in free HgB w/o a change
– May be nl initially
in Hct
– Patchy infiltrate
• DIC occasionally
– Pulm edema
• ABG – metabolic acidosis &
hypoxemia

18
Pertolongan korban
 Pre hospital treatment
• Careful search for pulses.

If pulses presented :
• Kompresi dada → mengantisipasi Sinus
bradikardia dan fibrilasi atrium
 Treatment

• Initial resuscitation:

• CPR
• air way should be clear

• Abdominal thrust should not be

used
• Cervical spine should be protected
Emergency unit management

• Korban sebaiknya di observasi 8-12

jam wallaupun mereka asymptomatic

• Pemantauan Serial berulang paru dan

penilaian neurologis.
• Chest X RAY
 Emergency unit management

Patients discharge after 8-12 hours if no

evidence of :

• significant injury
• bronchospasm
• tachypnea
• inadequate oxigenation
 KORBAN HARUS
DIRAWAT
• Supplement O2
• NaHCO3
• Diuretic for pulmonary edema .
• Broncodilators for brochospasme .
• Antibiotic for contaminated water.
• Anticonvolsion treatment for seizure
 Treatment

• Naso Gastric Tube

• ECG monitoring for diagnosis and
treatment of arrhythmia.
• Hypothermia treatment passive,active
• If a child is hypoglycemic 0/5-1g/kg
dextrose
 ETT is needed if…

1. Apnea ,cyanosis .
2. Hypoventilation.
3. Hemodynamic iNstability.
4. Protect air way in patient with
depressed Mental
 Treatment (cont)

• A few patients develop require

mechanical ventilation.
for at least 24-48 hours.

• evaluated of oxigenation with ABG

• Rewarming effort should be

continued until T is at least 32-
34c (passive, active)
• Pasien harus dievaluasi ketat terhadap
Status neurologis

• Pemeriksaan neurologis selama 24-72 jam

pertama adalah prognosis terbaik dari
kondisi CNS
 Prognosis

1.Overall about 75% of pediatric

submersion victims survive.

Good recovery did not occur in:

• Abnormal brainstem function
• Absence of purposeful movement at
24 hr
 Poor prognosis

1. Submersion duration>10 minute

2. Age <3 years
3. CPR>25minutes
4. patient core<T33c
5. GCS<5
6. persistent apnea that CPR is
need
 prognosis

• PH<7.1
• Water temperature <10 c
• Children who remain comatose
24 hr after initiating
resuscitation
 Treatment discontinue

• submersion victim in non-icy

water that remain systole
• despite 30-45 min of aggressive
CPR
SEKIAN.