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Definition

A disorder characterized by hypoxemia, with or without aspiration, following submersion in fresh or salt water.

History

Symptoms: Alteration in mental status, tachypnea, wheezing, cyanosis, hypothermia, laryngospasm.

General: Prolonged submersion in fresh or salt water is frequentlY associated with motor or recreational vehicles, boating, or shallow water diving accidents. Water entering the upper airway results in laryngospasm. Ten to twenty percent of near-drowning episodes occur without direct aspiration, but present with hypoxemia on the basis of persistent laryngospasm. In aspiration events, the extent of injury is dependent on the amount of water inhaled.

Age: Any, but primarily in the first or second decades. Incidence of 90,000/yr with a 5 to 1 male to female ratio.

Onset: Rapid.

Duration: Postimmersion symptoms may occur 24 to 48 hours after the event.

Intensity: Varies from patients who are awake and alert to those who are comatose with severe cardiopulmonary dysfunction.

Aggravating Factors: Co-existant multi system trauma (e.g., spinal cord injury).

Alleviating Factors: Early intervention, correction of hypoxia.

Associated Factors: Often occurs in the setting of multi system trauma. Cervical spine injuries may be present (e.g., diving injuries). Substance abuse or child abuse are frequently encountered.

Physical Examination

General: Patient presentations range along a continuum from mild respiratory and cardiovascular sequelae to cardiovascular arrest and coma. Core body temperature is recorded to evaluate for hypothermia.

Cardiovascular: The patient may experience cardiac arrest due to prolonged hypoxemia.

Neurologic: Mental status changes (e.g., confusion, lethargy) due to hypoxemia or direct neurologic trauma (e.g., head or spinal cord injuries) may be present. Definitive mental status evaluation should be performed after hypothermia is corrected. Cervical spine should be palpated for tenderness in diving injuries to evaluate for potential injury.

Pulmonary: Persistent laryngospasm is a common occurrence and must be ruled out by careful airway inspection in the immediate resuscitative period. Auscultation may reveal wheezirig, rales, or rhonchii. Tachypnea and cyanosis are common. Symptoms consistent with pulmonary edema.

Pathophysiology

Laryngospasm is due to water entering the upper airway. Eighty to ninety percent of near drowning episodes are associated with aspiration. The extent of pulmonary injury is dependent on the amount of water aspirated.

Diagnostic Studies

Laboratory

Electrolytes: Usually show minor changes in serum sodium and chloride regardless of the salt content of the water aspirated.

Arterial blood gasses: A profound metabolic acidosis is common as is hypoxia and hypercarbia. Serial arterial blood gasses are utilized to assess the adequacy of airway and ventilatory support.

Toxicology screen: For ETOH and drugs. Frequently associated with near-drowning episodes, especially those occurring with alterations in neurologic function.

Radiology

Chest x-ray: Consistent with non cardiac pulmonary edema.

Cervical spine radiographs: If the patient was diving, to rule out fracture.

Skeletal survey: Indicated if multiple trauma suspected.

Abdominal radiographs: May show gastric dilitation.

Other

ECG: May show supraventricular tachycardia due to hypoxia, acidosis, or cardiac arrest.

Differential Diagnosis

As near drowning is due to an acute, traumatic event, the concept of differential diagnosis does not apply.

Treatment

Inspect the upper airway to rule out laryngospasm. Maintain an adequate airway, with intubation if necessary, especially if the signs of hypoxemia are present. Maintenance of the airway will reduce the likelihood of gastric dilitation or aspiration of gastric contents. Intubated patients should be placed on an FIO2 of 100 percent. Positive end expiratory pressure ventilation may be required to ensure adequate gas exchange. Nasogastric tube (on low intermittent suction) may be placed to decompress gastric dilitation and to prevent aspiration of gastric contents. Cardiac monitoring and appropriate cardiac support are indicated, in accordance with the Advanced Cardiac Life Support guidelines.

Hypothermia can occur with even brief periods of immersion. It is treated with warmed intravenous solutions and oxygen. Core body temperature must be monitored.

Pediatric Considerations

The diving reflex, manifested by slowed heart rate, shunting of blood preferentially to the brain and heart in response to cold water submersion, is more prominent in the young patient. Patient survival has been documented with submersions of up to 40 minutes. Resuscitative measures should be aggressively attempted despite an initially bleak presentation.

Obstetrical Considerations

No specific indications.

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Acupressure is an ancient healing art of traditional Chinese medicine that uses finger pressure on key points (called acupoints) on the surface of the skin to stimulate the body’s natural self-curative abilities. It’s considered a form of massage therapy or bodywork. In acupressure, local symptoms are considered an expression of the condition of the body as a whole (mind, body, and spirit). Acupressure sessions focus not only on relieving discomfort, but also on reducing tensions and toxicities in the body before they develop into an illness. More than 5,000 years ago, the Chinese discovered that pressing certain points on the body relieved pain where it occurred and also benefited other parts of the body remote from the pain and the pressure point. They also found other points that not only alleviated pain but also influenced the functioning of certain internal organs. The distinction between acupuncture and acupressure (the older of the two techniques) is that needles are used in acupuncture, whereas a firm but gentle pressure of the hands is the basis for acupressure.

The purpose of acupressure is to relax muscular tension and balance the vital energy forces of the body through channels or meridians. The twelve meridians are pathways along the body associated with different internal organs. In theory, obstruction in a meridian causes the energy to flow more slowly, or even stop, resulting in a malfunction or dysfunction in the organ associated with that meridian. Each point along the meridian has a specific purpose and is used for specific health problems. Each point can also be used to help form a diagnosis. Theoretically, a stomach problem arises if an obstruction in the stomach meridian slows down the flow of energy. If the obstruction is removed or dissolved, the energy flow becomes regular and the stomach function returns. However, even though it may be the stomach meridian that is blocked, other areas of the body may also be affected because everything in the body interrelates.

Acupoints are places on the skin that are especially sensitive to bioelectric impulses in the body and conduct these impulses readily. The points follow the body’s meridians. Stimulating these points with pressure (or heat or needles) triggers the release of endorphins, the neurochemicals that relieve pain. As a result, the flow of blood and oxygen to the affected area is increased and pain is blocked. Tension tends to concentrate around points. When a muscle is chronically tense or in spasm, the muscle fibers contract due to the secretion of lactic acid caused by fatigue, trauma, stress, chemical imbalance, or poor circulation. As a point is pressed, the muscle tension yields to the finger pressure, enabling the fibers to elongate and relax, blood to flow freely, and toxins to be released and eliminated.

In addition to manipulation of acupoints, a skilled therapist reviews the whole person, taking into account facial and tongue diagnosis, energy pulses, and symptoms, both physical and spiritual. The concepts underlying traditional Chinese medicine and acupressure are qi (vital energy), yin and yang, the five element theory, and the zang-fu organ system.

Everything in the universe is composed of and defined by qi, sometimes called chi or ki (all pronounced chee). Qi, or vital energy, is said to be the basis of life; this concept is a fundamental belief in traditional Chinese medicine. In the human body, the original qi is transmitted from parents to children at conception and is stored in the kidneys. Grain qi is derived from the digestion of food. The lungs extract natural air qi from inhaled air. It all comes together to produce normal qi that permeates the entire body.

The concept of yin and yang holds that everything in nature has two opposite aspects. The opposition of yin and yang is reflected mainly in their ability to control each other. Warmth and heat (yang) may dispel cold, while coolness and cold (yin) may lower a high temperature. Under normal conditions in the human body, a relative physiologic balance is maintained through the mutual opposition of yin and yang. If an excess or deficiency of either yin or yang occurs, the physiologic balance of the body is affected and illness develops.

In the five element theory, each of the internal organs is linked to one of the five elements in the natural world, namely wood, fire, earth, metal, and water. For example, the heart is linked to fire. Classification according to these elements explains both physiologic and pathologic phenomena and guides clinical diagnosis and treatment. For example, a person with a red complexion accompanied by a bitter taste in the mouth suggests an excess of heart (fire) that must be reduced.

All five elements must exist in balance in the body. If one element predominates, the others will become unbalanced and illness will result.

In the zang-fu organ system, the main physiologic functions of the zang organs heart, lungs, spleen, liver, kidneys, and pericardium are the manufacture and storage of essential substances. The fu organs including gallbladder, stomach, small intestine, large intestine, and bladder receive and digest food and transmit and excrete wastes. In the Chinese system, the organs are discussed always with reference to their functions and to their relationships with other organs and other parts of the body. There isn’t an exact correlate to the anatomy and physiology of Western medicine because of the way Chinese medicine developed over the centuries. The individual is viewed as a whole with interrelationships of the above concepts affecting health and illness.

Other forms of acupressure are do in, tsubo, and shiatsu. Do in is stretching and self massage of the acupoints to provide physical energy and mental relaxation. Tsubo, developed by K. Serizawa of Tokyo University, refers to keyacupoints (or tsubos)on the meridians where energy flow to the zang-fu organs tends to stagnate. Shiatsu, the Japanese version of acupressure, also incorporates some gentle manipulation and body stretches along with using the pressure points. Some Swedish massage therapists have also studied acupressure and incorporated it in their treatments.

Benefits And Uses of Acupressure

Acupressure is said to reduce tension, increase circulation, and enable the body to relax deeply. It’s reportedly effective in helping to relieve headache, eyestrain, sinus problems, neck pain, lower backache, arthritis, muscle ache, and fatigue. The treatment has also been reported to relieve ulcer pain, menstrual cramps, constipation, and indigestion.

Acupressure is also a useful self-help therapy and first-aid treatment; for example, it has been shown to reduce the frequency and severity of asthma attacks and promote more effective breathing. The Chinese have used acupressure as a beauty treatment for thousands of years; the points can be used to improve skin condition and tone and relax the facial muscles. By relaxing and toning the back muscles, acupressure makes the spinal adjustments in chiropractic treatment easier and more effective. The deep relaxation promoted by acupressure relieves anxiety and promotes restful sleep. By relieving stress, acupressure strengthens resistance to disease and promotes wellness.

How the treatment is performed?

Treatment is performed over light cotton clothing. The practitioner usually works on a mat on the floor, but may use a traditional massage table.

The practitioner uses the thumbs and fingers to press key points on the surface of the skin to locate the stagnation of meridian flow. Pressure is then used to remove the obstruction so that energy can flow as it should and the organ involved can resume its normal function. The pressure releases muscle tension, increases blood circulation, and promotes the function of qi (the body’s life force) to aid in healing. Often a point that initially feels sore will improve simply by pressing on it.

In shiatsu and tsubo, practitioners may also use their elbows, knees, and feet to reach the pressure points. Shiatsu also incorporates some stretching movements.

Side Effects of Acupressure

While shiatsu and tsubo carry little risk if performed correctly, some people object to the pressure. There can be moments where the pressure in a tender spot borders on pain, but this gives way to relief when the pressure is released.

Clinical considerations

• Acupressure should not be performed on a person who has just eaten or on anyone with a high fever.
• Pressure should not be applied to areas of inflammation or to wounds. Caution should be used with persons suffering from cancer or heart disease, pregnant women, and the elderly. Gentle pressing techniques can be used in place of the more vigorous ones.
• Certain points, such as LI 4, must not be used in pregnant women because stimulation of those points can cause premature contractions in the uterus.
• If pain occurs, the patient should ask the practitioner to adjust the pressure to a more comfortable level.
• With the self-massage of do in, the individual may tend to work too vigorously and not give the body time to adjust to the stretches.

Research summary

Studies suggest that sensory nerves are probably analogs of meridians because most acupoints are localized near nerve fibers. Pressure can induce a wide array of physiologic responses in nerve fibers and in nerve endings. Dishant Shah’s study suggests that some changes in the brain’s response to tactile stimuli can be caused by acupressure treatments (Shah, 1999).

Various studies have examined the effectiveness of acupressure in the treatment of morning sickness in pregnant women, post-surgical nausea and vomiting, headaches, motion sickness, backache, and so forth. Research results are mixed.

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