Near-Drowning — MCQs
In an accident case, after the arrival of medical team, all should be done in early management except;
Diagnostic of antemortem drowning:
What is the definition of dry drowning?
Hypothermia is used in all except:
The dead body of a 20 year old man found in the sea was brought in for postmortem examination. Which of the following findings would you see in seawater drowning? 1. Hemoconcentration 2. Pulmonary edema 3. Hyponatremia 4. Hypernatremia 5. Hemolysis
Immersion syndrome is also known as?
Hydrocution is:
What is the best indicator of antemortem drowning?
The first and the most important measure in the management of a severely injured patient is to:
A patient presents with a gunshot wound on 4th intercostal space producing pneumothorax. The suction pressure needed for drainage is
Near-Drowning Indian Medical PG Practice Questions and MCQs
Question 1: In an accident case, after the arrival of medical team, all should be done in early management except;
- A. Glasgow coma scale
- B. Check BP (Correct Answer)
- C. Stabilization of cervical vertebrae
- D. Check Respiration
Explanation: ***Check BP*** - In the **immediate/early management** of trauma (primary survey), while circulation assessment is crucial, the **initial assessment of circulation** focuses on: - **Pulse rate and quality** (radial, carotid) - **Capillary refill time** - **Skin color and temperature** - **Active hemorrhage control** - **Formal blood pressure measurement** with a cuff, while important, is typically recorded during or after these rapid initial assessments, as it takes more time to obtain an accurate reading. - In the context of this question, among the four options listed, BP measurement is relatively less immediate compared to the other life-saving priorities (airway protection, breathing assessment, C-spine stabilization, and GCS). - **Note:** This is a nuanced distinction - BP is assessed during primary survey, but the other three options have more immediate life-threatening implications if not addressed. *Glasgow coma scale* - **GCS assessment** is part of the **"D" (Disability)** step in the ATLS primary survey. - It is performed early to assess neurological status and level of consciousness. - GCS <8 indicates need for **definitive airway protection** (intubation). - This is a critical early assessment that guides immediate management decisions. *Stabilization of cervical vertebrae* - **C-spine immobilization** is part of the **"A" (Airway)** step - "Airway with cervical spine protection." - It is performed **simultaneously** with airway assessment using a **rigid cervical collar**. - This is the **first priority** in trauma management to prevent secondary spinal cord injury. - All trauma patients should be assumed to have C-spine injury until proven otherwise. *Check Respiration* - **Respiratory assessment** is part of the **"B" (Breathing)** step in the ATLS primary survey. - This involves checking: - **Respiratory rate and pattern** - **Chest wall movement** - **Air entry bilaterally** - **Signs of tension pneumothorax or flail chest** - This is an immediate life-saving priority and must be assessed early.
Question 2: Diagnostic of antemortem drowning:
- A. Emphysema aquosum
- B. Paltaufs hemorrhage
- C. Water in esophagus
- D. Presence of foreign material in clenched hands (Correct Answer)
Explanation: ***Presence of foreign material in clenched hands.*** - The presence of **foreign material** (such as weeds, sand, or gravel) in the **clenched hands** of a drowned victim suggests a struggle for survival while alive in the water. - This finding is strong evidence of **vital reaction**, indicating the individual was alive and actively struggling during submergence, making it highly indicative of antemortem drowning. *Emphysema aquosum* - Refers to **overinflation of the lungs** and is a common finding in drowning, resulting from fluid aspiration and spasmodic respiratory efforts. - While supportive of drowning, it can also be seen in other forms of **asphyxia** and is not specific enough to definitively diagnose antemortem drowning versus postmortem immersion. *Paltaufs hemorrhage* - Describes **subpleural hemorrhages** found on the lungs, often seen in cases of drowning. - These hemorrhages are a non-specific sign and can be present in other causes of death involving **venous congestion** or **asphyxia**, thus not definitive for antemortem drowning. *Water in esophagus* - While the aspiration of water is a hallmark of drowning, finding water in the **esophagus** (and stomach) can occur in both antemortem and **postmortem immersion**. - This finding alone does not reliably distinguish between someone who was alive and swallowed water during drowning versus someone who was dead and immersed in water.
Question 3: What is the definition of dry drowning?
- A. Drowning in salt water
- B. Drowning with minimal water aspiration
- C. Drowning due to laryngospasm (Correct Answer)
- D. Drowning in cold water with hypothermia
Explanation: ***Drowning due to laryngospasm*** - **Dry drowning** specifically refers to drowning events where there is little to no water found in the lungs, typically due to **laryngospasm**. - This reflex closure of the vocal cords prevents water from entering the trachea and lungs, leading to **asphyxia**. *Drowning in salt water* - This describes the **type of water** involved in the drowning, not a specific physiological mechanism like "dry drowning." - **Saltwater drowning** can cause acute respiratory distress syndrome (ARDS) and pulmonary edema due to osmotic shifts. *Drowning with minimal water aspiration* - While dry drowning involves minimal water aspiration, this choice is less precise as the **cause** of the minimal aspiration is the crucial factor. - The mechanism distinguishing dry drowning is the **laryngospasm**, not just the amount of aspirated water. *Drowning in cold water with hypothermia* - This scenario describes **cold-water immersion** complications, which can include hypothermia and a preserved diving reflex. - While it has distinct physiological effects, it is not the definition of **dry drowning** but rather a broader category of drowning incidents.
Question 4: Hypothermia is used in all except:
- A. Hyperthermia
- B. Arrhythmia (Correct Answer)
- C. Neonatal asphyxia
- D. Cardiac surgery
Explanation: ***Arrhythmia*** - While sometimes used in specific cardiac procedures or to protect organs during cardioplegia, **therapeutic hypothermia** is not a primary treatment for general cardiac arrhythmias due to its potential to exacerbate certain rhythm disturbances. - **Hypothermia** can paradoxically induce **arrhythmias** itself, particularly bradycardia and ventricular fibrillation, making it unsuitable for general arrhythmia management [1]. *Hyperthermia* - **Therapeutic hypothermia** is used to reduce high body temperatures in conditions like **malignant hyperthermia** and **heatstroke** to prevent organ damage [2]. - By actively cooling the body, hypothermia counteracts the harmful effects of sustained, extreme elevations in body temperature. *Neonatal asphyxia* - **Therapeutic hypothermia** is a standard treatment for **neonatal hypoxic-ischemic encephalopathy** (HIE) to reduce brain injury. - Cooling the infant's body temperature helps to slow down damaging metabolic processes after oxygen deprivation. *Cardiac surgery* - **Hypothermia** is commonly employed during **cardiac surgery** to protect organs, especially the brain and heart, from ischemia during periods of reduced blood flow. - **Moderate to deep hypothermia** can significantly reduce metabolic demands, extending the safe duration of cardiopulmonary bypass and aortic cross-clamping [3].
Question 5: The dead body of a 20 year old man found in the sea was brought in for postmortem examination. Which of the following findings would you see in seawater drowning? 1. Hemoconcentration 2. Pulmonary edema 3. Hyponatremia 4. Hypernatremia 5. Hemolysis
- A. 2,4 and 5
- B. 2,3 and 5
- C. 1 and 3
- D. 1 and 4 (Correct Answer)
Explanation: ***1 and 4*** - In **seawater drowning**, the hypertonic seawater (3-4% salt) creates an osmotic gradient that pulls plasma fluid from the blood into the alveoli, leading to **hemoconcentration**. - The absorption of hypertonic seawater into the bloodstream results in **hypernatremia** and hyperchloremia. - These are the characteristic electrolyte and hematologic findings specific to seawater drowning. *2, 4 and 5* - While **hypernatremia** is correct, this option incorrectly includes **pulmonary edema** (which is non-specific to drowning type) and **hemolysis** (which is characteristic of freshwater drowning, not seawater). - **Hemolysis** occurs in freshwater drowning when hypotonic water enters the bloodstream, causing red blood cells to swell and lyse. *2, 3 and 5* - This option is incorrect as it includes findings characteristic of **freshwater drowning**: **hyponatremia** and **hemolysis**. - In freshwater drowning, hypotonic water absorption causes hemodilution (not hemoconcentration), leading to hyponatremia and hemolysis. - **Pulmonary edema** is present in both types but does not differentiate between them. *1 and 3* - While **hemoconcentration** is correct for seawater drowning, **hyponatremia** is incorrect. - Hyponatremia is a feature of freshwater drowning due to dilution of serum sodium by absorbed hypotonic water.
Question 6: Immersion syndrome is also known as?
- A. Hydrocution (Correct Answer)
- B. Wet drowning
- C. Dry drowning
- D. Secondary drowning
Explanation: ***Hydrocution*** - **Immersion syndrome**, or hydrocution, is a sudden death that occurs immediately upon immersion in cold water. - It is believed to be caused by a **vasovagal reflex** triggered by the sudden temperature change, leading to cardiac arrest. *Wet drowning* - This term refers to conventional drowning where an individual inhales water, leading to respiratory compromise and death. - It is characterized by the presence of **fluid in the lungs**, which is not the primary mechanism in immersion syndrome. *Dry drowning* - **Dry drowning** occurs when water does not enter the lungs; instead, the glottis spasms and closes, preventing air and water from entering. - This leads to suffocation, often hours after the initial water exposure, and is distinct from the immediate cardiac event of immersion syndrome. *Secondary drowning* - **Secondary drowning**, or delayed drowning, refers to complications that arise hours or days after a near-drowning incident due to inhaled water causing pulmonary edema. - It involves a delayed physiological response rather than an immediate reflex.
Question 7: Hydrocution is:
- A. Wet drowning
- B. Near drowning
- C. Dry drowning
- D. Immersion syndrome (Correct Answer)
Explanation: ***Immersion syndrome*** - **Hydrocution**, also known as **immersion syndrome**, refers to sudden death that occurs immediately upon immersion in cold water. - It is typically caused by a sudden **vagal nerve reflex** leading to **bradycardia** and **asystole** due to the sudden temperature change and not necessarily due to aspiration of water. *Wet drowning* - **Wet drowning** involves the aspiration of fluid into the lungs, leading to respiratory compromise and subsequent death. - This is not the primary mechanism of death in hydrocution, which is typically a reflex cardiac arrest. *Near drowning* - **Near drowning** refers to survival, at least temporarily, after an immersion incident, regardless of whether aspiration occurred. - Hydrocution results in immediate death, thus it is not considered near drowning. *Dry drowning* - **Dry drowning** occurs when the glottis spasms and prevents water from entering the lungs, leading to asphyxia. - While aspiration of water does not occur, the mechanism differs from hydrocution where death is due to a vagal reflex affecting the heart.
Question 8: What is the best indicator of antemortem drowning?
- A. Presence of froth in nostrils (Correct Answer)
- B. Cutis anserina (gooseflesh)
- C. Washerwoman's hand (skin changes)
- D. Presence of water in stomach
Explanation: ***Presence of froth in nostrils*** - The presence of **fine, white, stable froth** (often referred to as **"mushroom-like" froth**) at the mouth and nostrils is a strong indicator of antemortem (before death) drowning. - This froth is formed by the mixing of air, water, and pulmonary surfactant as the victim struggles to breathe, and it is stable due to the presence of surfactant. *Cutis anserina (gooseflesh)* - **Cutis anserina** results from the contraction of the arrectores pilorum muscles due to cold water or fear, creating goosebumps. - While it can be seen in drowning victims, it is a **non-specific sign** and can occur postmortem as well, making it unreliable for determining antemortem drowning. *Washerwoman's hand (skin changes)* - **Washerwoman's hand** refers to the wrinkling and pallor of the skin of the palms and soles, which occurs due to prolonged immersion in water. - This is a postmortem change and indicates that the body was in water for an extended period, but it does **not provide direct evidence** of drowning as the cause of death. *Presence of water in stomach* - The presence of water in the stomach is an **unreliable indicator** of antemortem drowning. - Water can be swallowed involuntarily during the drowning process, but it can also be present due to drinking water before death or even postmortem influx.
Question 9: The first and the most important measure in the management of a severely injured patient is to:
- A. Splinting fractures
- B. Arrest bleeding
- C. Start I.V. fluids
- D. To maintain airway (Correct Answer)
Explanation: ***To maintain airway*** - Establishing a **patent airway** is the absolute first step in managing any severely injured patient, as **airway compromise** can rapidly lead to hypoxia and death. - The ABCDE (Airway, Breathing, Circulation, Disability, Exposure) approach to trauma prioritizes **airway management** immediately to ensure oxygenation. *Splinting fractures* - While important for pain control and preventing further injury, **splinting fractures** is not the immediate priority over securing an airway. - This intervention falls under the 'D' (disability) or 'E' (exposure) in the primary survey of trauma care. *Arrest bleeding* - **Controlling severe external bleeding** is critical, but only after an **airway has been secured** and any immediate life-threatening breathing problems addressed. - Uncontrolled hemorrhage is a major cause of preventable death in trauma, but **airway patency** precedes it as per trauma protocols. *Start I.V. fluids* - Initiating **intravenous fluids** is crucial for resuscitating patients in shock due to blood loss. - However, it comes after ensuring a **patent airway** and adequate breathing, as per the ATLS guidelines for trauma management.
Question 10: A patient presents with a gunshot wound on 4th intercostal space producing pneumothorax. The suction pressure needed for drainage is
- A. 10 cm H2O
- B. 50 cm H2O
- C. Less than 5 cm H2O
- D. 20 cm H2O (Correct Answer)
Explanation: **20 cm H2O** - A suction pressure of **-20 cm H2O (or -2 kPa)** is the standard recommended setting for a chest tube connected to wall suction in cases of pneumothorax. - This pressure provides sufficient negative pressure to evacuate air and fluid while minimizing the risk of lung injury or excessive suction. *10 cm H2O* - While sometimes used, **-10 cm H2O** may not be sufficient for effective re-expansion of the lung, especially in a traumatic pneumothorax where the leak might be significant. - It might be considered for a very small or resolving pneumothorax, but less common for acute trauma. *50 cm H2O* - This pressure level is **excessively high** and carries a significant risk of causing lung damage, such as inducing a **bronchopleural fistula** or exacerbating an existing one. - High suction can also lead to rapid re-expansion pulmonary edema. *Less than 5 cm H2O* - Such **low suction pressure** is generally considered inadequate for actively draining a pneumothorax and promoting lung re-expansion. - This level of suction might only be appropriate for a spontaneous, very small pneumothorax or when simply maintaining patency of a tube with one-way valve drainage.
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