Submersion injury

Background

• Defined as respiratory impairment from submersion in liquid (regardless of pt outcome)
• No significant clinical differences between fresh-water and salt-water injuries and no significant clinical differences between dry and wet drowning

Epidemiology

• Common in children <5yr, teenagers, and elderly

Pathophysiology

Submersion leads to panic which leads to voluntary breath holding followed by laryngospasm and then reflex inspiration which results in aspiration.

Clinical Features

History

• Important to get witness and EMS accounts
• Ask about trauma, ETOH, temperature of water, submersion time, PMH
• Important to assess for trauma and causes of syncope resulting in drowning
• Always consider non-accidental trauma

Primary Survey

• A-Intubate if not breathing or unable to protect the airway
• B-If pt is severly hypothermic, ventilate at half the normal rate
• C-Watch for "afterdrop" with rewarming when hypothermic
  • Peripheral vasodilation -> cool blood returning to the heart
• D-Baseline neurological exam is crucial
• E-Remove all wet clothing, observe for signs of trauma

Differential Diagnosis

• Trauma

Diagnosis

• CXR (pulm edema)
• Labs
  • CBC, Chemistry, troponin, coags, UA, total CK
• CT head/C-spine (if history of trauma)
• ECG
  • Dysrhythmias are common in hypothermia

Treatment

Neurologic

• Assume C-spine injury if unclear mechanism
• Intubate to protect airway if indicated
• Control seizures if they occur, consider sub-clinical status epilepticus

Pulmonary

• O2 to keep SaO2 >95%
• Significant injury often requires intubation and mechanical ventilation (high PEEP)
• If severly hypothermic, ventilate at half the normal rate

Cardiovascular

• IV fluid for volume depletion (common secondary to cold diuresis)
• Arrhythmias
  • Defibrillate with normal Joules
  • If initial defib attempt unsuccessful and temp <32, rewarm to 32 deg and reattempt
  • Rewarm with passive versus active depending on degree of hypothermia

ID

• Empiric Antibiotics
• Only consider if concerned for pulmonary aspiration (must cover pseudomonas)

Resuscitation

• The length of resuscitation to achieve ROSC must weigh against devastating neuro injury with ROSC after prolonged resuscitation
• Recommend at least 30 min in warm water drowning, 60 min in cold water
• Longest submersion time with full recovery is 66 min, occurred in cold water with ECMO rewarming

Potassium

• Value >10 mmol/dL not compatible with resuscitation in patients with hypothermia

Disposition

• GCS >13, O2 sat >95%, normal pulm exam
  • Consider discharge after 4-6hr of obs
• GCS <13, supp O2 required, or abnormal pulm exam
  • Admit

Prognosis

• Poor prognosis associated with:
  • Prolonged submersion and resuscitation, low GCS, warm water, asystolic rhythm, male
  • Hypothermia is actually a POOR prognisticator as it indicates prolonged submersion

See Also

Hypothermia