Submersion injury
Background
- “Experiencing respiratory impairment from submersion or immersion [1]"
- No longer old classifications (near-drowning, wet, dry, active, passive) changed by WHO in 2003
- Submersion:airway below liquid’s surface
- Immersion:splashed liquid
- No significant clinical differences between fresh-water and salt-water injuries and no significant clinical differences between dry and wet drowning
Epidemiology
- 6th most common cause of accidental death in the US
- Bimodal age distribution
- Children<5
- Containers, pools, bathtubs
- Males 15-25
- Usually associated with tox
- Beaches, rivers, lakes
- Associated with lower SES
- Higher incidence in Southern States and in the summer
- Children<5
Causes/Risk Factors
- Inadequate Supervision
- Underlying Neurological Event (stroke, seizure, weakness)
- Behavioral/Developmental Disorders
- Cardiac Events
- Long QT, MI, HOCM
- Intoxication
- Trauma
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
- Hypothermia
- Immersion pulmonary edema
- Marine toxins, envenomations, and bites
- Scuba diving emergencies
- Submersion injury (drowning and near-drowning)
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
- Consider if immersion with grossly dirt water (sewage, glades...)
- 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[2]
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 for full inpatient monitoring
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[3]
See Also
Video
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References
- ↑ Szpilman, D., Bierens, J. J., Handley, A. J., & Orlowski, J. P. (2012). Drowning. N Engl J Med, 366(22), 2102-2110. doi: 10.1056/NEJMra1013317
- ↑ Bolte R and Black P. The use of extracorporeal rewarming in a child submerged for 66 minutes. JAMA. 1988; 260: 377-9.
- ↑ Kieboom JK, et al. Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study. BMJ. 2015 Feb 10;350:h418full text