Submersion injury
(Redirected from Submersion Injuries (Drowning))
Background
- Definition: "The process of experiencing respiratory impairment from submersion/immersion in liquid"[1]
- Term "near-drowning" no longer used
Consider Secondary Causes
Drowning Outcomes by Duration[2]
Duration of submersion | Risk of death or poor outcome |
---|---|
0–5 min | 10% |
6–10 min | 56% |
11–25 min | 88% |
>25 min | nearly 100% |
^Signs of brain-stem injury predict death or severe neurological consequences
Pathophysiology
- Submersion → voluntary breath holding → aspiration → coughing/laryngospasm → aspiration continues → hypoxia → death[3]
- Aspiration destroys surfactant which → alveolar collapse, atelectasis, non-cardiogenic pulmonary edema, and V-Q mismatch.
- Fresh vs salt water has no clinical relevance[4]
Clinical Features
- Pulmonary [5][6] [7]
- Hypoxemia due to aspiration
- Hypoxemia varies with severity but may be seen even with small volume aspiration (1-3mL) due to interference with alveolar gas exchange [8]
- Shortness of breath
- Crackles
- Wheezing
- May progress to pulmonary edema or ARDS despite adequate ventilation
- Neurologic [9]
- System most susceptible to hypoxemia
- Cerebral edema
- Elevated ICP
- Severity worsened with prolonged hypoxia
- Cardiovascular [10]
- Hypoxemia and hypothermia may cause arrhythmias
- Sinus tachycardia, sinus bradycardia, a-fib
- Metabolic
- Respiratory / metabolic acidosis
- Electrolyte disturbances are uncommon but may be seen with submersion in media with unusually high electrolyte concentrations (such as the dead sea) [11]
- Hypothermia [12]
Differential Diagnosis
- Hypothermia
- Immersion pulmonary edema
- Marine toxins, envenomations, and bites
- Scuba diving emergencies
- Submersion injury (drowning and near-drowning)
Evaluation
Workup
- CXR (on arrival and after 4 hours)
- ABG - lactic acidosis
- Serum sodium does not correlate to fresh water vs. salt water drowning
- Other work-up generally not needed unless specifically indicated by history or exam[3], but may consider:
Diagnosis
- Typically a clinical diagnosis
Classification[14]
Grade | Presentation | Recommended Treatment | Survival |
---|---|---|---|
0 | Responds normally, lungs clear to auscultation, no cough | Do not transport | 100% |
1 | Responds normally, lungs clear to auscultation, has a cough | Discharge | 100% |
2 | Responds normally, rales in some lung fields, has a cough | Nasal cannula, observe in ED | 99.4% |
3 | Responds normally, rales in all lung fields, has a cough, normotension | Non-rebreather, progress to positive pressure or intubation if needed, admit | 94.8% |
4 | Responds normally, rales in all lung fields, has a cough, hypotension | Non-rebreather with likely progression to positive pressure or intubation, IV fluids and pressors as needed, admit to ICU | ~80%% |
5 | Unresponsive but has a pulse | Positive pressure ventilation with likely progression to intubation, IV fluids and vasopressors if needed, admit to ICU | ~60% |
6 | Unresponsive with no pulse after 5 rescue breaths | ACLS protocol | 7% |
Management
Prehospital
- Immediate resuscitation if indicated [15]
- Assess need for CPR but do not delay removal from water
- Ventilation is a higher priority in drowning victims in cardiac arrest than in other situations requiring CPR
- Deliver two rescue breaths immediately upon reaching shallow water or a stable surface; early breaths have been associated with improved survival [16]
- If no response to rescue breaths with chest rise, continue to standard CPR algorithm
- Administer high flow O2 and intubate apneic patients
- Do not routinely immobilize c-spine without suspicion based on mechanism or clinical signs [17]
Emergency Department
- Supportive care based on presentation is cornerstone of management[18]
- Consider CPAP if inadequate tidal volume with high flow O2
- OG tube for gastric distension
- Indications for intubation:
- Comatose or unable to protect airway
- Hypoxemia or hypercapnia on ABG despite high flow O2 (PaO2 below 60, PaCO2 above 50)
- Continue resuscitation efforts in hypothermic patients until core temperature rises to at least 30 C (not dead until warm and dead) [19]
- Routine antibiotics in ED are not necessary, but broad spectrum coverage may be indicated for submersion in heavily contaminated water
Disposition
- Discharge after 4-6 hours of observation if:
- Normal mental status, SpO2 >95% on room air, normal CXR and respiratory exam
- Admit all others
See Also
References
- ↑ World Health Organization (WHO) "Global Report on Drowning". http://www.who.int/violence_injury_prevention/global_report_drowning/Final_report_full_web.pdf (Accessed 02/01/2017)
- ↑ Szpilman, David; Bierens, Joost J.L.M.; Handley, Anthony J.; Orlowski, James P. (4 October 2012). "Drowning". The New England Journal of Medicine. 366 (22): 2102–2110. doi:10.1056/NEJMra1013317. PMID 22646632.
- ↑ 3.0 3.1 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
- ↑ Orlowski JP, Szpilman D. Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am. 2001;48(3):627-646. doi:10.1016/s0031-3955(05)70331-x
- ↑ Olshaker JS. Near drowning. Emerg Med Clin North Am. 1992;10(2):339
- ↑ Bierens et al. Drowning. Curr Opin Crit Care. 2002;8(6):578
- ↑ DeNicola et al. Submersion injuries in children and adults. Crit Care Clin 1997; 13: pp. 477
- ↑ Layon et al. Drowning: Update 2009. Anesthesiology 2009; 110: pp. 1390
- ↑ McGillicuddy. Cerebral protection: pathophysiology and treatment of increased intracranial pressure. Chest. 1985;87(1):85
- ↑ Rivers et al. Drowning. Its clinical sequelae and management. Br Med J. 1970;2(5702):157
- ↑ Yagyl et al. Near drowning in the dead sea. Electrolyte imbalances and therapeutic implications. Arch Intern Med. 1985;145(1):50
- ↑ Collis ML: Survival behaviour in cold water immersion. In (eds): Proceedings of the Cold Water Symposium. Toronto, Canada: Royal Life-Saving Society of Canada, 1976
- ↑ Watson RS, Cummings P, Quan L, et al. Cervical Spine Injuries Among Submersion victims. J Trauma 2001; 51:658.
- ↑ Szpilman D. Near-drowning and drowning classification:a proposal to stratify mortality based on the analysis of 1,831 cases. Chest 112(3):660-665, 1997.
- ↑ Schmidt AC, et al. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning. Wilderness Environ Med. 2016 Jun;27(2):236-51
- ↑ Szpilman D, et al. In-water resuscitation: Is it worthwhile? Resuscitation 2004; 63: pp. 25
- ↑ Vanden Hoek TL et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S829
- ↑ Layon AJ et al. Drowning: Update 2009. Anesthesiology. 2009;110(6):1390
- ↑ American Heart Association; ILCOR : Submersion or near-drowning. Circulation 2000; 102: pp. I-233