Submersion injury: Difference between revisions

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==Background==
==Background==
*“Experiencing respiratory impairment from submersion or immersion”
*Definition: "The process of experiencing respiratory impairment from submersion/immersion in liquid"<ref name="WHO">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)</ref>
**No longer old classifications (near-drowning, wet, dry, active, passive) changed by WHO in 2003
**Term "near-drowning" no longer used
*Submersion:airway below liquid’s surface
 
*Immersion:splashed liquid
===Consider Secondary Causes===
*No significant clinical differences between fresh-water and salt-water injuries and no significant clinical differences between dry and wet drowning
*[[Ethanol intoxication]]
===Epidemiology===
*[[Syncope]]
*6th most common cause of accidental death in the US
*[[Cardiac arrhythmia]]
*Bimodal age distribution
*[[ACS]]
**Children<5
*[[Non-accidental trauma]]
***Containers, pools, bathtubs
 
**Males 15-25
===Drowning Outcomes by Duration<ref>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.</ref>===
***Usually associated with tox
{| class="wikitable"
***Beaches, rivers, lakes
|-
**Associated with lower SES
! Duration of submersion
**Higher incidence in Southern States and in the summer
!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===
===Pathophysiology===
Submersion leads to panic which leads to voluntary breath holding followed by laryngospasm and then reflex inspiration which results in aspiration.
*Submersion → voluntary breath holding → aspiration → coughing/laryngospasm → aspiration continues → hypoxia → death<ref name="Szpilman">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</ref>
 
*Aspiration destroys surfactant which → alveolar collapse, atelectasis, non-cardiogenic pulmonary edema, and V-Q mismatch.
== Clinical Features ==
*Fresh vs salt water has no clinical relevance<ref>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</ref>
===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===
==Clinical Features==
*A-Intubate if not breathing or unable to protect the airway
*Pulmonary <ref>Olshaker JS. Near drowning. Emerg Med Clin North Am. 1992;10(2):339</ref><ref>Bierens et al. Drowning. Curr Opin Crit Care. 2002;8(6):578</ref> <ref>DeNicola et al. Submersion injuries in children and adults. Crit Care Clin 1997; 13: pp. 477</ref>
*B-If pt is severly hypothermic, ventilate at half the normal rate
**[[Hypoxemia]] due to aspiration
*C-Watch for "afterdrop" with rewarming when hypothermic
**Hypoxemia varies with severity but may be seen even with small volume aspiration (1-3mL) due to interference with alveolar gas exchange <ref>Layon et al. Drowning: Update 2009. Anesthesiology 2009; 110: pp. 1390</ref>
**Peripheral vasodilation -> cool blood returning to the heart
**[[Shortness of breath]]
*D-Baseline neurological exam is crucial
**Crackles
*E-Remove all wet clothing, observe for signs of trauma
**[[Wheezing]]
**May progress to [[pulmonary edema]] or [[ARDS]] despite adequate ventilation
*Neurologic <ref>McGillicuddy. Cerebral protection: pathophysiology and treatment of increased intracranial pressure. Chest. 1985;87(1):85</ref>
**System most susceptible to hypoxemia
**Cerebral edema
**[[Elevated ICP]]
**Severity worsened with prolonged hypoxia
*Cardiovascular <ref>Rivers et al. Drowning. Its clinical sequelae and management. Br Med J. 1970;2(5702):157</ref>
**Hypoxemia and [[hypothermia]] may cause [[arrhythmias]]
**[[Sinus tachycardia]], sinus [[bradycardia]], [[a-fib]]
*Metabolic
**Respiratory / [[metabolic acidosis]]
**[[Electrolyte disturbance]]s are uncommon but may be seen with submersion in media with unusually high electrolyte concentrations (such as the dead sea) <ref>Yagyl et al. Near drowning in the dead sea. Electrolyte imbalances and therapeutic implications. Arch Intern Med. 1985;145(1):50</ref>
*[[Hypothermia]] <ref>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</ref>


==Differential Diagnosis==
==Differential Diagnosis==
{{Water related injuries DDX}}
{{Water related injuries DDX}}


==Diagnosis==
==Evaluation==
*CXR (pulm edema)
===Workup===
*Labs
*[[CXR]] (on arrival and after 4 hours)
**CBC, Chemistry, troponin, coags, UA, total CK
*[[ABG]] - [[lactic acidosis]]
*CT head/C-spine (if history of trauma)
*Serum sodium does not correlate to fresh water vs. salt water drowning
*ECG
*Other work-up generally not needed unless specifically indicated by history or exam<ref name="Szpilman" />, but may consider:
**Dysrhythmias are common in hypothermia
**Labs, [[EKG]]
**[[CT head]]/C-spine (if history of trauma) - C-spine injury extremely unlikely without evidence or history of trauma (<0.5% in large cohort study)<ref>Watson RS, Cummings P, Quan L, et al. Cervical Spine Injuries Among Submersion victims. J Trauma 2001; 51:658.</ref>
 
===Diagnosis===
*Typically a clinical diagnosis
 
===Classification<ref>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.</ref>===
{| class="wikitable"
|-
! 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%
|}


==Treatment==
==Management==
===Neurologic===
===Prehospital===
*Assume C-spine injury if unclear mechanism
*Immediate resuscitation if indicated <ref>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</ref>
*Intubate to protect airway if indicated
*Assess need for [[CPR]] but do not delay removal from water
*Control seizures if they occur, consider sub-clinical status epilepticus
*Ventilation is a higher priority in drowning victims in cardiac arrest than in other situations requiring CPR
===Pulmonary===
*Deliver two rescue breaths immediately upon reaching shallow water or a stable surface; early breaths have been associated with improved survival <ref>Szpilman D, et al. In-water resuscitation: Is it worthwhile? Resuscitation 2004; 63: pp. 25</ref>
*O2 to keep SaO2 >95%
*If no response to rescue breaths with chest rise, continue to standard CPR algorithm
*Significant injury often requires intubation and mechanical ventilation (high PEEP)
*Administer high flow O2 and intubate apneic patients
*If severly hypothermic, ventilate at half the normal rate
*Do not routinely immobilize c-spine without suspicion based on mechanism or clinical signs <ref>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</ref>
===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===
===Emergency Department===
*The length of resuscitation to achieve ROSC must weigh against devastating neuro injury with ROSC after prolonged resuscitation
*Supportive care based on presentation is cornerstone of management<ref>Layon AJ et al. Drowning: Update 2009. Anesthesiology. 2009;110(6):1390</ref>
*Recommend at least 30 min in warm water drowning, 60 min in cold water
*Consider [[CPAP]] if inadequate tidal volume with high flow O2
*Longest submersion time with full recovery is 66 min, occurred in cold water with [[ECMO]] rewarming<ref>Bolte R and Black P. The use of extracorporeal rewarming in a child submerged for 66 minutes. JAMA. 1988; 260: 377-9.</ref>
*OG tube for gastric distension
===Potassium===
*Indications for [[intubation]]:
*Value >10 mmol/dL not compatible with resuscitation in patients with hypothermia
**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) <ref>American Heart Association; ILCOR : Submersion or near-drowning. Circulation 2000; 102: pp. I-233</ref>
*Routine antibiotics in ED are not necessary, but broad spectrum coverage may be indicated for submersion in heavily contaminated water


==Disposition==
==Disposition==
*GCS >13, O2 sat >95%, normal pulm exam
*Discharge after 4-6 hours of observation if:
**Consider discharge after 4-6hr of obs
**Normal mental status, SpO2 >95% on room air, normal CXR and respiratory exam
*GCS <13, supp O2 required, or abnormal pulm exam
*Admit all others
**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<ref>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:h418[http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4353310/ full text]</ref>


==See Also==
==See Also==
*[[Water-related injuries]]
*[[Water-related injuries]]
*[[Immersion pulmonary edema]]
*[[Immersion pulmonary edema]]
==Video==
{{#widget:YouTube|id=FznXbFcHLdM}}


==References==
==References==
<references/>
<references/>
[[Category:Environ]]
 
[[Category:Pulm]]
[[Category:Environmental]]
[[Category:Pulmonary]]

Latest revision as of 20:09, 17 April 2024

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

Differential Diagnosis

Water-related injuries

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:
    • Labs, EKG
    • CT head/C-spine (if history of trauma) - C-spine injury extremely unlikely without evidence or history of trauma (<0.5% in large cohort study)[13]

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

  1. ↑ 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)
  2. ↑ 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. ↑ 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
  4. ↑ 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
  5. ↑ Olshaker JS. Near drowning. Emerg Med Clin North Am. 1992;10(2):339
  6. ↑ Bierens et al. Drowning. Curr Opin Crit Care. 2002;8(6):578
  7. ↑ DeNicola et al. Submersion injuries in children and adults. Crit Care Clin 1997; 13: pp. 477
  8. ↑ Layon et al. Drowning: Update 2009. Anesthesiology 2009; 110: pp. 1390
  9. ↑ McGillicuddy. Cerebral protection: pathophysiology and treatment of increased intracranial pressure. Chest. 1985;87(1):85
  10. ↑ Rivers et al. Drowning. Its clinical sequelae and management. Br Med J. 1970;2(5702):157
  11. ↑ Yagyl et al. Near drowning in the dead sea. Electrolyte imbalances and therapeutic implications. Arch Intern Med. 1985;145(1):50
  12. ↑ 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
  13. ↑ Watson RS, Cummings P, Quan L, et al. Cervical Spine Injuries Among Submersion victims. J Trauma 2001; 51:658.
  14. ↑ 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.
  15. ↑ 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
  16. ↑ Szpilman D, et al. In-water resuscitation: Is it worthwhile? Resuscitation 2004; 63: pp. 25
  17. ↑ 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
  18. ↑ Layon AJ et al. Drowning: Update 2009. Anesthesiology. 2009;110(6):1390
  19. ↑ American Heart Association; ILCOR : Submersion or near-drowning. Circulation 2000; 102: pp. I-233
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