Submersion injury

Background

• “Experiencing respiratory impairment from submersion or immersion”
  • 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

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

Water-related injuries

• 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

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

See Also

• Water-related injuries
• Immersion pulmonary edema

Video

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