Submersion injury: Difference between revisions
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==Background==
==Background==
*''Experiencing respiratory impairment from submersion or immersion <ref>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
*Definition: "The process of experiencing respiratory impairment from submersion/immersion in liquid"<ref="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>
</ref>''
**Term "near-drowning" no longer used
**No longer old classifications (near-drowning, wet, dry, active, passive) changed by WHO in 2003
*Three possible outcomes = death, survival with morbidity, survival without morbidity
*Submersion:airway below liquid’s surface
*Consider secondary causes such as intoxication, syncope, cardiac arrhythmia, ACS, non-accidental trauma, etc.
*Immersion:splashed liquid
*No significant clinical differences between fresh-water and salt-water injuries and no significant clinical differences between dry and wet drowning
**Quantity of fluid determines pulmonary derangement
===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
 
===Causes/Risk Factors===
*Inadequate Supervision
*Underlying Neurological Event (stroke, seizure, weakness)
*Behavioral/Developmental Disorders
*Cardiac Events
**Long QT, MI, HOCM
*Intoxication
*Trauma


===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 leads to alveolar collapse, atelectasis, non-cardiogenic pulmonary edema, and V-Q mismatch.
*Aspiration destroys surfactant which → alveolar collapse, atelectasis, non-cardiogenic pulmonary edema, and V-Q mismatch.


==Clinical Features==
==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 patient is severely hypothermic, ventilate at half the normal rate
*C-Watch for "after drop" 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==
==Differential Diagnosis==
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==Evaluation==
==Evaluation==
*[[CXR]] (pulmonary edema)
*[[CXR]]
*Labs
*ABG
**CBC, Chemistry, troponin, coags, UA, total CK, ABG
 
*CT head/C-spine (if history of trauma)
*Other work-up generally not needed unless specifically indicated by history or exam<ref name="Szpilman" />, but may consider:
**C-Collar/C-spine Injury extremely low 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>
**Labs, EKG
*[[ECG]]
**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>
**Dysrhythmias are common in hypothermia


==Management==
==Management==
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*Intubate to protect airway if indicated
*Intubate to protect airway if indicated
*Control seizures if they occur, consider subclinical status epilepticus
*Control seizures if they occur, consider subclinical status epilepticus
===Pulmonary===
===Pulmonary===
*O2 to keep SaO2 >95%
*O2 to keep SaO2 >95%
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*Rewarm with passive versus active depending on degree of hypothermia
*Rewarm with passive versus active depending on degree of hypothermia
*Occurs more quickly in pediatric population secondary to lower body mass:surface area
*Occurs more quickly in pediatric population secondary to lower body mass:surface area
===ID===
===ID===
*Empiric [[Antibiotics]]
*Empiric [[Antibiotics]]
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*Recommend at least 30 min in warm water drowning, 60 min in cold water
*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<ref>Bolte R and Black P. The use of extracorporeal rewarming in a child submerged for 66 minutes. JAMA. 1988; 260: 377-9.</ref>
*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>
===Potassium===
===Potassium===
*Value >10 mmol/dL not compatible with resuscitation in patients with hypothermia
*Value >10 mmol/dL not compatible with resuscitation in patients with hypothermia


==Disposition==
==Disposition==
*GCS >13, O2 sat >95%, normal pulmonary 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 respiratory exam
*GCS <13, supp O2 required, or abnormal pulmonary exam
*Admit all others
**Admit for full inpatient monitoring


==Prognosis==
==Prognosis==
*Poor prognosis associated with: <ref>Bierens JJ, van der Velde EA, van Berkel M, van Zanten JJ. Submersion in The Netherlands: prognostic indicators and results of resuscitation. Ann Emerg Med 1990; 19:1390.</ref>
*Poor prognosis associated with: <ref>Bierens JJ, van der Velde EA, van Berkel M, van Zanten JJ. Submersion in The Netherlands: prognostic indicators and results of resuscitation. Ann Emerg Med 1990; 19:1390.</ref>
**Prolonged submersion time
**Prolonged submersion time (11-25 mins associated with 88% mortality rate)
***11-25mins associated with 88% mortality rate
**Time until BLS >10 mins
**Time until BLS >10 mins
**Resuscitation >30mins
**Resuscitation >30mins
**Initial GCS<5
**Initial GCS<5
**Age<3
**Age<3
**Core temperature <33C
**Core temperature <33C (Hypothermia is actually a POOR prognostic factor - 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>
***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==

Revision as of 05:04, 2 February 2017

Background

  • Definition: "The process of experiencing respiratory impairment from submersion/immersion in liquid"<ref="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>
    • Term "near-drowning" no longer used
  • Three possible outcomes = death, survival with morbidity, survival without morbidity
  • Consider secondary causes such as intoxication, syncope, cardiac arrhythmia, ACS, non-accidental trauma, etc.

Pathophysiology

  • Submersion → voluntary breath holding → aspiration → coughing/laryngospasm → aspiration continues → hypoxia → death[1]
  • Aspiration destroys surfactant which → alveolar collapse, atelectasis, non-cardiogenic pulmonary edema, and V-Q mismatch.

Clinical Features

Differential Diagnosis

Water-related injuries

Evaluation

  • Other work-up generally not needed unless specifically indicated by history or exam[1], 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)[2]

Management

Neurologic

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

Pulmonary

  • O2 to keep SaO2 >95%
  • Significant injury often requires intubation and mechanical ventilation (high PEEP)
    • Strong considerations for intubation: if on high flow oxygen with: O2 saturations <90%, or PaO2 <60 (adults) <80 (peds), or PaCO2> 50
  • If severely 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 temperature <32, rewarm to 32 deg and reattempt

Hypothermia

  • Rewarm with passive versus active depending on degree of hypothermia
  • Occurs more quickly in pediatric population secondary to lower body mass:surface area

ID

  • Empiric Antibiotics
  • Consider if immersion with grossly dirty 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[3]

Potassium

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

Disposition

  • Discharge after 4-6 hours of observation if:
    • Normal mental status, SpO2 >95% on room air, normal respiratory exam
  • Admit all others

Prognosis

  • Poor prognosis associated with: [4]
    • Prolonged submersion time (11-25 mins associated with 88% mortality rate)
    • Time until BLS >10 mins
    • Resuscitation >30mins
    • Initial GCS<5
    • Age<3
    • Core temperature <33C (Hypothermia is actually a POOR prognostic factor - indicates prolonged submersion)[5]

See Also

Video

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References

  1. ↑ 1.0 1.1 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
  2. ↑ Watson RS, Cummings P, Quan L, et al. Cervical Spine Injuries Among Submersion victims. J Trauma 2001; 51:658.
  3. ↑ Bolte R and Black P. The use of extracorporeal rewarming in a child submerged for 66 minutes. JAMA. 1988; 260: 377-9.
  4. ↑ Bierens JJ, van der Velde EA, van Berkel M, van Zanten JJ. Submersion in The Netherlands: prognostic indicators and results of resuscitation. Ann Emerg Med 1990; 19:1390.
  5. ↑ 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
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