Submersion injury

Background

• Definition: "The process of experiencing respiratory impairment from submersion/immersion in liquid"
  • 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
• Aspiration destroys surfactant which → alveolar collapse, atelectasis, non-cardiogenic pulmonary edema, and V-Q mismatch.

Differential Diagnosis

Water-related injuries

• Hypothermia
• Immersion pulmonary edema
• Marine toxins, envenomations, and bites
• Scuba diving emergencies
• Submersion injury (drowning and near-drowning)

Evaluation

• 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, 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)

Management

• Supportive care based on presentation is cornerstone of management.

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

• Water-related injuries
• Immersion pulmonary edema

Video

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