Submersion injury: Difference between revisions
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==Background== | ==Background== | ||
* | *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> | ||
</ref> | **Term "near-drowning" no longer used | ||
** | *Three possible outcomes = death, survival with morbidity, survival without morbidity | ||
* | |||
===Causes | ===Consider Secondary Causes=== | ||
* | *[[Ethanol intoxication]] | ||
* | *[[Syncope]] | ||
*[[Cardiac arrhythmia]] | |||
*Cardiac | *[[ACS]] | ||
*[[Non-accidental trauma]] | |||
* | |||
* | |||
===Pathophysiology=== | ===Pathophysiology=== | ||
Submersion | *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== | ==Clinical Features== | ||
*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> | |||
* | **[[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 <ref>Layon et al. Drowning: Update 2009. Anesthesiology 2009; 110: pp. 1390</ref> | ||
* | **[[Shortness of breath]] | ||
* | **Crackles | ||
**[[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== | ||
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==Evaluation== | ==Evaluation== | ||
*CXR ( | ===Workup=== | ||
* | *[[CXR]] (on arrival and after 4 hours) | ||
** | *[[ABG]] - [[lactic acidosis]] | ||
*CT head/C-spine (if history of trauma) | *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<ref name="Szpilman" />, 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)<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 | |||
==Management== | ==Management== | ||
=== | ===Prehospital=== | ||
* | *Immediate recitation 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> | ||
*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 <ref>Szpilman D, et al. In-water resuscitation: Is it worthwhile? Resuscitation 2004; 63: pp. 25</ref> | |||
*If no response to rescue breaths with chest rise, continue to standard CPR algorithm | |||
*Administer high flow 02 and intubate apneic patients | |||
* | *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> | ||
* | |||
* | |||
* | |||
=== | ===Emergency Department=== | ||
* | *Supportive care based on presentation is cornerstone of management<ref>Layon AJ et al. Drowning: Update 2009. Anesthesiology. 2009;110(6):1390</ref> | ||
* | *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 recitation 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== | ||
* | *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== | ==See Also== |
Revision as of 22:07, 28 September 2019
Background
- Definition: "The process of experiencing respiratory impairment from submersion/immersion in liquid"[1]
- Term "near-drowning" no longer used
- Three possible outcomes = death, survival with morbidity, survival without morbidity
Consider Secondary Causes
Pathophysiology
- Submersion → voluntary breath holding → aspiration → coughing/laryngospasm → aspiration continues → hypoxia → death[2]
- Aspiration destroys surfactant which → alveolar collapse, atelectasis, non-cardiogenic pulmonary edema, and V-Q mismatch.
Clinical Features
- Pulmonary [3][4] [5]
- 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 [6]
- Shortness of breath
- Crackles
- Wheezing
- May progress to pulmonary edema or ARDS despite adequate ventilation
- Neurologic [7]
- System most susceptible to hypoxemia
- Cerebral edema
- Elevated ICP
- Severity worsened with prolonged hypoxia
- Cardiovascular [8]
- 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) [9]
- Hypothermia [10]
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[2], but may consider:
Diagnosis
- Typically a clinical diagnosis
Management
Prehospital
- Immediate recitation if indicated [12]
- 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 [13]
- If no response to rescue breaths with chest rise, continue to standard CPR algorithm
- Administer high flow 02 and intubate apneic patients
- Do not routinely immobilize c-spine without suspicion based on mechanism or clinical signs [14]
Emergency Department
- Supportive care based on presentation is cornerstone of management[15]
- 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 recitation efforts in hypothermic patients until core temperature rises to at least 30 C (not dead until warm and dead) [16]
- 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
Video
{{#widget:YouTube|id=FznXbFcHLdM}}
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)
- ↑ 2.0 2.1 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
- ↑ 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.
- ↑ 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