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 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
**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
*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


===Causes/Risk Factors===
===Consider Secondary Causes===
*Inadequate Supervision
*[[Ethanol intoxication]]
*Underlying Neurological Event (stroke, seizure, weakness)
*[[Syncope]]
*Behavioral/Developmental Disorders
*[[Cardiac arrhythmia]]
*Cardiac Events
*[[ACS]]
**Long QT, MI, HOCM
*[[Non-accidental trauma]]
*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 → alveolar collapse, atelectasis, non-cardiogenic pulmonary edema, and V-Q mismatch.


==Clinical Features==
==Clinical Features==
===History===
*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>
*Important to get witness and EMS accounts
**[[Hypoxemia]] due to aspiration
*Ask about trauma, ETOH, temperature of water, submersion time, PMH
**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>
*Important to assess for trauma and causes of syncope resulting in drowning
**[[Shortness of breath]]
*Always consider non-accidental trauma
**Crackles
 
**[[Wheezing]]
===Primary Survey===
**May progress to [[pulmonary edema]] or [[ARDS]] despite adequate ventilation
*A-Intubate if not breathing or unable to protect the airway
*Neurologic <ref>McGillicuddy. Cerebral protection: pathophysiology and treatment of increased intracranial pressure. Chest. 1985;87(1):85</ref>
*B-If patient is severely hypothermic, ventilate at half the normal rate
**System most susceptible to hypoxemia
*C-Watch for "after drop" with rewarming when hypothermic
**Cerebral edema
**Peripheral vasodilation -> cool blood returning to the heart
**[[Elevated ICP]]
*D-Baseline neurological exam is crucial
**Severity worsened with prolonged hypoxia
*E-Remove all wet clothing, observe for signs of trauma
*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 (pulmonary edema)
===Workup===
*Labs
*[[CXR]] (on arrival and after 4 hours)
**CBC, Chemistry, troponin, coags, UA, total CK, ABG
*[[ABG]] - [[lactic acidosis]]
*CT head/C-spine (if history of trauma)
*Serum sodium does not correlate to fresh water vs. salt water drowning
**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>
*Other work-up generally not needed unless specifically indicated by history or exam<ref name="Szpilman" />, but may consider:
*ECG
**Labs, [[EKG]]
**Dysrhythmias are common in hypothermia
**[[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==
===Neurologic===
===Prehospital===
*Assume C-spine injury if unclear mechanism
*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>
*Intubate to protect airway if indicated
*Assess need for [[CPR]] but do not delay removal from water
*Control seizures if they occur, consider subclinical 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 02 and intubate apneic patients
*If severely 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 dirty 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 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==
*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 CXR and respiratory exam
*GCS <13, supp O2 required, or abnormal pulmonary exam
*Admit all others
**Admit for full inpatient monitoring
 
==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>
**Prolonged submersion time
***11-25mins associated with 88% mortality rate
**Time until BLS >10 mins
**Resuscitation >30mins
**Initial GCS<5
**Age<3
**Core Temp <33C
***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 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

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[2], 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)[11]

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

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