Submersion injury: Difference between revisions

m (Rossdonaldson1 moved page Submersion injuries to Submersion injury)
Line 24: Line 24:


==Differential Diagnosis==
==Differential Diagnosis==
*Trauma
{{Water related injuries DDX}}
{{Water related injuries DDX}}



Revision as of 10:25, 20 July 2015

Background

  • This topic covers drowning and near-drowning
  • Defined as respiratory impairment from submersion in liquid (regardless of pt outcome)
  • No significant clinical differences between fresh-water and salt-water injuries and no significant clinical differences between dry and wet drowning

Epidemiology

  • Common in children <5yr, teenagers, and elderly

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

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

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[1]

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[2]

See Also

References

  1. Bolte R and Black P. The use of extracorporeal rewarming in a child submerged for 66 minutes. JAMA. 1988; 260: 377-9.
  2. 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