Submersion injury: Difference between revisions

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*CT head/C-spine (if history of trauma)
*CT head/C-spine (if history of trauma)
**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>
**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>
*ECG
*[[ECG]]
**Dysrhythmias are common in hypothermia
**Dysrhythmias are common in hypothermia



Revision as of 10:12, 9 September 2016

Background

  • Experiencing respiratory impairment from submersion or immersion [1]
    • No longer old classifications (near-drowning, wet, dry, active, passive) changed by WHO in 2003
  • 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

  • Inadequate Supervision
  • Underlying Neurological Event (stroke, seizure, weakness)
  • Behavioral/Developmental Disorders
  • Cardiac Events
    • Long QT, MI, HOCM
  • Intoxication
  • Trauma

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 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

Water-related injuries

Evaluation

  • CXR (pulmonary edema)
  • Labs
    • CBC, Chemistry, troponin, coags, UA, total CK, ABG
  • CT head/C-spine (if history of trauma)
    • C-Collar/C-spine Injury extremely low without evidence or history of trauma <0.5% in large cohort study [2]
  • ECG
    • Dysrhythmias are common in hypothermia

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)
  • 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
    • 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

  • 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

  • GCS >13, O2 sat >95%, normal pulmonary exam
    • Consider discharge after 4-6hr of obs
  • GCS <13, supp O2 required, or abnormal pulmonary exam
    • Admit for full inpatient monitoring

Prognosis

  • Poor prognosis associated with: [4]
    • Prolonged submersion time
      • 11-25mins 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 prognisticator as it indicates prolonged submersion[5]

See Also

Video

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References

  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