Submersion Injuries

Richard Dionne MD CCFP-EMAvik Nath MD CCFP EM

March 21, 2013

Near Drowning Objectives

• Understand causal conditions

• Differentiate between fresh & salt water drownings

• Identify potential injuries

• Select appropriate diagnostic & management

• Consider treatment of hypothermia & trauma

Diving Emergency?

Definitions

• Drowning: – terminal outcome from submersion event – A process resulting in primary respiratory impairment from

submersion or immersion in a liquid medium

• Near-drowning: AHA no longer uses

• Submersion Injuries (non-fatal drowning): – survival, at least temporarily, after suffocation in a liquid

medium

• 3rd most common cause of accidental death overall, leading cause in < 5 yo

• ETOH / Drugs often associated

Risk Factors

• Inability to swim (overestimation of capabilities)

• Risk taking behaviour

• Inadequate supervision (bathtub, pools)

• Co morbidity: trauma, seizure, CVA, cardiac

Pathophysiology

Aspiration of 1-3 mL/kg destroys integrity of pulmonary surfactant

( lung compliance)

Alveolar collapse, atelectasis, Non-cardiogenic pulmonary edema

(ARDS), Intrapulmonary shunting, V/Q mismatch

Profound hypoxiaRespiratory acidosis, ARDS

Cardiovascular collapseNeuronal injury

…. Death

End Organ Effect

Immersion Syndrome

• Syncope secondary to cardiac dysrhythmias on sudden contact with water at least 5oC < body T

• QT prolongation & massive release of catecholamines plus vagal stimulation

• =>VF & asystole

• Resultant LOC leads to drowning

Salt vs Fresh Water: Does it Make a Difference?

• Historically felt to affect electrolytes, fluid shifting, hemolysis

• Intravascular abnormalities do not occur until aspirated water > 11 mL/kg

• Most aspirate <4 mL/kg

• Review of 91 submersion victims, no pt required emergent intervention for electrolyte abN

No significant clinical difference between the two!

Submersion Injuries

Fresh water Salt water

No difference

Surfactant is destroyed

Alveolar instability

Atelectasis & Compliance & Bronchospasm

V/Q mismatch

Hypoxia

Case

• 18 yo male• Boating with friends, “3 beers”• Fell off boat, submersion x 3 min• Brought to boat by friends, rescue

breathing started immediately

• What are the potential problems this pt may have?

• What is your immediate management?

• What investigations will you order?

• What is his prognosis?

• Which victims of submersion can I discharge?

Management of Care

• Prehospital

• Emergency

• Inpatient

Prehospital

• On scene:– Immediate Rescue Breathing (even before out of

water)… – Heimlich not proven …

– Bystander CPR (pulse check 30 sec.)• DO ABC’s as opposed to CAB!

– Consider trauma: C-spine precautions• 2000 pt study• 0.5 % (11 pts only) had C-spine injury• Usually obvious that injury occured

– Remove wet clothing, passive external rewarming (Hypothermia!)

Emergency Department

• ABC’s• Early airway

management

• Monitor: – cardiac, CORE T °(rectal)

• Rewarming

• Passive External• Active External • Active Internal

Inpatient Management

• Goal: • prevent further secondary neurologic injury and

minimise end-organ damage.

Submersion Injuries

• Gen: hypothermia, trauma

• GI: vomiting (swallow >> aspirate)

• Respiratory:– +’ve pressure

ventilation leads to gastric distention, risk of aspiration

– Aspiration of particulate contaminants

– Hypoxia from direct surfactant effects

– ARDS

Submersion Injuries

• CVS: dysrhythmias

• CNS: initial hypoxic injury or secondary reperfusion injury with resuscitation

• Renal: ARF due to lactic acidosis, prolonged hypoperfusion, rhabdo

• Heme: coagulopathies

What Investigations Do You Need?

• ECG: for dysrhythmias, prolonged QT

• ABG: any resp signs/symptoms

• Labs: electrolytes, renal function, CBC, glucose although usually N

• Screening for ETOH, drugs

• CXR: may underestimate severity initially

4 hours later….

Factors Affecting Survival

• Submersion > 10 min• CPR > 10 min• Resuscitation > 25 min• Water temo > 10 degrees• Age < 3• GCS < 5• ABG < 7.1 in Ed

Good vs Bad ???

Hypothermia: Good or Bad??

• Lowers cerebral metabolic rate, neuroprotective

• Diving reflex: shunting of blood centrally in response to cold water stimulus

• Causes bradycardia & apnea, decreased metabolic consumption

• Prolonged duration of submersion better tolerated

• Risks of malignant dysrhytmias

Poor Prognostic Factors

• > 10 minutes submersion• CPR initiated >10 min after rescue• Severe acidosis (pH < 7.1)• Unreactive pupils• GCS = 3 (comatose)• Hypothermia in ED ?• Need for ongoing CPR• Lack of spontaneous movement at

24hrs

Who can go home?

• Asymptomatic on presentation• Maintains normal room air sat• No CXR or ABG abnormalities …… D/C after 8 hour observation

Prevention

Children supervision

CPR courses to families with pools

Boating sobber & lifevests

Diving injuries

Caution: CAD / Seizure / Diabetics

Submersion Injuries: Overview

• Immediate resuscitative efforts is key!

• Consider associated trauma, ETOH/drugs

• Development of pulmonary injury may take time, initial CXR may be normal

• No clinical difference b/w salt & fresh H2O

• Majority of treatment is supportive, rewarming & not underestimate … Prevention !!!

• Monitor x 6-8 hr for asymptomatic pt with normal investigations

Questions ?