Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

29
Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013

Transcript of Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

Page 1: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

Submersion Injuries

Richard Dionne MD CCFP-EMAvik Nath MD CCFP EM

March 21, 2013

Page 2: Submersion Injuries Richard Dionne MD CCFP-EM Avik 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

Page 3: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

Diving Emergency?

Page 4: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

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

Page 5: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

Risk Factors

• Inability to swim (overestimation of capabilities)

• Risk taking behaviour

• Inadequate supervision (bathtub, pools)

• Co morbidity: trauma, seizure, CVA, cardiac

Page 6: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

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

Page 7: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

Profound hypoxiaRespiratory acidosis, ARDS

Cardiovascular collapseNeuronal injury

…. Death

End Organ Effect

Page 8: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

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

Page 9: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

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!

Page 10: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

Submersion Injuries

Fresh water Salt water

No difference

Surfactant is destroyed

Alveolar instability

Atelectasis & Compliance & Bronchospasm

V/Q mismatch

Hypoxia

Page 11: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

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

Page 12: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

• 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?

Page 13: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

Management of Care

• Prehospital

• Emergency

• Inpatient

Page 14: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

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!)

Page 15: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

Emergency Department

• ABC’s• Early airway

management

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

• Rewarming

• Passive External• Active External • Active Internal

Page 16: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

Inpatient Management

• Goal: • prevent further secondary neurologic injury and

minimise end-organ damage.

Page 17: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

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

Page 18: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

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

Page 19: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

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

Page 20: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.
Page 21: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

4 hours later….

Page 22: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

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

Page 23: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

Good vs Bad ???

Page 24: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

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

Page 25: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

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

Page 26: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

Who can go home?

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

Page 27: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

Prevention

Children supervision

CPR courses to families with pools

Boating sobber & lifevests

Diving injuries

Caution: CAD / Seizure / Diabetics

Page 28: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

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

Page 29: Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.

Questions ?