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Submersion Injury

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Other Names

  • Drowning
  • Near drowning
  • Fatal drowning
  • Nonfatal drowning

Background

  • This page refers to submersion injury, which is a a broad term which includes fatal and nonfatal drowning.

History

Epidemiology

  • General
    • Drowning is one of the leading causes of accidental deaths across the world[1]
    • US: 10 people die due to unintentional drowning daily, with one in five being children aged 14 and younger[2]
  • Pediatrics
    • Children ages one to four have the highest drowning rates; #2 cause of death in that age range second to congenital anomalies[2]
    • For each child who dies from drowning, another five children require ED care for nonfatal submersion[1]
  • Location
    • Home pool is most common for children under 5
    • Natural water sources (rivers, lakes, ocean) rates increase as age increases

Pathophysiology

  • General
    • Submersion injury is a broad term which includes fatal and nonfatal drowning events
    • Biggest predictor of poor outcome related to duration of submersion
  • Primary drowning
    • Most common in aquatic sports
    • Occurrs by misjudgement of the ability to cope with the aquatic environment or falling into the water while participating in the sport
  • Secondary drowning
    • Any other injury/trauma or sudden illness acting as a precipitant factor
    • This produces loss of consciousness or mentally or physically weakening the ability of the athlete to cope with the water

Etiology

  • General
    • Submersion, voluntary breath holding followed by aspiration
    • Aspiration causes coughing and laryngospasm, aspiration continues, hypoxia and subsequently death[3]
  • Pulmonary
    • Hypoxemia varies with severity
    • Hypoxia is the leading cause of cardiac arrest in submersion injuries
    • Occurs due to loss of surfactant leading to alveolar collapse, atelectasis, pulmonary edema, and V/Q mismatch
    • Pulmonary symptoms may be seen even with small volume aspiration (1-3mL) due to interference with alveolar gas exchange[4]
  • Neurologic
    • CNS most susceptible to hypoxemia
    • Typically develops cerebral edema, elevated intracranial pressure (ICP)
    • Severity correlates to duration of hypoxia
  • Cardiovascular
    • Arrhythmias include atrial fibrillation, sinus tachycardia, sinus bradycardia
  • Metabolic
    • Mixed respiratory and metabolic acidosis
    • Electrolyte disturbances are uncommon
  • Fresh vs Salt water aspiration
    • Distinction between fresh and salt water drowning is no longer considered important[5]
    • Volume of water aspirated is too small to cause clinically relevant electrolyte shifts

Associated Conditions

  • Hypothermia
    • Hypothermia is neuroprotective[6]
    • Case reports showing complete recovery of patients in cardiac arrest with hypothermia even with several hours of resuscitation required[7]

Risk Factors

  • Demographic
  • Behavioral
    • Risk taking behavior
    • Drug or alcohol use
  • Swimming related
    • Inadequate supervision by an adult
    • Overestimation of abilities at swimming or poor swimming skills
  • Environmental
  • Pediatric
    • Seizure disorder
    • Developmental delay
  • Sports

Differential Diagnosis

Differential Diagnosis Dive Medicine

Clinical Features

  • History
    • Pulmonary: shortness of breath, crackles, wheezing, respiratory distress[9]
    • Neurologic: altered mental status, unresponsive
    • Cardiovascular: syncope
  • Physical Exam
    • Pulmonary: hypoxemia, crackles, distress
    • Neuro: altered mental status, neuro deficits
    • Cardiovascular: syncope, cardiac arrest, arrhythmias including sinus tach, bradycardia or a-fib
    • Hypothermia

Evaluation

  • Diagnosis is primarily clinical

Radiographs

Laboratory

  • CBC
  • CMP
  • ABG
    • Metabolic acidosis
  • Lactate
    • Typically elevated

Electrocardiogram

  • Rhythms
    • Sinus tachycardia
    • Sinus bradycardia
    • Atrial fibrillation

Classification

Classification proposed by Szpilman[10]

Grade Presentation Emergency Department Treatment Survival
0 Responds normally, lungs clear to auscultation, no cough Do not transport 100%
1 Responds normally, lungs clear to auscultation, has a cough Discharge 100%
2 Responds normally, rales in some lung fields, has a cough Nasal cannula, observe in ED 99.4%
3 Responds normally, rales in all lung fields, has a cough, normotension Non-rebreather, progress to positive pressure or intubation if needed, admit 94.8%
4 Responds normally, rales in all lung fields, has a cough, hypotension Non-rebreather with likely progression to positive pressure or intubation, IV fluids and pressors as needed, admit to ICU ~80%%
5 Unresponsive but has a pulse Positive pressure ventilation with likely progression to intubation, IV fluids and vasopressors if needed, admit to ICU ~60%
6 Unresponsive with no pulse after 5 rescue breaths ACLS protocol 7%

Management

Prehospital

  • ACLS/ Airway
    • Provide two rescue breaths immediately
    • If chest doesn't rise, initiate CPR[11]
  • Hypothermia
    • Pulses may be difficult to palpate
    • Especially in a patient who is bradycardic or in atrial fibrillation.
    • Take time more time to palpate pulse, up to 60 seconds
    • Hypothermia is neuroprotective[6].

ED/ Hospital Management

  • Airway
    • Endotracheal intubation if necessary
  • Breathing
    • Maintain SpO2 > 94% (nasal cannula, non-rebreather, or NIPPV)
    • If intubated, use ARDS settings and follow ARDSnet protocol
    • Extra Corporeal Membrane Oxygenation: data limited by encouraging
  • Circulation
    • Common initial arrhythmias: sinus tachycardia, sinus bradycardia, and atrial fibrillation[12]
    • Swimming and diving can induce fatal arrythmias in patients with prolonged QT syndrome
  • Hypothermia
    • Neuroprotective effects
    • Studies have shown neurological intact outcomes in even prolonged resuscitations[13]
  • Duration of monitoring
    • All symptomatic patients should be monitored in the ED or hospital for a minimum of 6 hours[14]
  • Antibiotics
    • Indicated if water is grossly contaminated[15]
  • Not recommended
    • Glucocorticoids are not recommended and may interfere with healing and should not be given.
    • Surfactant: data is limited on the use of exogenous surfactant

Prevention

  • General
    • Supervision in and around water
    • Use a life vest
    • Avoid alcohol or drugs while swimming
    • Know local weather conditions
    • Have a swimming buddy
    • Know where lifeguards are

Rehab and Return to Play

Rehabilitation

  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Drowning outcomes by Duration[16]
Duration of submersion Risk of death or poor outcome
0–5 min 10%
6–10 min 56%
11–25 min 88%
>25 min nearly 100%

^Signs of brain-stem injury predict death or severe neurological consequences

Prognosis

  • Predictors of good outcome
    • Spilzman class 0-3 which represents the vast majority of cases[10]
  • Predictors of poor outcome[17]
    • Increased duration of submersion is the biggest predictor of poor outcome[18]
    • Serum potassium >10 mmol/L (in children >12 years old) is high predictor of poor outcomes.
    • End tidal CO2 <2 kPa with high quality chest compressions has a poor prognosis.

Complications

  • Neurological injury
    • Common in nonfatal drowning injuries
    • Ranges from memory or learning disabilities to permanent vegetative state

See Also

References

  1. ↑ 1.0 1.1 Centers for Disease Control and Prevention (CDC). Nonfatal and fatal drownings in recreational water settings–United States, 2001-2002. MMWR Morb Mortal Wkly Rep. 2004;53(21):447-452.
  2. ↑ 2.0 2.1 Centers for Disease Control and Prevention (CDC). Home and recreational safety: water safety. October 7, 2020. 2020. Accessed October 8, 2020. https://www.cdc.gov/homeandrecreationalsafety/water-safety/waterinjuries-factsheet.html.
  3. ↑ 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
  4. ↑ Layon et al. Drowning: Update 2009. Anesthesiology 2009; 110: pp. 1390
  5. ↑ Orlowski JP, Szpilman D. Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am. 2001;48(3):627-646. doi:10.1016/s0031-3955(05)70331-x
  6. ↑ 6.0 6.1 Bierens JJ, Knape JT, Gelissen HP. Drowning. Curr Opin Crit Care. 2002;8(6):578-586. doi:10.1097/00075198-200212000-00016
  7. ↑ Burke CR, Chan T, Brogan TV, et al. Extracorporeal life support for victims of drowning. Resuscitation. 2016;104:19-23. doi:10.1016/j.resuscitation.2016.04.005
  8. ↑ Papa L, Hoelle R, Idris A. Systematic review of definitions for drowning incidents. Resuscitation. 2005;65(3):255-264. doi:10.1016/j.resuscitation.2004.11.030.
  9. ↑ Olshaker JS. Near drowning. Emerg Med Clin North Am. 1992;10(2):339
  10. ↑ 10.0 10.1 Szpilman D. Near-drowning and drowning classification:a proposal to stratify mortality based on the analysis of 1,831 cases. Chest 112(3):660-665, 1997.
  11. ↑ DeNicola LK, Falk JL, Swanson ME, Gayle MO, Kissoon N. Submersion injuries in children and adults. Crit Care Clin. 1997;13(3):477-502. doi:10.1016/s0749-0704(05)70325-0
  12. ↑ Schmidt AC, Sempsrott JR, Hawkins SC, Arastu AS, Cushing TA, Auerbach PS. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning. Wilderness Environ Med. 2016;27(2):236-251. doi:10.1016/j.wem.2015.12.019.
  13. ↑ Quan L, Mack CD, Schiff MA. Association of water temperature and submersion duration and drowning outcome [published correction appears in Resuscitation. 2014 Sep;85(9):1304]. Resuscitation. 2014;85(6):790-794. doi:10.1016/j.resuscitation.2014.02.024.
  14. ↑ Noonan L, Howrey R, Ginsburg CM. Freshwater submersion injuries in children: a retrospective review of seventy-five hospitalized patients. Pediatrics. 1996;98(3 Pt 1):368-371.
  15. ↑ Layon AJ, Modell JH. Drowning: Update 2009. Anesthesiology. 2009;110(6):1390-1401. doi:10.1097/ALN.0b013e3181a4c3b8
  16. ↑ Szpilman, David; Bierens, Joost J.L.M.; Handley, Anthony J.; Orlowski, James P. (4 October 2012). "Drowning". The New England Journal of Medicine. 366 (22): 2102–2110. doi:10.1056/NEJMra1013317. PMID 22646632.
  17. ↑ Rudolph SS, Barnung S. Survival after drowning with cardiac arrest and mild hypothermia. ISRN Cardiol. 2011;2011:895625. doi:10.5402/2011/895625
  18. ↑ Bierens JJLM, edWarner D, Knape J. Recommendations and consensus: brain resuscitation in the drowning victim. In: Bierens JJLM, ed. Drowning: Prevention, Rescue, Treatment. Berlin, SpringerVerlag, 2006; pp. 436–439
Created by:
John Kiel on 4 August 2022 16:38:47
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Last edited:
12 August 2022 15:57:06
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