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Submersion Injury
From WikiSM
Contents
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
- Pediatrics
- 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
Risk Factors
- Demographic
- Male[8]
- 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
- Barotrauma of descent
- Otic Barotrauma: "ear squeeze"
- Sinus Barotrauma: "sinus squeeze"
- Mask Squeeze: air in the mask decreases in volume during a dive, creating negative pressure
- Barodentalgia: trapped dental air causing squeeze
- At depth injuries
- Oxygen Toxicity: harmful effects of breathing oxygen at higher partial pressures than normal
- Nitrogen Narcosis: toxic effects of breathing nitrogen-containing gases while at depth
- Hypothermia: decrease core temperature with prolonged exposure to cold water
- Carbon Monoxide Toxicity: CO toxicity typically results from a faulty air compressor
- Caustic Cocktail: Inhalation of absorbent material used to scrub CO2 mixes with water
- Barotrauma of ascent
- Pulmonary Barotrauma: occurs when diver breathing compressed air ascends too rapidly
- Decompression Sickness: Dissolved nitrogen comes out of solution, forms bubbles in blood and tissue ("the bends")
- Arterial Gas Embolism
- Alternobaric vertigo
- Facial baroparesis (Bells Palsy)
- Other
- Immersion Pulmonary Edema: also termed swimming induced pulmonary edema
- Salt water aspiration
- Submersion Injury: includes drowning, near drowning
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
- Standard Chest Radiograph
- Obtain on all patients
- Findings: pulmonary edema
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
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
- Internal
References
- ↑ 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.
- ↑ 2.0 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.
- ↑ 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
- ↑ Layon et al. Drowning: Update 2009. Anesthesiology 2009; 110: pp. 1390
- ↑ 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
- ↑ 6.0 6.1 Bierens JJ, Knape JT, Gelissen HP. Drowning. Curr Opin Crit Care. 2002;8(6):578-586. doi:10.1097/00075198-200212000-00016
- ↑ 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
- ↑ 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.
- ↑ Olshaker JS. Near drowning. Emerg Med Clin North Am. 1992;10(2):339
- ↑ 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.
- ↑ 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
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ Layon AJ, Modell JH. Drowning: Update 2009. Anesthesiology. 2009;110(6):1390-1401. doi:10.1097/ALN.0b013e3181a4c3b8
- ↑ 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.
- ↑ Rudolph SS, Barnung S. Survival after drowning with cardiac arrest and mild hypothermia. ISRN Cardiol. 2011;2011:895625. doi:10.5402/2011/895625
- ↑ 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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