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

2. Near Drowning Objectives
Understand causal conditions
Differentiate between fresh & salt water drownings
Identify potential injuries
Select appropriate diagnostic & management
Consider treatment of hypothermia & trauma

3. Diving Emergency?

4. Definitions Drowning: Near-drowning: AHA no longer uses
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

5. Risk Factors Inability to swim (overestimation of capabilities)
Risk taking behaviour
Inadequate supervision (bathtub, pools)
Co morbidity: trauma, seizure, CVA, cardiac

6. 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

7. End Organ Effect Profound hypoxia Respiratory acidosis, ARDS
Cardiovascular collapse
Neuronal injury
…. Death

8. 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

9. 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!

10. Surfactant is destroyed Atelectasis &  Compliance & Bronchospasm
Submersion Injuries
Fresh water Salt water
No difference 
Surfactant is destroyed
Alveolar instability
Atelectasis &  Compliance & Bronchospasm
V/Q mismatch
Hypoxia

11. 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

12. 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?

13. Management of Care
Prehospital
Emergency
Inpatient

14. 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!)

15. Emergency Department ABC’s Monitor: Rewarming Early airway management
cardiac, CORE T °(rectal)
Rewarming
Passive External
Active External
Active Internal

16. Inpatient Management Goal:
prevent further secondary neurologic injury and minimise end-organ damage.

17. 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

18. 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

19. 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

21. 4 hours later….

22. 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

23. Good vs Bad ???

24. 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

25. 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

26. Who can go home? Asymptomatic on presentation
Maintains normal room air sat
No CXR or ABG abnormalities
…… D/C after 8 hour observation

27. Prevention Children supervision CPR courses to families with pools
Boating sobber & lifevests
Diving injuries
Caution: CAD / Seizure / Diabetics

28. 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

29. Questions ?
Near-Drowning