Submersion Injuries

Alexandra Wilson MD

Drowning -Epidemiology

• 1500 deaths each year
• Males 4x as likely to be involved
• < 4 yrs and 15-19 yo at greatest risk

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Epidemiology-drowning

• Causes:
• 1yo: bathtubs/buckets/NAT
• 1–5-year-old: swimming pools
• 15–19-year-old : bodies of water/ boating /ETOH use

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Drowning

• History
• Submersion time
• Associated trauma
• Attempted rescue maneuvers
• PMH seizures/cardiac/drug ETOH use

Outcome

• Duration of submersion > 5-10 minutes *
• Resuscitation duration >25 minutes
• Glasgow coma scale <5 (i.e., comatose)
• Persistent apnea and requirement of cardiopulmonary resuscitation in the emergency department
• Arterial blood pH <7.1 upon presentation
• Lack of spontaneous purposeful movement at 24 hours ominous

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Cold water or just cold?�

Water temperature not patient temperature is the issue!

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• Hypothermia decreases metabolic rate
• Neuro-protective effects ice water drowning? Water temp < 10^oC/50^oF account for almost all reported cases of survival after prolonged submersion (>15 min)

Drowning-pathophysiology

Pulmonary:

• hypoxemia due to laryngospasm /aspiration
• Surfactant can be diluted/disrupted

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Cardiac:

• Dysfunction due to hypoxemia/metabolic acidosis/pulmonary hypertension
• Dysrhythmias due to acidosis/hypoxia

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Drowning-pathophysiology

• CNS: hypoxemia leading to neuronal cell death
• Systemic: capillary leak, MODS (hepatic, renal, GI, DIC)

Edema fluid

Vasogenic

Cytotoxic

Drowning-treatment

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• Treat ARDS: Intubation/Lung recruitment strategies /Surfactant
• Hemodynamic Stability Volume/ buffer/inotropic support
• Maintain Euglycemia
• Targeted Temperature Management – aim normothermia, possible role for hypothermia
• Avoid hypercapnia, elevate head of bed but no role for other measures taken in patients with TBI ( hyperosmolar therapy, CSF drainage etc. as different pathophysiology and not supported by evidence)

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HIE Nothing new under the sun ( or ice!)

Targeted Temperature Management

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Temperature 32-36 ^O for min 24 hours for unresponsive adults after ROSC followed by slow rewarming

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2015 AHA Guidelines

Case

EMS brings a 2 yo near drowning victim to the ED in full arrest after a 50 min resuscitation. The attending wants to cease CPR but the RN states that the patient’s temperature is only 92°. It is 55 degrees outside . They turn to you for advice- what do you say?

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1. the patient is hypothermic and therefore their prognosis may be better than expected
2. the patient temperature is due to exposure from a prolonged “downtime” and does not improve his prognosis

Caveats in Ischemic Brain Injury

• Neurologic examination - the most important information you have
• Histories may be unreliable/ unavailable
• Difficult to prognosticate and treat based on imaging alone