Drowning and Submersion Injuries

Authors: Morgan McCarthy, MD (EM Resident Physician, Northwestern Memorial Hospital) and Emilie Powell, MD, MS MBA (Associate Professor of Emergency Medicine, Northwestern Memorial Hospital) // Reviewed by: Edward Lew, MD (@elewMD); Alex Koyfman, MD (@EMHighAK); and Brit Long, MD (@long_brit)

Case:

On a hazy, warm summer Sunday afternoon, the EMS call goes off, you get the brief story: 12-year-old jumped into the Lake and did not resurface, patient was found by bystander submerged in water after 10 minutes and family started CPR immediately until EMTs arrived to site. Arrival time is 4 minutes.


Background:

Drowning is one of the leading causes of accidental deaths across the world [1], and unfortunately a common ED presentation. Each day in the United States, 10 people die due to unintentional drowning, with one in five being children aged 14 and younger [2]. Children ages one to four have the highest drowning rates, making drowning the leading 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]. Many nonfatal submersion injuries result in neurologic disabilities ranging from memory or learning disabilities to permanent vegetative state. While it is most common for children under five to drown in a home pool, as age increases the rates of drowning in natural water such as rivers, lakes, and beaches also increases. Males have a higher incidence [3,4].


Prehospital Care:

The care of a submerged person should focus on ventilation. Loss of surfactant, pulmonary edema, and hypoxia from V/Q mismatch are all results of fluid aspiration in submersion injuries. Hypoxemia is the leading cause for cardiac arrest and neurologic dysfunction, and therefore ventilation should be the main priority [4]. For pre-hospital care, the patient should receive two rescue breaths. If their chest does not rise, CPR should begin immediately [5]. If the patient is hypothermic, pulses may be difficult to palpate, especially in a patient who is bradycardic or in atrial fibrillation. For a patient who is hypothermic, a minute of pulse check should occur prior to chest compressions. Additionally, hypothermia is neuroprotective [6,7]. There have been studies showing complete recovery of patients in cardiac arrest with hypothermia even with several hours of resuscitation required [7].


ED Management:

Airway:

Indications for intubation remain the same: inability to protect the airway and inability to maintain a PaO2 above 60, or SpO2 above 90%, with using high flow nasal cannula, non-rebreather or non-invasive positive pressure ventilation (NIPPV) [6].

 

Breathing:

If the patient is maintaining their airway, supplemental oxygen should be given to maintain SpO2 > 94% by nasal cannula, non-rebreather, or NIPPV (CPAP or BIBPAP). If the patient requires intubation, begin with Acute Respiratory Distress Syndrome (ARDS) settings on the ventilator with a tidal volume of 6-8 mL/kg, a plateau pressure < 30 mmHg, and increased PEEP [8]. At institutions with available resources, ECMO can be used to treat severe pulmonary edema and ARDS with initial data being encouraging but limited [7]. Glucocorticoids are not recommended and may interfere with healing and should not be given. Data is limited on the use of exogenous surfactant. Finally, antibiotics should only be given if water is grossly contaminated [8]. The distinction between fresh and salt water drowning is no longer important as the volume of water aspirated is too small to cause clinically relevant electrolyte shifts. The main issue in both scenarios is the loss of surfactant [9].

 

Circulation:

Common initial arrhythmias following submersion include sinus tachycardia, sinus bradycardia, and atrial fibrillation [9]. Additionally, swimming and diving can induce fatal arrythmias in patients with prolonged QT syndrome [9]. Hypothermia has neuroprotective effects and many studies demonstrate that resuscitations that last up to multiple hours could still have promising functional neurologic outcomes and even complete recovery [10]. However, it is generally accepted that a serum potassium >10 mmol/L (in children >12 years old) is high predictor of poor outcomes. Additionally, a EtCO2 <2 kPa with high quality chest compressions has a poor prognosis. In these cases, prolonged resuscitation may be futile or lead to poor neurologic outcomes [11]. Every symptomatic patient, such as shortness of breath, cough, fatigue, nausea, or vomiting should be monitored in the ED or hospital for a minimum of 6 hours, even if deemed to require no acute interventions at presentation [12].

 

Laboratory Data:

  • CBC
  • CMP
  • Lactate
  • Troponin
  • Blood gas
  • EKG
  • Urine toxicology
  • Blood alcohol level

 

Imaging Data:

  • CXR (Initial CXR may be normal and lag behind symptoms, however is useful in tracking the patient’s condition)
  • Make sure to assess for other signs of trauma. Cervical spine injuries are uncommon (<0.5%), however make note of mechanism of drowning while not letting a c-collar deter from airway protection [13].

Prevention:

Often in the ED we see persons at their most vulnerable, ‘worst case-scenario,’ in which they may need lifesaving care. However, many times we see patients for near-misses, where the opportunity to intervene and discuss drowning and submersion injuries could prevent further injury or even death. Risk factors for drowning include: inadequate supervision by an adult, an overestimation of abilities at swimming or poor swimming skills, risk-taking activities including drugs and alcohol, development of hypothermia while swimming, and seizures or developmental delay in children [1]. Discussing constant supervision in and around water, using a life vest, avoiding alcohol, knowing local conditions, as well as always swimming with a buddy or with lifeguards has great potential to save a life [1,2].


Clinical Pearls:

  • Resuscitation focus should be on ventilation due to loss of surfactant.
  • Hypothermia can be neuroprotective: hours of resuscitation may still lead to complete recovery.
  • Antibiotics should only be given if water was grossly contaminated, glucocorticoids are not recommended, and there is no strong data on the use of surfactant.
  • Symptomatic patients, those with shortness of breath, chest pain, cough, nausea or vomiting, should be monitored in the ED for a minimum for 6 hours and should be counseled on prevention and risk factors for drowning.

References / Further Reading

  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. 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. 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.
  4. Salomez F, Vincent JL. Drowning: a review of epidemiology, pathophysiology, treatment and prevention. Resuscitation. 2004;63(3):261-268. doi:10.1016/j.resuscitation.2004.06.007
  5. 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
  6. 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. Layon AJ, Modell JH. Drowning: Update 2009. Anesthesiology. 2009;110(6):1390-1401. doi:10.1097/ALN.0b013e3181a4c3b8
  9. 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.
  10. 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.
  11. Rudolph SS, Barnung S. Survival after drowning with cardiac arrest and mild hypothermia. ISRN Cardiol. 2011;2011:895625. doi:10.5402/2011/895625.
  12. 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.
  13. Watson RS, Cummings P, Quan L, Bratton S, Weiss NS. Cervical spine injuries among submersion victims. J Trauma. 2001;51(4):658-662. doi:10.1097/00005373-200110000-00006.

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