Submersion Injuries

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Submersion Injuries

• Richard Dionne MD CCFP-EM
• Assistant Professor Emergency Medicine
• Ottawa Hospital-University of Ottawa
• Assistant Medical Director
• Ottawa Base Hospital Paramedic Program
• Fellowship Director EMS Disaster Medicine
• April 2nd, 2008

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Near Drowning Objectives

• Understand causal conditions
• Differentiate between fresh salt water
  drownings
• Identify potential injuries
• Select appropriate diagnostic management
• Consider treatment of hypothermia trauma

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Definitions

• Drowning
• terminal outcome from submersion event
• Near-drowning AHA no longer uses
• Submersion Injuries
• survival, at least temporarily, after
  suffocation in a liquid medium
• 3rd most common cause of accidental death
  overall, leading cause in lt 5 yo
• ETOH / Drugs often associated

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Immersion Syndrome

• Syncope secondary to cardiac dysrhythmias on
  sudden contact with water at least 5oC lt body T
• QT prolongation massive release of
  catecholamines plus vagal stimulation
• gtasystole and VF
• Resultant LOC leads to drowning

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Risk Factors

• Inability to swim (overestimation of capabilities
• Risk taking behaviour
• Substance abuse (in gt50 of adult drownings)
• Inadequate supervision (bathtub)
• Concomitant conditions trauma, seizure, CVA,
  cardiac event

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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

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End Organ Effect

• Profound hypoxia
• Respiratory acidosis, ARDS
• Cardiovascular collapse
• Neuronal injury
• . Death

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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 gt 11 mL/kg
• Most aspirate lt4 mL/kg
• Review of 91 submersion victims, no pt required
  emergent intervention for electrolyte abN
• No significant clinical difference between the
  two!

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Management of Care

• Prehospital
• Emergency
• Inpatient

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Prehospital

• On scene
• Immediate Rescue Breathing (even before out of
  water) Heimlich not proven
• Bystander CPR (pulse check 30 sec.)
• Consider trauma C-spine precautions
• Remove wet clothing, passive exernal rewarming
  (Hypothermia!)

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Emergency Department

• ABCs
• Early airway management
• Cardiac monitor, CORE (rectal) temp
• Immediate rewarming (Hypothermia)
• Passive External
• Active External
• Active Internal

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Inpatient Management

• Goal prevent further secondary neurologic injury
  and minimise end-organ damage.

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Submersion Injuries

• Gen hypothermia, trauma
• GI vomiting (swallow gtgt aspirate)
• Respiratory
• ve pressure ventilation leads to gastric
  distention, risk of aspiration
• Aspiration of particulate contaminants
• Hypoxia from direct surfactant effects
• ARDS

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Submersion Injuries

• CVS dysrhythmias
• CNS initial hypoxic injury or secondary
  reperfusion injury with resuscitation
• Renal ARF due to lactic acidosis, prolonged
  hypoperfusion, rhabdomyolysis
• Heme coagulopathies

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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

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Factors Affecting Survival

• Age
• Water temperature
• Duration degree of hypothermia
• Diving reflex
• Resuscitation efforts
• Prior medical conditions

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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 tolerated
• Cold water speeds development of exhaustion, LOC
  and dysrhythmias

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Poor Prognostic Factors

• gt 10 minutes submersion
• CPR initiated gt10 min after rescue
• Severe acidosis (pH lt 7.1)
• Unreactive pupils
• GCS 3 (comatose)
• Hypothermia in ED ?
• lt 3 yo
• Need for ongoing CPR
• Lack of spontaneous movement at 24hrs

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Who can go home?

• Asymptomatic on presentation
• Maintains normal room air sat
• No CXR or ABG abnormalities
• D/C after 8 hour observation

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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