Submersion Injuries Richard Dionne MD CCFP-EM Avik Nath MD CCFP EM March 21, 2013.
Submersion Injuries
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Transcript of Submersion Injuries
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Submersion Injuries
Richard Dionne MD CCFP-EMAssistant Professor Emergency Medicine
Ottawa Hospital-University of OttawaAssistant Medical Director
Ottawa Base Hospital Paramedic ProgramFellowship 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 < 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 < body T
• QT prolongation & massive release of catecholamines plus vagal stimulation
• =>asystole 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 >50% 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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Profound hypoxiaRespiratory acidosis, ARDS
Cardiovascular collapseNeuronal injury
…. Death
End Organ Effect
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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 > 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!
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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
• ABC’s• 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 >> 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
• > 10 minutes submersion• CPR initiated >10 min after rescue• Severe acidosis (pH < 7.1)• Unreactive pupils• GCS = 3 (comatose)• Hypothermia in ED ?• < 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