Submersion injury


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  • In 1995, it accounted for 24% of child injury mortality. The country’s unique geography and the frequent occurrence of typhoons and floods put Filipino children at risk. Typhoons, tropical storms, and floods count as the most common mode of disaster, affecting close to 49 million individuals in a ten-year span.
  • Immersion is to be covered in water. For drowning to occur, usually at least the face and airway are immersed. Submersion is when the entire body, including the airway, is under water.
  • Sudden death may result from cold-induced heart disorders. The victim drowns from loss of consciousness in the water but immersion syndrome is the initiating factor. Cover your face with your hands if you ever fall into icy waters to minimize effects of cold water.
  • Duration of submersion is critical because arterial oxygen tension falls exponentially during asphyxia. The maximum submersion period before irreversible damage occurs is uncertain but probably usually 3-5 min. There have been reported cases of prolonged submersion (10-40 min) with complete recovery especially of children in cold water. Although full recovery is rare after >20 min submersion, CPR should always be tried. The target organ of submersion injury is the lung. The single most important consequence of near-drowning is hypoxemia often associated with acidosis.
  • Although differences observed between fresh-water and salt-water aspirations in electrolyte and fluid imbalances are frequently discussed, they are rarely of any clinical significance for people who have experienced near drowning. The distinction between fresh-water and salt-water submersion injury is primarily academic, as initial treatment is not affected by water type.
  • Acute submersion hypothermia may delay the onset of irreversible damage making complete recovery possible despite prolonged submersion. Uncontrolled involuntary hyperventilation occurs in immersion in a cold medium
  • Acute renal impairment is known to occur frequently in near-drowning and while usually mild (serum creatinine <0.3 mmol/L or 3.4 mg/dL), severe renal impairment requiring dialysis may occur.
  • The most common cause is posthypoxic encephalopathy.
  • Submersion injury

    2. 2. WHO Facts on Drowning Unintentional Injuries in Children <15 years (WHO, 2001)
    3. 4. U.S. Facts <ul><li>In 2000, there were 3,482 unintentional drownings in the United States, an average of 9 people/day. </li></ul><ul><li>Drowning is the 2 nd leading cause of injury-related death among children under <15 years. </li></ul><ul><li>-- U.S. Centers for Disease Control and Prevention </li></ul><ul><li>The majority of children who survive (92%) are discovered within 2 minutes following submersion and most children who die (86%) are found after 10 minutes. Nearly all who require CPR die or are left with severe brain injury. </li></ul><ul><li>-- National Safe Kids Campaign </li></ul>
    4. 5. PPS Statement 2004 <ul><li>Drowning is the leading cause of child injury death in the Philippines (about 8 fatalities:100,000 children age 1-17 years in the 2003 DOH study) </li></ul><ul><li>The Philippines holds the world record for deaths at sea as well as the world record for the worst single tragedy at sea (an average of 1 shipping tragedy per year since 1987) </li></ul><ul><li>The Philippines is also considered the most disaster-prone country in the world, having been hit with 10 major disasters per year since 1991 </li></ul><ul><li>Young children are susceptible to home drowning, older child victims drown at public pools and natural bodies of water while alcohol use accounts for a significant portion of adolescent and young adult drowning </li></ul>
    5. 6. Definition <ul><li>Drowning </li></ul><ul><ul><li>The process of experiencing respiratory impairment from submersion/immersion in liquid </li></ul></ul><ul><ul><li>Drowning outcomes: Death, Morbidity and No morbidity </li></ul></ul><ul><li>-- 2002 World Congress on Drowning </li></ul>
    6. 7. Definition <ul><li>Immersion Syndrome </li></ul><ul><ul><li>Syncope resulting from cardiac dysrhythmias on sudden contact with water that is < 5 0 C </li></ul></ul><ul><ul><li>The mammalian diving reflex occurring and producing apnea, bradycardia, and vasoconstriction of nonessential vascular beds with shunting of blood to the coronary and cerebral circulation </li></ul></ul>
    7. 8. Definition <ul><li>Secondary Drowning </li></ul><ul><ul><li>Death or serious clinical deterioration following a near-drowning event </li></ul></ul><ul><ul><li>Caused by deficient alveolar gas exchange due to primary alveolar membrane dysfunction and loss of surfactant </li></ul></ul><ul><ul><li>Characterized by a latent period of 1-48 hours of relative respiratory well-being </li></ul></ul><ul><ul><li>Can happen after fresh or salt water immersion </li></ul></ul><ul><ul><li>Occurs in 2-5% of all submersion incidents </li></ul></ul>
    8. 9. Definition <ul><li>Drowning: Submersion in water causing suffocation and death within the 1 st 24 hr </li></ul><ul><li>Near-drowning: A submersion incident in which there is survival for at least 24 hr irrespective of eventual outcome </li></ul><ul><li>Near-drowning with delayed death: When a near-drowning victim later dies </li></ul>
    9. 10. Definition <ul><li>Scenario 1 </li></ul><ul><li>15-yr-old boy rescued by the life guard from the swimming pool, off the water coughing with no respiratory distress. </li></ul><ul><li>Water Rescue: Minimal manifestations not requiring interventions or transport to the ER </li></ul>
    10. 11. Definition <ul><li>Scenario 2 </li></ul><ul><li>2-yr-boy found by his mother unresponsive at the bottom of the bathtub. CPR started and EMT transported him to the ER. Child regained his consciousness and was vigorously crying in the ER. </li></ul><ul><li>Submersion (Near-drowning) Victim: Significant manifestations requiring interventions and transport to the ER </li></ul>
    11. 12. Definition <ul><li>Scenario 3 </li></ul><ul><li>12-yr-old boy found in the middle of a swimming pool unresponsive, last seen by friends 3 hours ago. Resuscitated but died 3 days later in the ICU. </li></ul><ul><li>Drowned Victim: A fatal event regardless to the time of occurrence </li></ul>
    12. 13. International Liaison Committee on Resuscitation (ILCOR) Advisory Statement* <ul><li>The following terms should be abandoned : </li></ul><ul><ul><li>Dry versus Wet drowning </li></ul></ul><ul><ul><li>Active versus Passive versus Silent drowning (Witnessed vs Unwitnessed) </li></ul></ul><ul><ul><li>Secondary drowning </li></ul></ul><ul><ul><li>Drowned and Near-drowned </li></ul></ul><ul><li>*Idris AH, Berg RA, Bierens J, et al. Recommended Guidelines for Uniform Reporting of Data from Drowning: The &quot;Utstein Style” Circulation. 2003;108:2565-2574 </li></ul>
    13. 14. Classification <ul><li>According to type of water </li></ul><ul><ul><li>Fresh-water drowning: occurs in hypotonic water such as pools or rivers </li></ul></ul><ul><ul><li>Salt-water drowning: occurs in hypertonic water such as seas (about 3% saline) </li></ul></ul><ul><li>According to water temperature </li></ul><ul><ul><li>Warm-water drowning: occurs at water temperatures of > 20° C </li></ul></ul><ul><ul><li>Cold-water drowning: occurs at water temperatures of <20° C </li></ul></ul><ul><ul><li>Very-cold-water drowning: refers to submersion in water at temperatures of < 5° C </li></ul></ul>
    14. 15. Pathophysiology Dry drowning, 10-20%, secondary to Airway Hypoxemia Multi-organ effects Wet drowning, 80-90%, secondary to Aspiration Submersion Incident (Critical period probably 3-5 min) Involuntary Gasping (Aspiration of water into the hypopharynx Laryngospasm (Parasympathetically mediated
    15. 16. Nature of Inhaled Fluid <ul><li>Fresh-water : Hypotonic  inactivation of pulmonary surfactant  atelectasis  poorly compliant lung  intrapulmonary shunting  ventilation-perfusion mismatching  hypoxemia </li></ul><ul><li>Salt-water : Hypertonic  osmotic gradient  protein-rich intravascular fluid into already fluid-filled alveoli  increased intrapulmonary shunting  ventilation-perfusion abnormality  hypoxemia </li></ul>
    16. 17. Fluid Temperature & Absorption <ul><li>Aspirated cold fresh water is rapidly absorbed, can cause significant “core” cooling including cerebral hypothermia </li></ul><ul><li>Aspirated cold sea water less likely to be rapidly absorbed, can cause intense central cooling </li></ul><ul><li>Submersion in icy water with hyperventilation  massive absorption  severe intravascular hemolysis with hyperkalemic circulatory arrest </li></ul><ul><li>Usually smaller volumes aspirated  mild hemolysis with hematuria and possible renal failure </li></ul><ul><li>Submersion in stagnant, warm fresh water may result in massive gram-negative pneumonia </li></ul>
    17. 18. Volume of Fluid Aspiration <ul><li>Most patients have fluid aspiration of <4 ml/kg </li></ul><ul><li>Acute fluid aspiration of as little as 2.2 ml/kg produces a profound decrease in arterial oxygen tension </li></ul><ul><li>After aspiration of 11 ml/kg of fresh or sea water, the PaO 2 consistently drops to 30-40 mm Hg and remains depressed for at least 72 hr in survivors </li></ul><ul><li>Aspiration of >22 ml/kg is required before significant intravascular volume and electrolyte changes develop </li></ul><ul><li>Ingestion, rather than aspiration, is more likely to cause clinically significant electrolyte imbalances, including hyponatremia from ingestion of large volumes of fresh water (especially in children) </li></ul>
    18. 19. Hypoxia Results <ul><li>Gradual decrease in cardiac output </li></ul><ul><li>Intense vasoconstriction leading to further decrease in cardiac output and hypotension </li></ul><ul><li>Brain is severely damaged </li></ul><ul><li>Eventually cardiac arrest, gradual asystole rather than ventricular fibrillation </li></ul>
    19. 20. Children Versus Adults <ul><li>Lower ratio of body mass to surface area…….Hypothermia develops quickly ........ ? Neuroprotective </li></ul><ul><li>The diving reflex may play protective role in infants and children </li></ul>
    20. 21. <ul><li>Sex: </li></ul><ul><ul><li>M:F ratios approximately 12:1 for boat-related drowningsand 4:1 for non–boat-related drowning </li></ul></ul><ul><ul><li>In bathtub incidents girls predominate in incidence </li></ul></ul><ul><li>Age incidence: </li></ul><ul><ul><li>Children younger than 4 years </li></ul></ul><ul><ul><li>Young adults aged 15-24 years </li></ul></ul>Prevention of Drowning in Infants, Children and Adolescents. Pediatrics 2003 August;112(2):440-445.
    21. 23. Some Precipitating Events <ul><li>Syncope or seizure </li></ul><ul><li>Impairment of judgment, level of consciousness and/or motor function by drugs, alcohol or hypothermia </li></ul><ul><li>Unconsciousness from any other cause </li></ul><ul><li>Circulatory arrest (e. g. pulseless electrical activity or ventricular fibrillation) </li></ul><ul><li>Hyperventilation before breathholding under water </li></ul><ul><li>Trauma </li></ul>
    22. 24. <ul><li>Taken by primary author to illustrate shallow water blackout how such drownings really appear. The traditional image of drowning involves the splashing, waving and shouting that one has come to expect from the movies. In reality, victims usually go silently and without any visible struggle to attract attention and in pools they are discovered exactly like in this picture. The pool you see in the picture (in Darwin, NT, Australia) actually suffered a shallow water blackout incident two years before this staged picture and the photograph shows exactly how the victim was discovered. </li></ul><ul><li> </li></ul>
    23. 25. A sign with 83 tally marks warns hikers on the trail to Hanakapiai Beach, Hawaii. Children have drowned in buckets and toilets.
    24. 26. Clinical Manifestations <ul><li>Asymptomatic </li></ul><ul><li>Symptomatic </li></ul><ul><ul><li>Altered vital signs (e. g. hypothermia, tachycardia, bradycardia) </li></ul></ul><ul><ul><li>Anxious appearance </li></ul></ul><ul><ul><li>Tachypnea, dyspnea, or hypoxia (if dyspnea occurs, no matter how slight, the patient is considered symptomatic) </li></ul></ul><ul><ul><li>Metabolic acidosis (may exist in asymptomatic patients as well) </li></ul></ul><ul><ul><li>Altered level of consciousness, with neurological deficit </li></ul></ul>
    25. 27. Clinical Manifestations <ul><li>Cardiopulmonary arrest </li></ul><ul><ul><li>Apnea </li></ul></ul><ul><ul><li>Asystole (55%), ventricular tachycardia/fibrillation (29%), bradycardia (16%) </li></ul></ul><ul><ul><li>Immersion syndrome </li></ul></ul><ul><li>Obviously dead </li></ul><ul><ul><li>Normothermic with asystole </li></ul></ul><ul><ul><li>Apnea </li></ul></ul><ul><ul><li>Rigor mortis </li></ul></ul><ul><ul><li>Dependent lividity </li></ul></ul><ul><ul><li>No apparent CNS function </li></ul></ul>
    26. 28. Treatment: Prehospital <ul><li>Don’t drain water from lungs </li></ul><ul><li>No Heimlich unless with evidence of airway obstruction </li></ul>
    27. 29. Investigations <ul><li>Arterial blood gases </li></ul><ul><ul><li>Arterial blood gas (ABG) analysis probably the most reliable clinical parameter in patients who are asymptomatic or mildly symptomatic; a surprising degree of hypoxia can exist without clinical signs </li></ul></ul><ul><li>Draw blood for a rapid glucose determination, CBC, electrolyte levels, lactate level, and coagulation profile and collect urine for urinalysis, if indicated </li></ul><ul><ul><li>If initial tests show elevated serum creatinine, marked metabolic acidosis, abnormal urinalysis, or significant lymphocytosis, serial estimations of serum creatinine should be performed </li></ul></ul>
    28. 30. Investigations <ul><li>Consider blood alcohol level and urine toxicology screen for use of drugs </li></ul><ul><li>Chest radiograph </li></ul><ul><ul><li>For evidence of aspiration, pulmonary edema or segmental atelectasis and evaluation of ET placement </li></ul></ul><ul><li>Cervical spine radiograph or CT scan in individuals with an appropriate history of neck pain, or if doubt exists </li></ul><ul><ul><li>Non-contrast head CT scan in an individual with altered mental status and unclear history </li></ul></ul><ul><li>Continuous pulse oximetry </li></ul><ul><li>Electrocardiogram if evidence of significant tachycardia, bradycardia, or dysrhythmia </li></ul>
    29. 31. Procedures <ul><li>ET and mechanical ventilation may be indicated in awake individuals unable to maintain adequate oxygenation on O 2 by mask or via continuous positive airway pressure (CPAP) or in whom airway protection is warranted </li></ul><ul><li>Other criteria for ET intubation include the following: </li></ul><ul><ul><li>Altered level of consciousness and inability to protect airway or handle secretions </li></ul></ul><ul><ul><li>High alveolar-arterial (A-a) gradient - PaO 2 of 60-80 mm Hg or less on 15 L oxygen non-rebreathing mask </li></ul></ul><ul><ul><li>Respiratory failure - PaCO 2 >45 mm Hg </li></ul></ul><ul><ul><li>Worsening ABG results </li></ul></ul>
    30. 32. Procedures <ul><li>Intubated victims may require positive end-expiratory pressure (PEEP) with mechanical ventilation to maintain adequate oxygenation; PEEP may improve ventilation patterns in the noncompliant lung by: </li></ul><ul><ul><li>Shifting interstitial pulmonary water into the capillaries </li></ul></ul><ul><ul><li>Increasing lung volume via prevention of expiratory airway collapse </li></ul></ul><ul><ul><li>Providing better alveolar ventilation and decreasing capillary blood flow </li></ul></ul><ul><ul><li>Increasing the diameter of both small and large airways to improve distribution of ventilation </li></ul></ul>
    31. 33. Procedures <ul><li>Extracorporeal membrane oxygenation (ECMO) has been shown to be beneficial in individuals with respiratory compromise despite intubation and aggressive mechanical ventilation and persistent hypothermia unresponsive to other warming methods </li></ul><ul><li>Bronchoscopy may be necessary for removal of significant inhaled sediment </li></ul><ul><li>Aggressive warming, with method dependent on the degree of hypothermia and the patient's response </li></ul><ul><li>Central venous pressure monitoring may be warranted </li></ul><ul><li>Urinary catheterization for ongoing urine output measurement may be warranted </li></ul>
    32. 35. Prognosis <ul><li>About 75% of near-drowning victims who receive medical treatment survive ( or 20-25% mortality rate ) </li></ul><ul><li>Among the survivors, most serious outcome is neurological damage, reported incidence is 0-21% </li></ul><ul><li>Comatose patients on arrival at the hospital who required appropriate CPR were found to have nearly a 50% survival rate without brain damage whether treated mildly or aggressively </li></ul><ul><li>In general, severe anoxic injury occurs in: </li></ul><ul><ul><li>Flaccid, comatose patient </li></ul></ul><ul><ul><li>Submersion >6 min in warm water </li></ul></ul><ul><ul><li>In those requiring CPR in the ER </li></ul></ul><ul><ul><li>In those needing continuous mechanical ventilation </li></ul></ul>
    33. 36. Mortality Causes In Hospitalized Drowning Victims <ul><li>Brain death attributable to severe hypoxic or ischemic brain injury </li></ul><ul><li>Acute respiratory distress syndrome (ARDS) </li></ul><ul><li>Multi-organ system dysfunction secondary to severe hypoxic or ischemic insult </li></ul><ul><li>Sepsis syndrome attributable to aspiration pneumonia or nosocomial infections </li></ul>
    34. 37. Predictors of Neurological Outcome <ul><li>Orlowski Score*: 1 point for each of five unfavorable factors if present </li></ul><ul><ul><li>Age <3 yr </li></ul></ul><ul><ul><li>Maximum submersion time estimated >5 min </li></ul></ul><ul><ul><li>No resuscitative efforts for > 10 min after rescue </li></ul></ul><ul><ul><li>Comatose on admission to ER </li></ul></ul><ul><ul><li>Arterial pH < 7.10 </li></ul></ul><ul><li>Score of < 2 = >90% chance of full recovery </li></ul><ul><li>Score of > 3 = 5% probability of survival </li></ul><ul><li>*Orlowski JP. Prognostic Factors in Pediatric Cases of Drowning and Near-drowning. JACEP 1979 May;8(5):176-9. </li></ul>
    35. 38. Predictors of Neurological Outcome
    36. 39. *Zuckerman GB, Gregory PM & Santos-Damiani SM. Predictors of Death and Neurologic Impairment in Pediatric Submersion Injuries. Arch Pediatr Adolesc Med. 1998 Feb;152(2):134-40.
    37. 40. Preventive Measures* <ul><li>Four-Sided Fencing of Pools </li></ul><ul><li>Pool Alarms and Pool Covers </li></ul><ul><li>Swimming Instruction </li></ul><ul><li>Supervision/Lifeguards </li></ul><ul><li>Resuscitation </li></ul><ul><li>Personal Flotation Devices </li></ul><ul><li>*Report of Brenner RA and Committee on Injury, Violence, and Poison Prevention. Prevention of Drowning in Infants, Children and Adolescents. Pediatrics 2003 August;112(2):440-445. </li></ul>
    38. 41. Vasily, Perov: The Drowned , 1867 &quot;Victims go quietly, often unnoticed.&quot; Thank You!