Submersion injury

SUBMERSION SUBMERSION INJURYINJURY

(NEAR-DROWNING)(NEAR-DROWNING)

Myrna D.C. San Pedro, MD, FPPSMyrna D.C. San Pedro, MD, FPPS

WHO Facts on DrowningWHO Facts on Drowning

Unintentional Injuries in Children <15 years (WHO, 2001)

U.S. FactsU.S. Facts

• In 2000, there were 3,482 unintentional drownings in In 2000, there were 3,482 unintentional drownings in the United States, an average of 9 people/day. the United States, an average of 9 people/day.

• Drowning is the 2Drowning is the 2ndnd leading cause of injury-related leading cause of injury-related death among children under <15 years.death among children under <15 years.

-- U.S. Centers for Disease Control and Prevention-- U.S. Centers for Disease Control and Prevention

• The majority of children who survive (92%) are The majority of children who survive (92%) are discovered within 2 minutes following submersion and discovered within 2 minutes following submersion and most children who die (86%) are found after 10 most children who die (86%) are found after 10 minutes. Nearly all who require CPR die or are left with minutes. Nearly all who require CPR die or are left with severe brain injury.severe brain injury.

-- National Safe Kids Campaign-- National Safe Kids Campaign

PPS Statement 2004PPS Statement 2004• Drowning is the leading cause of child injury death in Drowning is the leading cause of child injury death in

the Philippines (about 8 fatalities:100,000 children age the Philippines (about 8 fatalities:100,000 children age 1-17 years in the 2003 DOH study)1-17 years in the 2003 DOH study)

• The Philippines holds the world record for deaths at sea The Philippines holds the world record for deaths at sea as well as the world record for the worst single tragedy as well as the world record for the worst single tragedy at sea (an average of 1 shipping tragedy per year since at sea (an average of 1 shipping tragedy per year since 1987)1987)

• The Philippines is also considered the most disaster-The Philippines is also considered the most disaster-prone country in the world, having been hit with 10 prone country in the world, having been hit with 10 major disasters per year since 1991major disasters per year since 1991

• Young children are susceptible to home drowning, older Young children are susceptible to home drowning, older child victims drown at public pools and natural bodies of child victims drown at public pools and natural bodies of water while alcohol use accounts for a significant water while alcohol use accounts for a significant portion of adolescent and young adult drowningportion of adolescent and young adult drowning

DefinitionDefinition

• DrowningDrowning The process of experiencing The process of experiencing

respiratory impairment from respiratory impairment from submersion/immersionsubmersion/immersion in liquid in liquid

Drowning outcomes: Death, Drowning outcomes: Death, Morbidity and No morbidityMorbidity and No morbidity

-- -- 2002 World Congress on 2002 World Congress on DrowningDrowning

DefinitionDefinition• Immersion SyndromeImmersion Syndrome

Syncope resulting from cardiac Syncope resulting from cardiac dysrhythmias on sudden contact with dysrhythmias on sudden contact with water that is water that is <<5500 C C

The mammalian diving reflex The mammalian diving reflex occurring and producing apnea, occurring and producing apnea, bradycardia, and vasoconstriction of bradycardia, and vasoconstriction of nonessential vascular beds with nonessential vascular beds with shunting of blood to the coronary and shunting of blood to the coronary and cerebral circulation cerebral circulation

DefinitionDefinition• Secondary DrowningSecondary Drowning

Death or serious clinical deterioration Death or serious clinical deterioration following a near-drowning eventfollowing a near-drowning event

Caused by deficient alveolar gas exchange Caused by deficient alveolar gas exchange due to primary alveolar membrane due to primary alveolar membrane dysfunction and loss of surfactantdysfunction and loss of surfactant

Characterized by a latent period of 1-48 Characterized by a latent period of 1-48 hours of relative respiratory well-beinghours of relative respiratory well-being

Can happen after fresh or salt water Can happen after fresh or salt water immersionimmersion

Occurs in 2-5% of all submersion incidentsOccurs in 2-5% of all submersion incidents


• Drowning: Drowning: Submersion in water causing Submersion in water causing suffocation and death within the 1suffocation and death within the 1stst 24 hr 24 hr

• Near-drowning: Near-drowning: A submersion incident in A submersion incident in which there is survival for at least 24 hr which there is survival for at least 24 hr irrespective of eventual outcomeirrespective of eventual outcome

• Near-drowning with delayed death:Near-drowning with delayed death: When a near-drowning victim later diesWhen a near-drowning victim later dies


• Scenario 1Scenario 115-yr-old boy rescued by the life 15-yr-old boy rescued by the life guard from the swimming pool, off guard from the swimming pool, off the water coughing with no the water coughing with no respiratory distress.respiratory distress.

• Water Rescue:Water Rescue: Minimal Minimal manifestations not requiring manifestations not requiring interventions or transport to the ERinterventions or transport to the ER

DefinitionDefinition• Scenario 2Scenario 2

2-yr-boy found by his mother unresponsive 2-yr-boy found by his mother unresponsive at the bottom of the bathtub. CPR started at the bottom of the bathtub. CPR started and EMT transported him to the ER. Child and EMT transported him to the ER. Child regained his consciousness and was regained his consciousness and was vigorously crying in the ER.vigorously crying in the ER.

• Submersion (Near-drowning) Victim:Submersion (Near-drowning) Victim: Significant manifestations requiring Significant manifestations requiring interventions and transport to the ERinterventions and transport to the ER

DefinitionDefinition• Scenario 3Scenario 3

12-yr-old boy found in the middle of a 12-yr-old boy found in the middle of a swimming pool unresponsive, last swimming pool unresponsive, last seen by friends 3 hours ago. seen by friends 3 hours ago. Resuscitated but died 3 days later in Resuscitated but died 3 days later in the ICU.the ICU.

• Drowned Victim:Drowned Victim: A fatal event A fatal event regardless to the time of occurrenceregardless to the time of occurrence

International Liaison Committee on International Liaison Committee on Resuscitation (ILCOR) Resuscitation (ILCOR) Advisory Advisory Statement*Statement*

• The following terms should be The following terms should be abandonedabandoned:: Dry versus Wet drowningDry versus Wet drowning Active versus Passive versus Silent Active versus Passive versus Silent

drowning (Witnessed vs Unwitnessed)drowning (Witnessed vs Unwitnessed) Secondary drowningSecondary drowning Drowned and Near-drownedDrowned and Near-drowned*Idris AH, Berg RA, Bierens J, et al. *Idris AH, Berg RA, Bierens J, et al. Recommended Guidelines for Uniform Recommended Guidelines for Uniform Reporting of Data from Drowning: The Reporting of Data from Drowning: The "Utstein Style” "Utstein Style” Circulation.Circulation. 2003;108:2565- 2003;108:2565-25742574

ClassificationClassification• According to type of waterAccording to type of water

1)1) Fresh-water drowning: Fresh-water drowning: occurs in hypotonic occurs in hypotonic water such as pools or riverswater such as pools or rivers

2)2) Salt-water drowning: Salt-water drowning: occurs in hypertonic occurs in hypertonic water such as seas (about 3% saline) water such as seas (about 3% saline)

• According to water temperatureAccording to water temperature1)1) Warm-water drowning: Warm-water drowning: occurs at water occurs at water

temperatures of temperatures of >>20° C20° C2)2) Cold-water drowning: Cold-water drowning: occurs at water occurs at water

temperatures of <20° Ctemperatures of <20° C3)3) Very-cold-water drowning: Very-cold-water drowning: refers to refers to

submersion in water at temperatures of submersion in water at temperatures of <<5° C5° C

PathophysiologyPathophysiology

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

Nature of Inhaled FluidNature of Inhaled Fluid• Fresh-waterFresh-water: Hypotonic : Hypotonic inactivation of inactivation of

pulmonary surfactant pulmonary surfactant atelectasis atelectasis poorly compliant lung poorly compliant lung intrapulmonary intrapulmonary shunting shunting ventilation-perfusion ventilation-perfusion mismatching mismatching hypoxemia hypoxemia

• Salt-waterSalt-water: Hypertonic : Hypertonic osmotic gradient osmotic gradient protein-rich intravascular fluid into protein-rich intravascular fluid into already fluid-filled alveoli already fluid-filled alveoli increased increased intrapulmonary shunting intrapulmonary shunting ventilationventilation-perfusion abnormality perfusion abnormality hypoxemia hypoxemia

Fluid Temperature & Fluid Temperature & AbsorptionAbsorption• Aspirated cold fresh water is rapidly absorbed, can Aspirated cold fresh water is rapidly absorbed, can

cause significant “core” cooling including cerebral cause significant “core” cooling including cerebral hypothermiahypothermia

• Aspirated cold sea water less likely to be rapidly Aspirated cold sea water less likely to be rapidly absorbed, can cause intense central coolingabsorbed, can cause intense central cooling

• Submersion in icy water with hyperventilation Submersion in icy water with hyperventilation massive absorption massive absorption severe intravascular severe intravascular hemolysis with hyperkalemic circulatory arresthemolysis with hyperkalemic circulatory arrest

• Usually smaller volumes aspirated Usually smaller volumes aspirated mild mild hemolysis with hematuria and possible renal hemolysis with hematuria and possible renal failurefailure

• Submersion in stagnant, warm fresh water may Submersion in stagnant, warm fresh water may result in massive gram-negative pneumonia result in massive gram-negative pneumonia

Volume of Fluid Volume of Fluid AspirationAspiration

• Most patients have fluid aspiration of <4 ml/kgMost patients have fluid aspiration of <4 ml/kg• Acute fluid aspiration of as little as 2.2 ml/kg Acute fluid aspiration of as little as 2.2 ml/kg

produces a profound decrease in arterial oxygen produces a profound decrease in arterial oxygen tensiontension

• After aspiration of 11 ml/kg of fresh or sea water, After aspiration of 11 ml/kg of fresh or sea water, the PaOthe PaO22 consistently drops to 30-40 mm Hg and consistently drops to 30-40 mm Hg and remains depressed for at least 72 hr in survivorsremains depressed for at least 72 hr in survivors

• Aspiration of >22 ml/kg is required before Aspiration of >22 ml/kg is required before significant intravascular volume and electrolyte significant intravascular volume and electrolyte changes developchanges develop

• Ingestion, rather than aspiration, is more likely to Ingestion, rather than aspiration, is more likely to cause clinically significant electrolyte imbalances, cause clinically significant electrolyte imbalances, including hyponatremia from ingestion of large including hyponatremia from ingestion of large volumes of fresh water (especially in children) volumes of fresh water (especially in children)

Hypoxia ResultsHypoxia Results• Gradual decrease in cardiac Gradual decrease in cardiac

outputoutput• Intense vasoconstriction leading Intense vasoconstriction leading

to further decrease in cardiac to further decrease in cardiac output and hypotensionoutput and hypotension

• Brain is severely damagedBrain is severely damaged• Eventually cardiac arrest, Eventually cardiac arrest,

gradual asystole rather than gradual asystole rather than ventricular fibrillationventricular fibrillation

Children Versus AdultsChildren Versus Adults

• Lower ratio of body mass to Lower ratio of body mass to surface area…….Hypothermia surface area…….Hypothermia develops quickly ........ ? develops quickly ........ ? NeuroprotectiveNeuroprotective

• The diving reflex may play The diving reflex may play protective role in infants and protective role in infants and childrenchildren

• Sex:Sex: M:F ratios approximately 12:1 for boat-related M:F ratios approximately 12:1 for boat-related

drowningsand 4:1 for non–boat-related drowningdrowningsand 4:1 for non–boat-related drowning In bathtub incidents girls predominate in incidenceIn bathtub incidents girls predominate in incidence

• Age incidence:Age incidence: Children younger than 4 yearsChildren younger than 4 years Young adults aged 15-24 yearsYoung adults aged 15-24 years

Prevention of Drowning in Infants, Children and Adolescents. Pediatrics 2003 August;112(2):440-445.

Some Precipitating Some Precipitating EventsEvents• Syncope or seizureSyncope or seizure• Impairment of judgment, level of Impairment of judgment, level of

consciousness and/or motor function consciousness and/or motor function by drugs, alcohol or hypothermiaby drugs, alcohol or hypothermia

• Unconsciousness from any other causeUnconsciousness from any other cause• Circulatory arrest (e. g. pulseless Circulatory arrest (e. g. pulseless

electrical activity or ventricular electrical activity or ventricular fibrillation)fibrillation)

• Hyperventilation before breathholding Hyperventilation before breathholding under waterunder water

• TraumaTrauma

Taken by primary author to Taken by primary author to illustrate shallow water blackout illustrate shallow water blackout how such drownings really how such drownings really appear. The traditional image of appear. The traditional image of drowning involves the splashing, drowning involves the splashing, waving and shouting that one has waving and shouting that one has come to expect from the movies. come to expect from the movies. In reality, victims usually go In reality, victims usually go silently and without any visible silently and without any visible struggle to attract attention and struggle to attract attention and in pools they are discovered in pools they are discovered exactly like in this picture. The exactly like in this picture. The pool you see in the picture (in pool you see in the picture (in Darwin, NT, Australia) actually Darwin, NT, Australia) actually suffered a shallow water blackout suffered a shallow water blackout incident two years before this incident two years before this staged picture and the staged picture and the photograph shows exactly how photograph shows exactly how the victim was discovered.the victim was discovered.

http://en.wikipedia.org/wiki/http://en.wikipedia.org/wiki/DrowningDrowning

A sign with 83 tally A sign with 83 tally marks warns hikers on marks warns hikers on the trail to Hanakapiai the trail to Hanakapiai Beach, Hawaii. Beach, Hawaii.

Children have Children have drowned in buckets drowned in buckets and toilets.and toilets.

http://en.wikipedia.org/wiki/Drowninghttp://en.wikipedia.org/wiki/Drowning

Clinical ManifestationsClinical Manifestations1.1. AsymptomaticAsymptomatic

2.2. SymptomaticSymptomatic• Altered vital signs (e. g. hypothermia, Altered vital signs (e. g. hypothermia,

tachycardia, bradycardia)tachycardia, bradycardia)• Anxious appearanceAnxious appearance• Tachypnea, dyspnea, or hypoxia (if Tachypnea, dyspnea, or hypoxia (if

dyspnea occurs, no matter how slight, the dyspnea occurs, no matter how slight, the patient is considered symptomatic) patient is considered symptomatic)

• Metabolic acidosis (may exist in Metabolic acidosis (may exist in asymptomatic patients as well) asymptomatic patients as well)

• Altered level of consciousness, with Altered level of consciousness, with neurological deficitneurological deficit

Clinical ManifestationsClinical Manifestations3.3. Cardiopulmonary arrestCardiopulmonary arrest

• ApneaApnea• Asystole (55%), ventricular Asystole (55%), ventricular

tachycardia/fibrillation (29%), tachycardia/fibrillation (29%), bradycardia (16%)bradycardia (16%)

• Immersion syndrome Immersion syndrome 4.4. Obviously deadObviously dead

• Normothermic with asystoleNormothermic with asystole• ApneaApnea• Rigor mortisRigor mortis• Dependent lividityDependent lividity• No apparent CNS functionNo apparent CNS function

Treatment: PrehospitalTreatment: Prehospital

• Don’t drain Don’t drain water from water from lungslungs

• No Heimlich No Heimlich unless with unless with evidence of evidence of airway airway obstructionobstruction

InvestigationsInvestigations• Arterial blood gasesArterial blood gases

Arterial blood gas (ABG) analysis probably the Arterial blood gas (ABG) analysis probably the most reliable clinical parameter in patients who are most reliable clinical parameter in patients who are asymptomatic or mildly symptomatic; a surprising asymptomatic or mildly symptomatic; a surprising degree of hypoxia can exist without clinical signsdegree of hypoxia can exist without clinical signs

• Draw blood for a rapid glucose determination, CBC, Draw blood for a rapid glucose determination, CBC, electrolyte levels, lactate level, and coagulation electrolyte levels, lactate level, and coagulation profile and collect urine for urinalysis, if indicatedprofile and collect urine for urinalysis, if indicated If initial tests show elevated serum creatinine, If initial tests show elevated serum creatinine,

marked metabolic acidosis, abnormal urinalysis, or marked metabolic acidosis, abnormal urinalysis, or significant lymphocytosis, serial estimations of significant lymphocytosis, serial estimations of serum creatinine should be performedserum creatinine should be performed

InvestigationsInvestigations• Consider blood alcohol level and urine toxicology Consider blood alcohol level and urine toxicology

screen for use of drugsscreen for use of drugs• Chest radiographChest radiograph

For evidence of aspiration, pulmonary edema or For evidence of aspiration, pulmonary edema or segmental atelectasis and evaluation of ET segmental atelectasis and evaluation of ET placementplacement

• Cervical spine radiograph or CT scan in individuals Cervical spine radiograph or CT scan in individuals with an appropriate history of neck pain, or if with an appropriate history of neck pain, or if doubt existsdoubt exists Non-contrast head CT scan in an individual with Non-contrast head CT scan in an individual with

altered mental status and unclear historyaltered mental status and unclear history• Continuous pulse oximetryContinuous pulse oximetry• Electrocardiogram if evidence of significant Electrocardiogram if evidence of significant

tachycardia, bradycardia, or dysrhythmiatachycardia, bradycardia, or dysrhythmia

ProceduresProcedures• ET and mechanical ventilation may be indicated in ET and mechanical ventilation may be indicated in

awake individuals unable to maintain adequate awake individuals unable to maintain adequate oxygenation on Ooxygenation on O22 by mask or via continuous positive by mask or via continuous positive airway pressure (CPAP) or in whom airway protection is airway pressure (CPAP) or in whom airway protection is warrantedwarranted

• Other criteria for ET intubation include the following: Other criteria for ET intubation include the following: Altered level of consciousness and inability to Altered level of consciousness and inability to

protect airway or handle secretions protect airway or handle secretions High alveolar-arterial (A-a) gradient - PaOHigh alveolar-arterial (A-a) gradient - PaO2 2 of 60-80 of 60-80

mm Hg or less on 15 L oxygen non-rebreathing mask mm Hg or less on 15 L oxygen non-rebreathing mask Respiratory failure - PaCORespiratory failure - PaCO22 >45 mm Hg >45 mm Hg Worsening ABG resultsWorsening ABG results

ProceduresProcedures• Intubated victims may require positive end-expiratory Intubated victims may require positive end-expiratory

pressure (PEEP) with mechanical ventilation to pressure (PEEP) with mechanical ventilation to maintain adequate oxygenation; PEEP may improve maintain adequate oxygenation; PEEP may improve ventilation patterns in the noncompliant lung by:ventilation patterns in the noncompliant lung by: Shifting interstitial pulmonary water into the Shifting interstitial pulmonary water into the

capillariescapillaries Increasing lung volume via prevention of Increasing lung volume via prevention of

expiratory airway collapseexpiratory airway collapse Providing better alveolar ventilation and Providing better alveolar ventilation and

decreasing capillary blood flowdecreasing capillary blood flow Increasing the diameter of both small and large Increasing the diameter of both small and large

airways to improve distribution of ventilationairways to improve distribution of ventilation

ProceduresProcedures• Extracorporeal membrane oxygenation (ECMO) has Extracorporeal membrane oxygenation (ECMO) has

been shown to be beneficial in individuals with been shown to be beneficial in individuals with respiratory compromise despite intubation and respiratory compromise despite intubation and aggressive mechanical ventilation and persistent aggressive mechanical ventilation and persistent hypothermia unresponsive to other warming methodshypothermia unresponsive to other warming methods

• Bronchoscopy may be necessary for removal of Bronchoscopy may be necessary for removal of significant inhaled sedimentsignificant inhaled sediment

• Aggressive warming, with method dependent on the Aggressive warming, with method dependent on the degree of hypothermia and the patient's responsedegree of hypothermia and the patient's response

• Central venous pressure monitoring may be Central venous pressure monitoring may be warrantedwarranted

• Urinary catheterization for ongoing urine output Urinary catheterization for ongoing urine output measurement may be warrantedmeasurement may be warranted

PrognosisPrognosis• About 75% of near-drowning victims who receive About 75% of near-drowning victims who receive

medical treatment survive (medical treatment survive (or 20-25% mortality rateor 20-25% mortality rate) ) • Among the survivors, most serious outcome is Among the survivors, most serious outcome is

neurological damage, reported incidence is 0-21%neurological damage, reported incidence is 0-21%• Comatose patients on arrival at the hospital who Comatose patients on arrival at the hospital who

required appropriate CPR were found to have nearly required appropriate CPR were found to have nearly a 50% survival rate without brain damage whether a 50% survival rate without brain damage whether treated mildly or aggressivelytreated mildly or aggressively

• In general, severe anoxic injury occurs in:In general, severe anoxic injury occurs in: Flaccid, comatose patientFlaccid, comatose patient Submersion >6 min in warm waterSubmersion >6 min in warm water In those requiring CPR in the ERIn those requiring CPR in the ER In those needing continuous mechanical In those needing continuous mechanical

ventilationventilation

Mortality Causes In Mortality Causes In Hospitalized Drowning VictimsHospitalized Drowning Victims

• Brain death attributable to severe hypoxic or Brain death attributable to severe hypoxic or ischemic brain injuryischemic brain injury

• Acute respiratory distress syndrome (ARDS)Acute respiratory distress syndrome (ARDS)• Multi-organ system dysfunction secondary Multi-organ system dysfunction secondary

to severe hypoxic or ischemic insultto severe hypoxic or ischemic insult• Sepsis syndrome attributable to aspiration Sepsis syndrome attributable to aspiration

pneumonia or nosocomial infectionspneumonia or nosocomial infections

Predictors of Neurological Predictors of Neurological OutcomeOutcome• Orlowski Score*:Orlowski Score*: 1 point for each of five 1 point for each of five

unfavorable factors if presentunfavorable factors if present1.1. Age <3 yrAge <3 yr2.2. Maximum submersion time estimated >5 minMaximum submersion time estimated >5 min3.3. No resuscitative efforts for No resuscitative efforts for >>10 min after 10 min after

rescuerescue4.4. Comatose on admission to ERComatose on admission to ER5.5. Arterial pH Arterial pH <<7.107.10

• Score of Score of <<2 = >90% chance of full recovery 2 = >90% chance of full recovery • Score of Score of >>3 = 5% probability of survival 3 = 5% probability of survival

*Orlowski JP. Prognostic Factors in Pediatric Cases *Orlowski JP. Prognostic Factors in Pediatric Cases of Drowning and Near-drowning. of Drowning and Near-drowning. JACEP JACEP 1979 1979 May;8(5):176-9.May;8(5):176-9.

Predictors of Neurological Predictors of Neurological OutcomeOutcome

*Zuckerman GB, Gregory PM & Santos-Damiani SM. Predictors of *Zuckerman GB, Gregory PM & Santos-Damiani SM. Predictors of Death and Neurologic Impairment in Pediatric Submersion Death and Neurologic Impairment in Pediatric Submersion Injuries. Injuries. Arch Pediatr Adolesc Med. Arch Pediatr Adolesc Med. 1998 Feb;152(2):134-40.1998 Feb;152(2):134-40.

Preventive Measures*Preventive Measures*

• Four-Sided Fencing of PoolsFour-Sided Fencing of Pools• Pool Alarms and Pool CoversPool Alarms and Pool Covers• Swimming InstructionSwimming Instruction• Supervision/LifeguardsSupervision/Lifeguards• ResuscitationResuscitation• Personal Flotation DevicesPersonal Flotation Devices

*Report of Brenner RA and Committee on *Report of Brenner RA and Committee on Injury, Violence, and Poison Prevention. Injury, Violence, and Poison Prevention. Prevention of Drowning in Infants, Children and Prevention of Drowning in Infants, Children and Adolescents. Adolescents. PediatricsPediatrics 2003 2003 August;112(2):440-445. August;112(2):440-445.

Vasily, Perov: Vasily, Perov: The DrownedThe Drowned, 1867, 1867

"Victims go quietly, often "Victims go quietly, often unnoticed."unnoticed."

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Submersion injury