With summer rapidly approaching, we are all waking from our winter slumber ready to the hit the beaches and take a little dip in the pools. Today we are going to immerse ourselves in all things water related. With all the knowledge in this post you will be able to flow right through your next shift without the fear of drowning related injuries crashing in like a vicious tsunami.  So, without further ado, lets dive right in. (puns all intended)

First, some definitions and facts:

  • Immersion
    • Body entry into a liquid medium
  • Submersion
    • Head below water
  • 3rd leading cause of accidental deaths
  • Epidemiology
    • Accidental childhood incidents
    • Nonaccidental injury
    • Shallow water blackout
    • ETOH
    • Scuba accidents
  • Factors common to drowning
    • Age; toddlers and teenage boys
    • Race: minorities
    • Gender: male>>female
    • Location
      • Home swimming pools, bathtubs, buckets
    • Drugs: i.e. ETOH
      • 25-50% of drowning deaths in adults contributed to by ETOH
    • Trauma 2/2 diving/falls
    • Preexisting disease
      • i.e. seizures or cardiac history
  • injuries associated with drowning
    • spinal cord injuries
      • i.e. diving injuries, falls from significant heights, boating injuries
    • hypothermia
    • aspiration
    • Respiratory failure or distress
      • Can progress to ARDS
    • Anoxic-ischemic encephalopathy
  • ED management
    • ABC…
      • If GCS > 8 consider intubation
      • If O2 sat >94% provide supplemental oxygen
    • …DE
      • Consider trauma as cause for or sequela of drowning depending on history
        • Perform thorough physical exam, assess for signs of trauma, provide C collar if concerned for spinal injury
    • Hypothermic?
      • Treat depending on how severe
        • i.e. warm blankets, warmed crystalloid fluids, foley and bladder irrigation, ,etc
    • If GCS >13 and O2 sat >/= 95%, low risk for complications
      • Observe for 4-6 hours and consider discharge
    • If patient is normothermic and in cardiopulmonary arrest consider terminating efforts as probability of recovery without serious neurologic complications is rare
  • Aspiration associated with drowning events
    • Most don’t prophylactic antibiotics
      • Antibiotics haven’t shown to improve outcomes and may lead to resistance
      • Consider if patient requires intubation and mechanical ventilation, delayed pulmonary infection may be a risk
        • Unusual organisms
          • Pseudomonas, vibrio, leptospirosis, Naegleria fowleri
  • Treatment
    • Correct acidosis, hypoxemia, hypoperfusion
      • Acidemia common due to hypoperfusion
    • Minimize risk for ARDS
  • Who gets hospitalized?
    • Respiratory symptoms
    • Abnormal CXR
    • Abnormal ABG
    • Hx of LOC
  • Prognosis
    • Most asymptomatic or mildly asymptomatic patients can be observed for 4-6 hours and discharged home with return precautions to include respiratory complaints or fever
    • Asystole on the scene or in the ED has a universally poor prognosis in both adult and pediatric patients
    • No ROSC after 30  minutes of CPR or if submerged for >1 hour consider terminating resuscitation
  • Prevention
    • Always supervise infants/toddles when in the bathtub or pools
    • Pool covers
    • Adequate fencing and restriction to pool access in young children
    • Swimming lessons and flotation devices
    • Avoid drugs/etoh when around open bodies of water
    • Swimmers with history of seizure disorder should always be monitored when in the water
    • Swim parallel in rip currents
    • CPR training

Citations

Cico S, Quan L. Drowning. In: Tintinalli JE, Stapczynski J, Ma O, Yealy DM, Meckler GD, Cline DM. eds. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8eNew York, NY: McGraw-Hill; 2016. http://accessmedicine.mhmedical.com.ezproxy.rush.edu/content.aspx?bookid=1658&sectionid=109438740. Accessed March 29, 2020.

 

Special thanks to Dr. Dan Popa for his fantastic presentation on drowning injuries and diving medicine!

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