Submersion Injuries and Drowning

Chapter 75 Submersion Injuries and Drowning



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Humankind is surrounded by water; it covers 75% of Earth’s surface, and is integral to survival and development. Water may also be life taking, responsible for hundreds of thousands of drowning deaths per year. The earliest recorded drowning resuscitation is from Syria in 1237 BC, when two soldiers rescued the king of Aleppo from the Orontos River. The king is shown being held upside down as part of an inversion technique that was used for thousands of years in an attempt to revive patients. During the late 16th century, several societies were founded in Europe in response to increasing numbers of deaths on commercial waterways, where boating and shipping were the primary mechanisms of transportation. Drowning subsequently became a substantial public health issue, and in response, several national societies were formed. With the proliferation of swimming pools and rapid expansion of recreational water activities, drowning has become not only an occupational hazard but also a significant recreational hazard. This chapter reviews classification, pathophysiology, clinical presentation, treatment, and prevention of submersion injuries and drowning while emphasizing the importance of safety and injury prevention.



Classification and Types of Submersion Injuries and Drowning


The process of injury or death caused by the effects of immersion or submersion in a liquid medium is called submersion injury. The term immersion refers to body entry into a liquid medium, whereas submersion refers to entry into a liquid medium where the body—particularly the head—is below the surface. Drowning is an international public health problem complicated by lack of a uniform definition, proliferation of many confusing subdefinitions, inadequate epidemiologic studies, and conflicting clinical management paradigms. After the 2002 World Conference on Drowning, a consensus panel and the World Health Organization adopted the following definition in 2005: “Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid.”227 According to this new classification system, drowning outcomes should be classified as drowning death, drowning with morbidity, and drowning without morbidity. It is critical to understand that drowning is now considered a process and not an outcome. Other water-related conditions that do not primarily involve the airway and respiratory system would be submersion injuries rather than drowning. For example, this definition of drowning specifically excludes water rescues during which submersion does not involve the respiratory system; if the rescued person maintains his or her airway above water throughout the event, then it would be considered a submersion injury rather than a drowning.226


The consensus panel of 2002 also concluded that the terms wet drowning, dry drowning, active drowning, passive drowning, silent drowning, near drowning, and secondary drowning should no longer be used as parts of drowning terminology.227 Because these terms are still widely in use in the medical literature and among laypersons, it is important to be familiar with them (while recognizing that they have no role in future research or clinical care of submersion injuries).


One of the most common previous classification systems divided drowning into two possible outcomes: drowning and near drowning. This classification system is problematic, because it often resulted in near drowning being excluded from epidemiologic and research studies of drowning. Modern categorization (i.e., after 2002) considers all types of drowning—drowning with death, drowning with morbidity, and drowning without morbidity—to be subsets of the overall category of drowning. Differentiating near drowning from drowning made sound epidemiologic data about nonfatal drowning scarce, despite the fact that information about survival from drowning can have a major impact on public health initiatives and understanding of optimal treatment protocols.154,227 In addition, separating near drowning from drowning likely results in systematic underreporting of drowning incidents, because any epidemiologic data about drowning could potentially exclude all survivors, which is a rare situation in medicine. For example, nobody would exclude survivors of pneumonia from epidemiologic or clinical discussions of that condition. Thus, the term near drowning should no longer be used in drowning terminology; it should instead be replaced by the preferred terms drowning with death, drowning with morbidity, and drowning without morbidity.226


Another common previous classification system differentiated drowning by presumed physiologic mechanism: wet or dry. Wet drowning is the more common event, and occurs when individuals aspirate fluid during drowning. About 80% to 90% of drowning deaths are believed to be the result of wet drowning. In the remaining cases, laryngospasm limits aspiration; this is considered dry drowning. Laryngospasm is a reflex response to submersion that protects the airway and lungs from aspiration; however, if it persists, leads to hypoxemia, loss of consciousness, and death as a result of asphyxiation with minimal aspiration of water (i.e., <10 mL). Knowledge of whether a drowning was wet or dry does not offer prognostic or treatment significance, and it is a discredited distinction. Although it makes intuitive sense that patients who do not aspirate significant amounts of water will have a better response to resuscitation, there is no evidence to support this.


Other classifications that describe the mechanism of drowning include active drowning, passive drowning, and shallow water syncope or shallow water blackout. Active drowning and passive drowning are now historic terms that most likely represented witnessed and unwitnessed drowning, respectively,227 and have no usefulness for epidemiologic or clinical understanding of drowning. Shallow water syncope is a syndrome that occurs primarily among competitive swimmers, free divers, and spear fishers who attempt to achieve long periods of underwater activity without the need to breathe. Individuals hyperventilate before submersion, resulting in a hypocapnic respiratory alkalosis. In humans, hypercapnea is a more potent stimulus to breathe than is hypoxemia. By artificially reducing the proportion of carbon dioxide in arterial blood, there is prolonged time until the compulsion to breathe. Simultaneously, the body’s consumption of oxygen may lead to dangerously low levels of blood oxygen. Because the drive to breathe from hypoxemia is less potent than the drive from acidosis or hypercarbia, the subjects may become unconscious from profound hypoxemia before the carbon dioxide level rises adequately to stimulate breathing, which may then lead to drowning.



Incidence and Epidemiology


The World Health Organization Global Burden of Disease Update estimated that 388,000 people drowned worldwide in 2004; this represented 0.7% of all deaths.241 Statistical data are likely underestimates of the true incidence of drowning. This is the result of underreporting, particularly in middle- and low-income countries, where many drowning patients never make it to a hospital, resulting in inconsistent data collection. It is estimated that, for every reported drowning death, another four go unreported. Codes from the International Classification of Diseases, ninth edition, have recently been altered to improve drowning and subtype categorizations, but many countries still fail to report sufficiently specific codes to the World Health Organization with regard to drowning mortality data.127 Drowning deaths caused by floods and natural disasters are not reflected in these numbers; this includes the great tsunami of December 2004, which resulted in more than 100,000 deaths by drowning, and Hurricane Katrina in New Orleans in 2005. Drowning deaths that result from assaults, suicides, and boating accidents are not typically classified as drowning deaths, because they are usually classified based on the primary cause of death and secondary diagnoses (i.e., drowning) are not captured for epidemiologic research.


Worldwide, drowning occurs overwhelmingly in low- and middle-income countries (>95%). In 2004, it was the fifth leading cause of death from injuries worldwide, after road traffic accidents, suicides, homicides, and other accidental injuries.241 India and China both have particularly high drowning mortality rates,129 together contributing 43% of all drowning deaths worldwide and 41% of the total disability-adjusted life years attributed to drowning worldwide.241 In China in 2001, drowning was the leading cause of injury death among children between the ages of 1 and 14 years.240 The global burden of drowning in 2002 is shown in Figure 75-1, online; territories are sized in proportion to the absolute number of people who died from drowning that year.



In the United States, the National Center for Injury and Prevention Control reported 4279 fatal unintentional drowning deaths in 2006, which is 1.4 deaths per 100,000 people.41 Boating-related incidents accounted for an additional 710 deaths.41 Drowning ranks as the tenth leading cause of injury death overall in the United States, but overwhelmingly affects younger age groups: drowning is the leading cause of unintentional injury death among children between the ages of 1 and 4 years, and ranks second among children between the ages of 5 and 14 years; it is the sixth leading cause of injury death for those between the ages of 15 and 24 years.40 California, Florida, and Texas reported the highest number of drowning deaths in 2006.38 It is estimated that for every child drowning death, an additional four are hospitalized for nonfatal drowning; many of these children require prolonged intensive care and may suffer permanent neurologic disability.40,127 Exact numbers of submersion injuries are unknown as a result of differences in coding from the International Classification of Diseases, ninth edition, and lack of uniform data collection.


The economic costs of submersion injuries and drowning are among the highest of any injury group, largely because the greatest morbidity and mortality occur among individuals between the ages of 0 and 15 years. At this young age, there is a large impact on future economic productivity. An estimated 1 million disability-adjusted life years were lost as a result of premature death or disability from drowning worldwide in 2004.187,240 In the United States, medical costs for a drowning patient can range from several thousand dollars for initial emergency department care to $180,000 per year for long-term care. A single submersion injury with severe neurologic impairment can cost more than $4.5 million over the victim’s lifetime.40



Risk Factors


Submersion injuries tend to involve particular populations, age groups, and locations (Box 75-1). Understanding the risk factors is important to implementing prevention and public health strategies to prevent submersion injuries and drowning.




Age


Young people have the highest likelihood of drowning. A bimodal age distribution characterizes drowning in children, with children less than 4 years old and adolescent males accounting for the peaks. There is an additional smaller peak later in life among persons who are more than 65 years old.181 In 2005, of all children between the ages of 1 and 4 years who died in the United States, 30% died from drowning.40 High risk of drowning among children occurs as a result of poor swimming ability, large head-to-body ratio (increasing risk of head submersion), lack of barriers around pools and bathtubs, and poor supervision (especially of toddlers). Children in this age group are developmentally able to move independently, but lack the ability to recognize water hazards or effect self-rescue. Despite the American Academy of Pediatrics recommendation never to leave a child unsupervised in the bathtub, one study reported that nearly 33% of parents leave their children unattended in this setting.205 Children bathing with a sibling who was less than 2 years old with brief unsupervised time were reported to account for 22% to 58% of bathtub drowning deaths.34 Drowning among adolescents and teenagers is often seen with risk-taking behaviors, lack of supervision, and drug and alcohol intake. The scene of drowning in this age group is most commonly a natural body of water, such as a lake, pond, or river. Incidents often occur far from medical assistance and may take place where rescue is challenging; however, these events are often witnessed.4,7,31,181,185 Among people who are more than 65 years old, deaths are evenly divided between open-water drowning and bathtub-related drowning, often from falls or exacerbations of concomitant illnesses (e.g., cardiac arrhythmias), which may not be recognized at autopsy.181



Gender


In 2005, males were four times more likely than females in all age groups to die from unintentional drowning in the United States.38 Drowning among females peaks at 1 year of age and declines throughout the rest of life. It is speculated that this trend is the result of increased risk-taking behavior and greater alcohol consumption among adolescent males as compared with females. Worldwide, males have a higher mortality rate from drowning as compared with females in all age groups and regions.175



Race


In the United States between 2000 and 2005, the rate of fatal drowning for blacks was 1.3 times higher than that of whites.41 The rate was 1.8 times higher than that of whites for Alaska natives and Native Americans.40 In Alaska, drowning rates are twice as high among Native American children as compared with white and black children.6 In the 10- to 14-year-old age group, the fatal drowning rate for blacks is 3.2 times that of white children of the same age, and is 2.8 times higher for Alaska native and Native American children.38 This pattern is reflected in the military, where black soldiers drown with a frequency of 62% greater than that of white soldiers.15 The reasons behind the racial differences in drowning rates are unclear, but factors such as decreased routine access to swimming pools, lower emphasis on swimming lessons, and less participation in recreational water-related activities are suspected.152 If, overall, minorities participate in fewer water-related activities, their drowning rates per exposure may be even higher than reported.26



Location


Any body of water, no matter how shallow or small, can be the site of drowning. Oceans, seas, and rivers account for fewer submersion events than do backyard pools, recreational lakes, bathtubs, and buckets of water. In the United States, submersion events involving young children occur primarily in fresh water; children who are less than 1 year old most often drown in bathtubs, buckets, or toilets, whereas those between the ages of 1 and 4 years most often drown in residential pools.* Despite these statistics, only a small proportion of home pools are properly protected, and most are easily accessible by ambulatory toddlers and curious children.195,209 One study found that most young children who drowned in residential pools had been out of sight of adults for less than 5 minutes, and were in the care of one or both parents at the time.179 Among individuals between the ages of 5 and 64 years, drowning typically occurs in open-water recreational settings such as lakes, rivers, and oceans.31,176 Persons who are more than 65 years old have the highest rates of bathtub drowning per age group.181


Visitors to domestic and international locations are at a higher risk for drowning as compared with natives in the same region. After motor vehicle accidents and homicide, drowning is the leading cause of injury death among U.S. citizens traveling abroad.220 In island locations, it is the leading cause of injury death; it accounts for 63% of traveler deaths by injury as compared with 3.5% for native citizens of the respective countries.84,220 Lack of familiarity with the environment,123 lack of understanding of local hydrology, overestimation of abilities, and presence of alcohol use while vacationing are likely contributors to drowning rates among travelers.


Submersion in vehicles is a cause of death by drowning that is not routinely classified as a drowning death, although the incidence of drowning in a submerged vehicle was as high as 5% to 10% of all motor vehicle accident deaths in one series.207,244 A more recent study210 demonstrated that, of 83 drowning deaths in vehicles, more than 92% of victims had insignificant traumatic injuries, suggesting that the primary source of death in submerged vehicles is drowning rather than trauma.


The Divers Alert Network reported 138 deaths internationally in 2006 from scuba diving accidents:56 51 of these were in the United States, with Florida having the highest incidence, followed by California. The cause of death was reported in 58 cases (77% of the total); of those, 86% were attributed to drowning, which is by far the most common cause of death in this series. Several patients had known preexisting medical conditions, including cardiovascular disease, which may have contributed to drowning. Death from scuba diving remains relatively infrequent, and 50-year data show an overall decrease in the diving-related mortality rate per diver.


Water birth (i.e., labor and delivery while immersed in water) is a risk factor for both submersion injury and drowning. Documented adverse neonatal outcomes from underwater birth include unexplained death, drowning, asphyxiation, water intoxication, hyponatremia with seizures, water aspiration leading to respiratory distress and failure, pulmonary edema, hypoxic–ischemic encephalopathy, and pneumonia and other infections, including Pseudomonas and Legionella infection.67,74,160,171 Other observational series have shown similar Apgar scores, rates of neonatal resuscitation, and complications for both regular births and water births.75,160 There has been a vigorous debate in the pediatrics community regarding the safety of this birth modality, but what is undisputed is that there are few reliable data demonstrating the safety of water birthing.198



Ability to Swim


Although they are very popular, swimming programs for young children do not fully protect against drowning; children should always be supervised while swimming. The American Academy of Pediatrics has long recommended that children should not receive swimming lessons if they are less than 4 years old. This policy was recently revised—amidst controversy in the pediatrics community—to reflect a study demonstrating that drowning victims between the ages of 1 and 4 years were less likely than matched controls (3% versus 26%, respectively) to have had formal swimming instruction.30 The latest recommendation is that children as young as 1 year old can be enrolled in formal survival swimming courses. This is part of a multipronged approach, and does not replace the need for direct supervision and use of pool barriers. Swimming lessons are recommended for nearly all children after the age of 4 years. Prevention focuses on supervision, restricting access to home pools, and reducing use of drugs and alcohol among teenagers around water.46


Highly experienced swimmers are not immune from drowning; competitive swimmers and breath-hold divers sometimes engage in intentional hyperventilation and die as a result of shallow water syncope or blackout. Breath-hold diving is defined as in-water activity without self-contained or surface-supplied breathing gas. Breath-hold activities include snorkeling, spear fishing, and free diving, from which there were 34 fatal drowning cases reported worldwide by the Divers Alert Network in 2006.56 More than one-half occurred in the United States, primarily in Florida, Hawaii, California, and Texas; this may be the result of higher rates of reporting in the United States as compared with worldwide rates, and suggests that safety and prevention strategies should be focused on specific geographic regions. Twelve cases were associated with blackout due to hypoxic loss of consciousness, likely as a result of intentional hyperventilation to prolong breath-holding time.


According to the International Swimming Federation, open-water swimming is defined as any competition that takes place in a lake, river, or ocean. Marathon open-water swimming was approved as an Olympic event for the 2008 Olympic Games in Beijing, China. Several studies have demonstrated a risk for hypothermia during open-water swimming competitions, but the extent of risk varied depending on the modality of temperature measurement used and remains unclear.27,36



Alcohol and Drugs


Alcohol has been implicated as a contributing factor in 25% to 50% of recreational water-related deaths and in 20% of boating-related fatalities.33,58,121,123,150 Studies have demonstrated blood alcohol levels of 100 mg/dL or more as a factor in 25% of boating-related fatalities,33 in 25% of teen drowning deaths,185 and in 33% of drowning deaths of young adults between the ages of 20 and 34 years. In Australia, 21% of people who drowned during a 5-year period had measurable levels of alcohol in their blood.66 Despite federal laws that prohibit alcohol use during recreation on the open water, a survey of adults in the United States showed that 31% of 597 respondents reported operating a motorboat while under the influence of alcohol; these operators were overwhelmingly males between the ages of 25 and 34 years.124 Impaired judgment caused by intoxicants can lead to accidents as well as loss of body heat, decreased laryngeal reflexes, higher risk of aspiration, decreased supervision of children, and decreased use of safety devices such as personal flotation devices (PFDs).181,248 Illicit recreational drug use with and without alcohol has been reported as a factor in water-related deaths.33 All types of drugs that affect judgment can result in watercraft overcrowding, speeding, failure to wear PFDs, and inattentive or reckless handling of watercraft.



Preexisting Disease


Risk of submersion injury or death in water increases significantly when medical conditions compromise the chance for self-rescue and survival. Situations are particularly dangerous for unpredictable medical conditions such as cardiac and neurologic conditions. Individuals with relevant preexisting conditions must take special care to never be alone and to optimize treatment for the underlying condition before engaging in water-related activities.


Seizure disorders have been shown to increase the risk of drowning among adults and children in both natural bodies of water and in homes.14,17,28 Drowning is the most common cause of unintentional death injury among patients with seizure disorders.183 One study found the risk of drowning among people with epilepsy to be 15 to 19 times greater than that of the general population.14 It is when patients are alone that the risk of death increases drastically. Other neurologic conditions (e.g., cerebrovascular accident, arteriovenous malformation) that manifest as seizure have been associated with drowning.77


Cardiac disorders associated with arrhythmias may manifest while a person is submerged in water; however, the exact mechanism for rhythm disturbance as a result of submersion remains to be determined.1,24 Long QT syndrome, a conduction disorder associated with sudden death, has been linked by forensic molecular screening to some drowning deaths, indicating a possible gene-specific arrhythmogenic presentation of long QT syndrome triggered by swimming; however, this remains a theoretic possibility.2,128 Adverse events, such as unstable tachycardia or loss of consciousness from myocardial infarction, may also lead to drowning deaths.



Child Abuse, Homicide, And Suicide


Abuse or neglect should be investigated in any suspicious pediatric submersion incident, which must undergo a thorough social service and legal investigation. One series found abuse or neglect to account for 19% of bathtub submersion deaths among patients less than 5 years old.185 In the adult population, homicide by drowning is relatively uncommon. The postmortem determination of death by drowning (as opposed to body disposal in water after another mechanism of homicide) is very difficult to make. Drowning by suicide is relatively uncommon.166,229,239 An Australian study of 123 suicides by drowning found women to more commonly choose bathtubs or the ocean for drowning, whereas men chose rivers, ditches, and lakes.35



Boating-Related Drowning


Recreational and commercial boating accidents are among the leading causes of unintentional drowning. Deaths result from capsized vessels or falls overboard. Risk is determined by water depth, temperature, distance from shore, and currents, including hydraulics at the bases of dams or spillways. Alcohol use, lack of personal protective equipment, and unsafe boating practices are involved in many boat-related drowning incidents.33,121 In 2008, the U.S. Coast Guard reported 3331 injuries and 710 deaths as a result of recreational boating accidents;224 519 of these deaths were the result of drowning and of these, 459 patients (90%) were not wearing PFDs or lifejackets. Studies suggest there is significant underuse of PFDs among recreational boaters.105,184 In the United States in 2008, alcohol was the leading contributing factor in fatal boating accidents, followed by operator inexperience and careless or reckless operation. The majority of fatal accidents occurred in open motorboats, followed by canoes and kayaks. States with the highest death rates (i.e., >10 per 100,000 registered boats) were Alaska, Hawaii, Montana, Idaho, Utah, Texas, Louisiana, and Vermont.224


The commercial fishing industry also contributes to boating-related drowning deaths internationally. The International Labor Organization estimated that 36 million people worldwide were employed in aquaculture industries in 1998; most are located in Asia and Africa. Death rates among commercially employed fisherman are among the highest of any occupation.122,190 In the United States, death rates of fishermen are 16 times higher than those of police and firefighters and 8 times higher than those of persons who drive motor vehicles for a living.223 Another population affected by water transport and drowning is that of refugees seeking asylum, who are often in rough weather and poorly equipped, overcrowded boats without lifejackets. A 2004 study reported that 4000 asylum seekers are estimated to drown annually at sea.59,180



Pathophysiology


The pathophysiology of submersion has been extensively studied in animal models, yet there remain ambiguities with regard to the exact sequence of events and mechanisms of drowning among humans. The effect of submersion on mammals was initially reported in the scientific literature during the late 1800s, and most early research involved animal models. In a classic monograph from 1965, Greene noted that the “inundation of the upper airway, the bronchial tree and segments of the alveolar spaces blocks gas exchange in the lung and produces asphyxia. Thus drowning involves the rapid development of hypoxemia, hypercapnia, and acidosis with the associated sequence of hypertension, bradycardia, apnea, and terminal gasping.”82 Although these observations remain largely accurate for humans, they were based on mammalian experiments designed to simulate drowning.94,125,161 Early animal research examined the hemodynamic and electrolyte effects of drownings that occurred in water types of different osmolality (i.e., saltwater versus freshwater drowning). Although some models indicated a pathophysiologic difference between the two, this has proved to be of limited applicability in humans. Early canine experiments showing hypervolemia in freshwater aspiration and hypovolemia and hypernatremia in saltwater aspiration149 have not been reproduced, and human research has failed to replicate the course observed in animals.196 Hypervolemia has not been observed in human fresh water aspiration, and most humans have total fluid aspiration of less than 4 mL/kg.132,145 More than twice that amount is required to effect the changes in blood volume seen experimentally. Similarly, an aspirated amount of 22 mL/kg is required before systemic electrolyte changes develop143; therefore, the distinction between saltwater and freshwater drowning is of limited utility for humans. Most authorities recommend discontinuation of this distinction so that the focus can be on the common pathway of hypoxemia, acidosis, pulmonary injury, and multiorgan system failure that remain the hallmarks of drowning pathophysiology.*





The Initial Event


Submersion begins when the patient’s airway lies below the surface of a liquid medium, usually water. There is typically an initial period of struggle with attempted breath holding. This may not occur during trauma-associated submersion, when the patient may have been unconscious before or upon entry into the water.117,169 After gasping occurs, the initial struggle is sometimes followed by laryngospasm to protect the lower airways from liquid in the upper airways (i.e., nares, oropharynx, larynx). Laryngospasm may limit the amount of water aspirated, and occurs in an estimated 7% to 10% of drowning cases.139,145 The relevance of this distinction to the ultimate pathophysiology is controversial.117,167,196 It is now felt that all submersion patients likely aspirate at least a small amount of liquid. Particularly during cold-water submersion, the initial event is accompanied by a drive to hyperventilate caused by stimulation of thermal skin receptors, in addition to increasing hypoxemia. During this initial time, patients will often swallow large amounts of water to avoid aspiration.145 Eventually, the outcomes of breath holding are hypoventilation, hypercapnea, respiratory acidosis, and hypoxemia. At a certain break point, breath-holding attempts are overwhelmed, and no further voluntary efforts can prevent respiration. Loss of consciousness ensues and cardiopulmonary arrest follows (Figure 75-3).



The duration of tissue hypoxemia, timing of rescue, and institution of effective cardiopulmonary resuscitation (CPR) and field resuscitation are significant factors that affect whether the initial submersion injury is survivable. Duration of submersion, water temperature, and tissue susceptibility to hypoxemia determine the effects of submersion on different organ systems and the likelihood of ultimate survival.



Pulmonary system


During submersion events, the lung is the first major interface between the environment and the body. Aspiration of water of any type and volume immediately affects alveolar ventilation, gas exchange, and the mechanical characteristics of the lung.54,71,169 Hypoxemia is the hallmark of pulmonary pathophysiology during submersion. Breath holding and apnea lead to a rise in partial pressure of carbon dioxide and a fall in partial pressure of oxygen in both the alveolus and arterial blood. In addition, inhalation of any liquid causes surfactant disruption and alveolar collapse, resulting in areas of ventilation/perfusion (image) mismatch, shunting, and further worsening of hypoxemia. Pulmonary sequelae may range from asymptomatic to acute respiratory distress syndrome (ARDS), depending on the amount of water aspirated and the duration of submersion. Usually symptoms of pulmonary involvement are present immediately; however, there are reports of delayed ARDS after an initially normal chest radiograph.54


Volumes of aspirated liquid of as little as 1 to 3 mL/kg are sufficient to cause disruptions in alveolar gas exchange and hypoxemia. Diminished pulmonary gas exchange occurs in part due to surfactant disruption as a result of aspiration. Surfactant is produced by type 2 pneumocytes, pulmonary epithelial cells responsible for maintaining alveolar surface tension, increasing pulmonary compliance, and preventing atelectasis. Disruption of surfactant leads to malfunctioning of the alveolar epithelial lining and increased image mismatch. Hyperosmolar saltwater draws fluid into the alveolar spaces, resulting in surfactant “washout” or dilution, and ultimately causing pulmonary edema; hypo-osmolar freshwater disrupts surfactant functioning and is directly cytotoxic to type 2 pneumocytes, resulting in image mismatch and loss of alveolar compliance.71,117 Interstitial and microvascular damage ensue in response to alveolar–capillary basement membrane disruption, releasing an inflammatory cascade that results in pulmonary edema caused by extravasation of fluid into the alveolar space, bronchospasm, worsening image mismatch, and hypoxemia.117 Areas of hypoxic pulmonary vasoconstriction further worsen shunting and increase pulmonary hypertension, leading to increased pressure across the alveolar–capillary basement membrane and further extravasation of fluid into the alveoli. In severe cases of submersion, patients present with ARDS, profound hypoxemia, noncardiogenic pulmonary edema, and a significant alveolar–arterial oxygen gradient. In profoundly ill patients, intubation and artificial ventilation may be required, increasing the risk of subsequent ventilator-associated lung injury and ventilator-associated pneumonia. With adequate resuscitation and treatment of patients without significant neurologic compromise, pulmonary dysfunction may initially be severe, but ultimate recovery of baseline lung function after submersion is the rule rather than the exception.83,145


Contamination by debris from petroleum products, sewage, sand, and organic matter is more common in saltwater and brackish water. Such debris accentuates the possibility of further inflammation and lung injury, which increase mortality rates. Inhalation of mud, sand, and other particulates may require fiber-optic bronchoalveolar lavage to cleanse the airways. Aspiration of microbes and related potential infections are discussed later. Figures 75-4 to 75-6 show examples of foreign-body and contaminant aspiration after drowning.





Swimming-induced pulmonary edema has been described in several case reports as affecting scuba divers, Navy SEALS, and individuals who engage in strenuous surface swimming (e.g., triathletes). The pathophysiology of this disorder is unclear, but proposed mechanisms include central blood pooling related to immersion and strenuous swimming resulting in elevated pulmonary artery pressure and diastolic dysfunction. Experimental equine data demonstrate increases in right ventricular and pulmonary arterial pressures with varying degrees of submersion in water, presumably resulting in capillary fracture. The case definition of swimming-induced pulmonary edema consists of acute hypoxemia during or immediately after a swimming event, a demonstrable chest radiograph abnormality with resolution within 48 hours in the absence of evidence of underlying pulmonary infection, and aspiration of water or attempted breathing against a closed glottis. The significance of this clinical entity is unclear, and it appears to be relatively uncommon.138,200



Central Nervous System


The central nervous system (CNS) is highly sensitive to even brief periods of hypoxemia and is the most susceptible organ system to the negative effects of submersion. The major determinant of survival and long-term morbidity from a submersion injury is the extent of CNS injury. Most submersion patients suffer a brief period of unconsciousness that is caused by cerebral hypoxemia. Full neurologic recovery rarely occurs after 5 to 7 minutes of anoxia in normothermic conditions; hypothermia under controlled circumstances can prolong this to more than 40 minutes.242 In most cases, prolonged submersion leads to death from neurologic asphyxia. Even with aggressive CPR and return of spontaneous circulation, submersion is associated with significant neurologic morbidity. Patients who present either awake or with blunted mental status have a better prognosis than those who present in a coma; mortality rate in one study was as high as 34% among patients who were comatose on arrival to the hospital.52,142 Of the surviving patients, 10% to 23% demonstrated severe and persistent neurologic sequelae.52,142 Prolonged hypoxemia and acidosis lead to neuronal cell death and demyelination.25,100,134 Thus, the longer the submersion, the more CNS damage suffered. Areas of high metabolic activity in the brain are most prone to damage from hypoxemia: gray matter (more than white), vascular end zones, cerebral cortex, thalamus, basal ganglia, and hippocampus. Initial computed tomography scanning of the brain after submersion that shows any abnormalities of edema, loss of differentiation between gray and white matter, or focal infarct is highly predictive of poor outcome.186,192


After the initial hypoxic event, subsequent reperfusion of damaged neurons can result in cell lysis as well as interstitial and cerebral edema that are further worsened by systemic acidosis, hypotension, hyperglycemia, and, if present, seizure activity.172 Hypothermia can increase cerebral tolerance of ischemia and hypoxemia, and prolonged submersion in cold water may ultimately be neuroprotective. There are multiple case reports of survival with good neurologic outcomes after prolonged submersion, particularly among children, and this is thought to be the result of decreased cerebral oxygen demand in the setting of hypothermia.* This requires rapidly induced hypothermia before the onset of anoxic damage, which occurs with sudden submersion in very cold water. Therapeutic hypothermia (TH) in cases of cardiac arrest have resulted in improved neurologic outcome, and there are several case reports of complete neurologic recovery after IH in drowning patients.12a,234,238a Drowning patients often arrive hypothermic at temperatures below the 32° to 34° C [90° to 93° F] of TH. This is an area of active research, and in the absence of randomized control trials of IH in non-ventricular fibrillation arrest, the decision to initiate TH is based on expert consensus and theoretical benefit. This is discussed further in Hypothermia, later.




Cardiovascular system


Cardiac rhythm, output, and function are affected by hypoxemia and acidosis, with more severe manifestations in prolonged submersion.153 Dysrhythmias may occur as a result of acidosis and hypoxemia. Decreased cardiac output may result from direct effects of hypoxemia on myocardium. Pulmonary hypertension caused by aspirated fluid can result in right ventricular overload and further decreased cardiac output. Patients with underlying cardiac disease may be more susceptible to the effects of hypoxemia on myocardial function. A sudden cardiac dysrhythmia may precipitate submersion and drowning in patients with preexisting cardiac disease, although this can be difficult to discern from submersion-related injury during a postmortem analysis. One small study showed a significant correlation between a personal or family history of drowning in subjects with autosomal dominant long QT syndrome, suggesting a gene-specific arrhythmogenic trigger for drowning.1,2 However, subsequent pathologic postmortem screening of drowning subjects has failed to show mutations in genes associated with long QT syndrome,128 so it remains a theoretic correlation.



Hematologic and Electrolyte Disturbances


Prior data indicating systemic electrolyte disturbances from aspiration of saltwater are of little practicality for human drowning patients, because such derangements are rarely seen. Although the massive instillation of saltwater in animal models has resulted in disturbances in sodium, chloride, magnesium, and calcium46,243,248 (presumably as a result of osmotic gradients across the alveolar epithelium), these results require a large volume of fluid aspiration (i.e., >22 mL/kg). With submersion, such volumes are rare.141,143,144 Similarly, canine models have demonstrated gross hemolysis, resulting in hyperkalemia and disseminated intravascular coagulation after large-volume aspiration; however, clinically relevant changes in hematocrit and hemoglobin levels are rarely seen in human submersion patients.145 Routine observation and laboratory analysis with treatment for gross abnormalities are all that are indicated in the hospital setting.



Hypothermia


For submersion patients who do not drown immediately, subsequent drowning may result from hypothermia.50,94 Water at 91.4° F (33° C) is thermally neutral, where heat loss equals heat production for a swimmer without clothes; water any colder than this leads to ongoing heat loss. The thermal conductivity of cold water is 25 to 30 times that of air.94,120 Even in only moderately cold water, hypothermia may ensue rapidly and lead to a loss of consciousness and subsequent drowning. This is particularly true among children, who have less subcutaneous fat and relatively greater body surface area as compared with adults.20,49,80,90 Survival is unlikely after 60 minutes in water that is cooler than 32° F (0° C); however, people can survive for up to 6 hours at a water temperature of 59° F (15° C)47 (Table 75-1).


TABLE 75-1 Estimated Survival Times in Cold Water































Water Temperature Exhaustion or Unconsciousness in Expected Survival Time
21–27° C (70–80° F) 3–12 hr 3 hr—indefinitely
16–21° C (60–70° F) 2–7 hr 2–40 hr
10–16° C (50–60° F) 1–2 hr 1–6 hr
4–10° C (40–50° F) 30–60 min 1–3 hr
0–4° C (32.5–40° F) 15–30 min 30–90 min
<0° C (<32° F) <15 min <15–45 min

(Courtesy U.S. Search and Rescue Task Force. http://www.ussartf.org/cold_water_survival.htm)


There are many factors that affect an individual’s response to cold-water submersion. In some cases, hypothermia appears to be protective if it coincides with the submersion event. Dramatic recoveries after prolonged hypothermia have been documented in children and adults.177,202,216,247 This is an area of active research in cardiac arrest, where therapeutic hypothermia (TH) has been shown to decrease cerebral metabolic demand and improve neurologic outcomes.99 Protocols for TH were adopted by the American Heart Association in 2002 and by the European Resuscitation Council in 2003 for out-of-hospital cardiac arrest patients. Case reports of survival after submersion in cold water with profound hypothermia have provoked questions as to whether this would provide the same physiologic effect of neuroprotection for submersion patients who become rapidly hypothermic, and might warrant maintenance of low core temperature in comatose submersion patients.117,230 A panel of experts during the World Congress on Drowning in 2002 concluded that “drowning victims with restoration of adequate spontaneous circulation who remain comatose should not be actively re-warmed to temperature values above 32° to 34° C (90° to 93° F). If core temperature exceeds 34° C (93.2° F), hypothermia at 32° to 34° C (90° to 93° F) should be achieved as soon as possible and sustained for 12 to 24 hours.”234 There are several cases of full neurologic recovery after submersion with subsequent TH148,231; however, optimal temperature management for submersion patients remains an area of active discussion.


The pathophysiologic response to hypothermia ranges from shivering with an increased metabolic rate to coma, massive metabolic acidosis, and spontaneous ventricular fibrillation. Patients progress from mild hypothermia, characterized by shivering, increased metabolic rate, and tachycardia, to profound hypothermia at varying rates, depending on the surrounding water temperature, protection and clothing, duration of exposure, and position in the water (Figure 75-7).



In some cases, patients suffer from immersion syndrome, which involves sudden death from bradycardia, tachycardia, or ventricular fibrillation and cardiac arrest from cold water exposure before onset of systemic hypothermia.169 Immersion in cold water (i.e., <5° C [<41° F]) produces a rapid fall in core body temperature. Heat loss through convection and conduction is further compounded by increased muscle activity during swimming and struggling.


The “diving reflex” in diving mammals is a vestigial but inducible reflex in humans that may contribute to survival in cases of prolonged submersion and subsequent hypothermia.49,80,91,132 The reflex is activated by vagal stimulation from cutaneous receptors that respond to cold by shunting blood to the brain and cardiac muscles and away from the skin, extremities, and splanchnic vascular beds, along with bradycardia and decreased metabolic rate. Bradycardia and vasoconstriction in all vascular beds (except those serving the heart and brain) results in preserved mean arterial pressure for those organs and overall decreased cardiac output. The reflex may be inducible in only 15% to 30% of humans,21 but may be a contributing factor for persons who survive submersion.62,80,111 However, some discount its role.


Immersion hypothermia occurs as the core temperature falls. It can be divided into three distinct phases. Times given are for immersion in 10° C (50° F) water.



Cold-Shock Response Time: 0 to 3 Minutes


Cold-shock response is the most common cause of drowning in cold water. Upon exposure to cold water, subjects may experience uncontrollable gasping that lasts approximately 1 to 3 minutes.32,61 This phenomenon may result in aspiration of water unless the head is kept above the surface. Sudden skin cooling results in increased peripheral vascular resistance of superficial blood vessels. Heart rate and cardiac output increase, and an outpouring of catecholamines may predispose these individuals to fatal dysrhythmias. Cooling of the periphery decreases nerve conduction, and muscle control becomes difficult, making any attempt at self-rescue virtually impossible. The priority for self-rescue during this phase is only to maintain the head above water. Patients should assume the heat escape lessening position (HELP) (Figure 75-8), if possible. If two or more persons are in the water, the huddle position (Figure 75-9) is recommended to lessen total body heat loss. Because children become hypothermic much more quickly than do adults, they should be placed in the middle of the huddle.







Management: The Element of Time


Time plays a significant role in determining the ultimate outcome of a rescue with submersion injuries. The duration of anoxic time may be unknown or unreliable for a variety of reasons, including an unwitnessed event or unrecognized call for help; the waving of hands or thrashing about may be confused with play activity. Witnesses may exhibit panic and frantic behaviors, further impairing effective rescue.


Time is of the essence. The published world record for conscious breath holding while underwater is 17 minutes and 4 seconds,219 and it should be noted that this feat was achieved after months of training under tightly controlled circumstances. Most humans are unable to stay conscious underwater or avoid aspiration after a few minutes. Irreversible neurologic deficits are common after 4 to 5 minutes.51 The longest documented period of submersion time in an unconscious patient with survival is 66 minutes23; this was a pediatric patient in cold water. Hypothermia may offer a protective benefit and prolong the time after which resuscitation can still be successful, and there are case reports in which patients survived after 40 minutes of submersion in cold water with complete or nearly complete recovery.202,216,247 The lowest recorded temperature in a human being with subsequent survival and neurologic recovery was the submersion injury of a Norwegian skier trapped in a frigid river, who had a core body temperature of 13.7° C (56.6° F) when extricated.73 Table 75-1 describes time parameters surrounding expected survival at various water temperatures.


An extremely rapid response is required in some cases, whereas no immediate response or body recovery is required in others. This decision depends on the characteristics of the patient, length of presumed submersion, possible associated traumatic injuries, and water temperature. It is unnecessary to put rescuers at risk to retrieve a submersion injury patient whose survival would defy physiologic reality. The initial evaluation and the total time of submersion should help clinicians determine the appropriate duration of resuscitative efforts on a drowned patient with potentially significant morbidity or brain death.



Clinical Presentation: A Case History


One of the authors of this chapter (RBS) took care of the patient described in the following paragraphs in an intensive care unit. The case demonstrates many of the clinical features of drowning patients. The patient was a 52-year-old previously healthy male who worked the night shift on a barge in the brackish waters of the Duwamish slough near Puget Sound. One night, the victim tripped on an uncoiled rope on the deck and fell 20 feet into the water. Despite struggling to swim, he lost his orientation and drifted under the barge. Another worker saw the patient fall and drift under the boat, so he astutely threw his flashlight into the water away from the side of the boat. The patient saw the light, desperately swam to it, and was subsequently pulled from the water by co-workers. His full time of submersion was approximately 2 minutes.


Emergency personnel transported the patient to Harborview Medical Center. In the emergency department, he was anxious but alert and oriented, and mildly short of breath with a cough. His vital signs were as follows: respiratory rate, 24 breaths/min; pulse, 115 beats/min; blood pressure, 145/100 mm Hg; and temperature, 36° C (96.5° F). The remainder of his examination was normal except for diffuse ronchi throughout both lung fields. Arterial blood gas levels were as follows: pH, 7.48; arterial partial pressure of carbon dioxide (PaCO2), 32 mm Hg; and arterial partial pressure of oxygen (PaO2), 58 mm Hg on a face mask with high flow oxygen. Chest radiography showed a normal cardiac silhouette with diffuse bilateral patchy opacities. He was admitted to the intensive care unit for observation.


Within the first hour, gas exchange worsened despite adequate alveolar ventilation. He was intubated and placed on mechanical ventilation with volume ventilation mode. Despite being on high concentrations of oxygen, his gas exchange capabilities further deteriorated, and he was given a trial of positive end-expiratory pressure (PEEP). At 15 cm H2O pressure, the patient’s blood pressure fell to 76/52 mm Hg. Volume resuscitation was increased. A pulmonary artery catheter was placed to monitor cardiac function. During the initial PEEP trial, pulmonary capillary wedge pressures were low (i.e., <10 mm Hg). Cardiac index fell from 2.8 to 1.8 L/min/m2 body surface area after PEEP was increased from 10 to 15 cm H2O. PEEP was therefore reduced to 10 cm H2O, and more vigorous volume resuscitation was instituted, after which cardiac index and blood pressure improved such that PEEP could safely be increased, which became necessary to maintain adequate oxygenation.


Over the next 6 days, the patient’s lung compliance initially decreased then increased; his chest radiograph worsened and then slowly improved; and gas exchange improved such that he was extubated on hospital day 10. It was another 2 months before he was able to be physically active, and he had dyspnea on exertion for approximately 6 months after his accident. At hospital discharge, pulmonary function tests showed a moderate decrease in both vital capacity and total lung capacity, mild obstruction of airflow, and severely decreased diffusion capacity for carbon monoxide. Over the next 6 months, the patient’s vital capacity and total lung capacity returned to normal, but diffusion capacity remained mildly decreased.


This case demonstrates a number of important features of submersion injury with aspiration and respiratory failure. First, the patient was extremely lucky for his fall to have been witnessed with subsequent rapid rescue, limiting exposure and submersion time. He arrived at the hospital conscious and alert, one of the best prognostic signs, and had no comorbid conditions. The history and clinical course suggest that he aspirated brackish water, which led to lung injury. His clinical course was consistent with acute lung injury from aspiration, and the initial worsening and subsequent improvement of lung mechanics and gas exchange were typical of ARDS. Fortunately, he had no other organ failure, and his recovery was unremarkable.


There is a spectrum of morbidity from submersion injuries, ranging from asymptomatic to unresponsive, apneic, and pulseless. Systems of classification based on observations from first-aid providers assist with the determination of which patients require hospitalization.212

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Sep 7, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Submersion Injuries and Drowning

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