Submersion Injuries



Submersion Injuries


Adam Cheng



Introduction



  • Drowning: death within 24 hours of a submersion incident


  • Near-drowning: survival for at least 24 hours following a submersion incident


  • Near-drowning 2-20 times more common than drowning


  • > 50% of drowning and near-drowning occur in children < 4 years of age


  • Second leading cause of accidental death in children


Risk Factors for Near-Drowning



  • Young age, particularly < 4 years


  • Child maltreatment and neglect


  • Alcohol intoxication: 40-50% of near-drowning associated with alcohol use


  • Drug abuse


  • Seizure disorder: 4- to 5-fold increased risk


  • Cardiac disorder: prior history of arrhythmias


  • Risk-taking behavior


  • Residential swimming pool: most drownings < age 4


  • Close proximity to rivers, lakes, canals, beaches: mostly adolescents


Pathophysiology



  • Final common event: hypoxemia


  • Dry drowning: water does not enter the lungs due to laryngospasm, but anoxia develops because of persistent laryngospasm



  • Wet drowning can be divided into two categories, with different pathophysiologic consequences: fresh water and sea water drowning






Figure 52.1 Sequence of Events


Fresh Water Near-Drowning



  • Hypotonic fresh water dilutes pulmonary surfactant and results in atelectasis and hypoxemia from ventilation-perfusion mismatch and intrapulmonary shunting


  • Hyponatremia and hypokalemia occur in 15% of cases: hypotonic fresh water is rapidly reabsorbed into the systemic circulation from alveoli


  • Hemolysis and hyperkalemia: large amounts of fresh water are aspirated, leading to hypotonic plasma and RBC hemolysis


Sea Water Near-Drowning



  • Pulmonary edema: hypertonic sea water attracts fluid into alveoli


  • Hypoxemia from shunting as fluid-filled alveoli continue to be perfused


  • Intravascular hypovolemia may occur


  • Electrolyte imbalances are uncommon









Table 52.1 Organ Systems Affected in Near-Drowning


















Central nervous system




  • Cerebral edema, increased intracranial pressure



  • Hypoxemic encephalopathy: hypothermia may be protective



  • Cord injury: from hypoxemia


Respiratory




  • Decreased pulmonary compliance and increased airway resistance



  • Noncardiogenic pulmonary edema from damage to alveolar-capillary membrane in both fresh water and sea water aspiration



  • Gastric aspiration, impaired oxygenation



  • Infection in grossly contaminated water


Cardiac




  • Dysrhythmias, hypovolemia, and hypotension


Metabolic




  • Combined metabolic and respiratory acidosis: in 50% of near-drowning victims



  • Hyponatremia or hypokalemia in freshwater drowning (hyperkalemia in rare cases)


Renal




  • Acute tubular necrosis, hemoglobinuria

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Jun 22, 2016 | Posted by in EMERGENCY MEDICINE | Comments Off on Submersion Injuries

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