SUBMERSION INJURIES

INTRODUCTION

Submersion injuries are the second leading cause of preventable mortality in the

pediatric age group. Drowning refers to death from submersion. Near drowning implies

survival for at least 24 hours after the incident. Submersion is followed by

laryngospasm then aspiration. At about 4 minutes there is circulatory inadequacy and

by six minutes microscopic CNS damage ensues. Surfactant washout results in

atelectasis, pulmonary edema, vasoconstriction, alveolitis and bronchospasm. The

distinction between salt and fresh water drowning and the presence of chlorine is not

clinically relevant.

RISK FACTORS

Like most environmental injuries there is a bimodal distribution of those involved. The

first peak is the toddler age group (“the young”). The second peak is the adolescent

male (“the restless”).

Risk factors for toddler submersion include: inadequate supervision, limited water

safety skills, access to residential swimming pools and bodies of water close to or in

the home (including bath tubs, entrapment in hot tubs, spas, whirlpools and large

containers such as 5 gallon buckets.)

Risk factors for adolescent males include risk-taking behaviors such as diving in

shallow bodies of water, use of alcohol, drugs and boating mishaps.

Patients with seizure disorders represent a distinct risk group. Adequate anticonvulsant

levels may not be protective and these patients should be specifically counseled

regarding water safety.

MANAGEMENT

The goals of management are the prevention of further anoxic damage and the

identification and treatment of complications.

The focus at the scene is establishing an adequate airway, breathing and circulation.

Efforts at pulmonary drainage (e.g. Heimlich maneuver) have not been supported by

the literature. Emergency department and intensive care unit management should

focus on standard resuscitation efforts.

Areas of additional concern in the submersion victim include cerebral resuscitation and

the management of hypothermia and dysrhythmias. Cerebral resuscitation involves

maintaining cerebral perfusion through; elevating the head of the bed, controlled

hyperventilation, minimizing stimuli and temperature and seizure control. The role of

corticosteroids, barbiturate coma and invasive monitoring has not been convincingly

established.

DISPOSITION

Patients should be admitted if they had any of the following:

• Loss of consciousness

• Submersion >1 min,

• Cyanosis

• Apnea

• Required any resuscitation efforts.

Predictors of severe neurologic injury or death include:

Time to return of spontaneous circulation if the key determinate of outcome

• Ongoing CPR in the ED

• Submersion >25 min

• Resuscitation >25 min

• Hypothermia (<34o PREVENTION Prevention is key and should focus on education, enforcement (legislation) and engineering. Infant swimming programs may lead to a false sense of security and should not take the place of supervision. Fully enclosed residential swimming pools with self-closing and latching gates should be mandated. First aid/resuscitation training should be encouraged for all caregivers. C).