Drowning and Submersion Injury

Question 1

The most important step to reducing the impact of drowning injury

Answer 1

Prevention,
followed by early initiation of CPR at the scene

Question 2

Highest drowning death rates were seen in what age groups

Answer 2

age 1-4 yrs
age 15-19 yrs

Question 3

Remarks on global impact of drwoning

Answer 3

1. Drowning injury is the 3rd leading cause of unintentional death worldwide.
2. More than half of the global drowning occurs in WHO Western Pacific and Southeast Asia regions

Question 4

Remarks on vocalization drowning

Answer 4

Vocalization is precluded by efforts to achieve maximal lung volume to keep the head above the water or by aspiration leading to laryngospasm

Question 5

Most common cause of mortality and long-term morbidity in drowning

Answer 5

CNS injury
irreversible hypoxic-ischemic CNS injury

Question 6

Prognosis in drowning

Answer 6

1. Submersions <5 mins are associated with a favorable prognosis,
   whereas those >25 mins are generally fatal
2. Submersion duration is most strongly related to good outcome, not water temperature
3. Cardiac arrest from drowning has a higher survival rate
4. Overall, early GCS assessments fail to adequately distinguish children who will survive intact from those with major neurologic injury

Question 7

Remarks on pulmonary injury in drowning

Answer 7

1. Pulmonary aspiration occurs in many drowning victims, but the amount of aspirated fluid is usually small.
2. In humans, aspiration of small amounts (1-3 mL/kg) can lead to marked hypoxemia and a 10-40% reduction in lung compliance.
3. Clinical management is not significantly different in saltwater and freshwater aspirations, because most victims do not aspirate enough fluid volume to make a clinical difference

Question 8

What are cold water immersion injuries

Answer 8

the victim remains afloat, keeping the head above water without respiratory impairment in cold waters

The definiction of cold water varies from <15 to 20 C

Immersion in cold water has immediate respiratory and cardiovascular effects

Question 9

Children are at increased risk of hypothermia because of

Answer 9

Their relatively high ratio of BSA to mass
Decreased subcutaneous fat
Limited thermogenic capacity

Question 10

What is cold water shock?

Answer 10

1. In adults, immersion in icy water results in intense involuntary reflex hyperventilation and to a decrease in breath-holding activity to <10 sec, which leads to fluid aspiration
2. Severe bradycardia, the diving reflex, occurs in adults but is transient and rapidly followed by supraventricular and ectopic tachycardia and hypertension.
   There is NO evidence that the diving reflex has any protective effect

Question 11

Remarks on resuscitation of drowning victims

Answer 11

1. CPR of drowning victims must include providing ventilation
2. Common themes in children who have good recovery are a short duration of event and initiation of CPR ASAP, before arrival of emergency medical services.

Question 12

Remarks on suspected airway foreign body in drowning patients

Answer 12

1. Abdominal thrusts should not be used for fluid removal, because many victims have a distended abdomen from swallowed water; abdominal thrusts may increase the risk of regurgitation and aspiration.
2. In cases of suspected airway foreign body, chest compressions or back blows are preferable maneuvers

Question 13

Remarks on C-spine precautions in drowning victims

Answer 13

1. The cervical spine should be protected in anyone with potential traumatic neck injury.
2. In low-impact submersions, spinal injuries are exceedingly rare, and routine spinal immobilization is not warranted

Question 14

Cardiac dysfunction in drowning patients

Answer 14

1. Unstable patients (i.e., arrhythmias) should be warmed to 34 C, taking care not to overheat
2. The provision of adequate oxygenation and ventilation is a prerequisite to improving myocardial function

Question 15

The most critical and effective neurologic intensive care measures after drowning are

Answer 15

rapid restoration and maintenance of adequate oxygenation, ventilation, and perfusion

Question 16

Changes in resuscitation in hypothermic patients

Answer 16

1. IV medications may be given at a lower frequency in moderate (30-34) hypothermia because of decreased drug clearance
2. When ventricular fibrillation is present in severely hypothermic victims (<30 C), defibrillation should be initiated but may not be effective until the core temperature is ≥30 C, at which time successful defibrillation may be more likely
3. Body temperature should be taken into account before resuscitative efforts are terminated
   Victims with profound hypothermia may appear clinically dead, but full neurologic recovery is possible, although rare

Question 17

Remark on active rewarming

Answer 17

Active rewarming should be limited to victims with cre body temperatures <32 C, but temperatures 32-37.5 should be allowed withour furter rewarming efforts

Question 18

Remarks on induction of therapeutic hypothermia

Answer 18

A specific recommendation for therapeutic hypothermia, especially in children, is not yet generally accepted

Question 19

Remarks on child supervision

Answer 19

1. Supervision of infants and young children means that a responsible adutld should be with the child every moment.
2. Even a brief moment of inattention, such as to answer a phone, get a drink, or hold a conversation, can have tragic consequences.
3. If the child does not swim, touch supervision is required, meaning that the caregiver should be within arm’s reach at all times