Submersion Injuries

Question 1

Define Drowning.

Answer 1

A process resulting in primary respiratory impairment from submersion or immersion in a liquid medium

Question 2

Is death always the result of drowning?

Answer 2

No, there is a such a thing as non fatal drowning

Question 3

Define non fatal drowning.

Answer 3

Survival, at least temporarily, after suffocation by submersion in a liquid medium

Question 4

Define wet non fatal drowning. When is sx onset?

Answer 4

Survival after aspiration of liquid into the lungs.

Sx onset can be immediate or delayed as long as 72 hours.

Question 5

Define dry non-fatal drowning. Is prognosis better or worse than wet drowning?

Answer 5

Survival after a period of asphyxia secondary to reflex laryngospasm.
Much better prognosis than wet drowning.

Question 6

Should we use the following terms?

near-drowning, secondary/delayed drowning, shallow water blackout, and dry drowning

Answer 6

no, they are outdated and their are more accurate terms and descriptions now

Question 7

Drowning ranks overall ____ for unintentional death, ___ for children under 4 years old

Answer 7

5th and 1st

Question 8

___% of deaths from drowning are children <14 years old

Answer 8

20%

Question 9

There is a (unimodal/bimodal/trimodal) age distribution for drowning deaths. What is/are the peak(s) and where do those drownings most commonly occur?

Answer 9

Bimodal
1st peak 1-5 y/o (pools, tubs, buckets) w/ ~7% due to neglect or abuse
2nd peak males 15-25 years old (rivers, lakes, oceans) w/ high incidence of ETOH involvement

Question 10

Why are non-fatal drowning incidents difficult to track?

Answer 10

Many do not present to ED, at least 5x more than fatal

Question 11

> 50% adult drowning deaths are due to ingestion of what substance?

Answer 11

Alcoholllllll

Question 12

Why does hypothermia lead to increased chance of drowning and death?

Answer 12

Hypothermia accelerates exhaustion and can cause cardiac arrhythmia

Question 13

Why should you never hyperventilate prior to going under water?

Answer 13

Hyperventilation artificially lowers CO2 levels, and as you are holding your breath O2 is metabolized and CO2 levels increase further. Body becomes starved of O2, and under normal circumstances, the increase in CO2 would trigger a breath, but bc the CO2 levels were so low upon submersion, there is not enough to initiate a breath, so you go unconscious. Once you lose consciousness, your body reacts and forces a breath, causing the lungs to fill with water. Without immediate rescue, death is almost certain.

Question 14

What three physiological results come from drowning?

Answer 14

Decreased lung compliance, ventilation-perfusion mismatch and intrapulmonary shunting

Question 15

What neurologic results of hypoxemia occur after drowning?

Answer 15

Neuronal damage, cerebral edema, and elevated intracranial pressure.

Question 16

What is the main cause of morbidity in drowning pts?

Answer 16

Cerebral hypoxia, additionally, ~20% of non-fatal drowning victims sustain neurologic damage with long term effects

Question 17

What pulmonary effects occur after drowning?

Answer 17

Fluid aspiration washes out surfactant causing non-cardiogenic pulmonary edema and ARDS

Question 18

What cardiovascular effects of hypoxemia occur after drowning?

Answer 18

Arrhythmias (hypothermia/hypoxia from submersion can cause sinus tachy and sinus brady, and AFib)

Question 19

What acid-base effects of hypoxemia occur after drowning?

Answer 19

Metabolic and/or respiratory ACIDOSIS fairly common

Question 20

What renal effects of hypoxemia occur after drowning?

Answer 20

Rarely acute tubular necrosis can occur leading to acute renal failure

Question 21

What hematologic effects of hypoxemia occur after drowning?

Answer 21

Rarely hemolysis and coagulopathy can occur

Question 22

How does CPR on a drowning victim differ from typical CPR protocol?

Answer 22

Ventilation first with 2 rescue breaths (differs from typical cardiac arrest patient)

Question 23

Is C-Spine immobilization recommended for drowning pts?

Answer 23

No

Question 24

Should the Heimlich maneuver be performed to remove water from the patient’s lungs after drowning?

Answer 24

No

Question 25

EMS should administer high flow oxygen by facemask to ____ ____patients, intubate____ patients, and initiate re-warming of ____ patients, post-drowning.

Answer 25

Spontaneously breathing
Apneic
Hypothermic

Question 26

In hypothermic patients, continue resuscitation and rewarming efforts until core temperature reaches ___F

Answer 26

95 F

Question 27

Continue high-flow O2 to maintain O2 saturation >___%

Answer 27

> 94%

Question 28

If you are utilizing CPAP/BiPAP to improve oxygenation and improve ventilation/perfusion mismatch, what should you be monitoring the patient for?

Answer 28

Hypotension secondary to increased intrathoracic pressure

Question 29

Inability to protect airway/neurologic deterioration, having a PaO2 <60 mmHg or O2 saturation <90 on high-flow O2, or having a PaCO2 >50 mmHg are all indications for what procedure?

Answer 29

Intubation!

Question 30

If intubated, you should also place a____ tube to counteract what?

Answer 30

Orogastric; gastric distension

Question 31

If opioid intoxication is suspected, what should you consider empirically administering?

Answer 31

Naloxone

Question 32

Should you obtain an Accucheck blood glucose on drowning pts?

Answer 32

Yes

Question 33

How do you tx a drowning pt w/ bronchospasm?

Answer 33

Inhaled beta agonists

Question 34

If a drowning pt develops PNA, what organisms to you suspect as potential culprits?

Answer 34

Pseudomonas, Proteus, Pseudallescheria boydii … GUILTY!

Question 35

What type of tx may be helpful in a drowning pt with ARDS?

Answer 35

Surfactant treatments

Question 36

Explain the hemodynamics of a hypothermic drowning pt who presents with cold diuresis.

Answer 36

Vasoconstriction, which results in blood being shunted to the pt’s core, which results in central volume receptors sensing fluid overload, which leads to decreased ADH production, which leads to diuresis and hypovolemia, which leads to hypotension and shock

Question 37

What is the most common fungal infection in non-fatal drowning victims?

Answer 37

Pseudallescheria boydii

Question 38

If a drowning pt does not have a c spine injury, what should be done to help avoid cerebral edema?

Answer 38

Elevated head of the bed by 30 degrees

Question 39

If a drowning pt is hypervolemic, what should be administered cautiously?

Answer 39

Diuretics

Question 40

What comorbidity should be tightly controlled in drowning patients?

Answer 40

Sz

Question 41

T/F As part of ongoing tx, you should administer neuromuscular blocking agents (i.e. succinylcholine) to drowning pts

Answer 41

FALSE, do not do this

Question 42

Asymptomatic drowning pts should be observed on a monitor for a minimum of ___ hours

Answer 42

8

Question 43

T/F Symptomatic drowning patients should be admitted to monitored setting until sx are resolved

Answer 43

True

Question 44

Factors that indicate a poor outcome/prognosis for drowning pts include:
Submersion >\_\_\_ minutes (most important)
Delay to BLS >\_\_\_minutes
Duration of resuscitation >\_\_\_ minutes
Age >\_\_\_ y/o 
Glasgow coma scale

Answer 44

Submersion >5 minutes (most important)
Delay to BLS >10minutes
Duration of resuscitation >25 minutes
Age >14 years (kids bounce back, older pts do not)
Glasgow coma scale <5
Continued apnea and need for CPR in ED
Arterial blood pH <7.1 on arrival to ED

Question 45

What should you do if you are caught in a rip current?

Answer 45

Swim parallel to shore.Once free of the current, swim diagonally toward shore.

Question 46

If drowning occurs in contaminated (not pool) water, and the pt is not responding to abx, what should be considered?

Answer 46

Fungal infection