Drowning and Submersion Injury
Lesson Objectives
By the end of this lesson, learners should be able to:
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Define drowning and submersion injury and understand pathophysiology.
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Identify risk factors and prognostic indicators.
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Recognize clinical features of mild, moderate, and severe drowning injuries.
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Perform initial assessment using the ABCDE approach.
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Implement appropriate resuscitation, oxygen therapy, and supportive care.
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Understand post-rescue monitoring, prevention of complications, and follow-up care.
Description
Drowning is defined as respiratory impairment from submersion or immersion in liquid, leading to hypoxia, which is the main injury mechanism. Outcomes range from non-fatal (with or without neurological sequelae) to fatal.
The severity depends on duration of submersion, water temperature, promptness and quality of rescue, and pre-existing conditions. Complications can include acute respiratory distress syndrome (ARDS), pulmonary oedema, hypothermia, cardiac arrhythmias, and neurological injury.
Clinical Features
| Category | Signs and Symptoms |
|---|---|
| General | Cyanosis, pallor, lethargy, vomiting |
| Respiratory | Tachypnoea, dyspnoea, cough, rales, crackles, frothy sputum, hypoxia |
| Cardiovascular | Bradycardia, hypotension, arrhythmias, shock |
| Neurological | Agitation, confusion, drowsiness, seizures, altered GCS, coma |
| Temperature | Hypothermia (core temperature <35°C) |
| Other | Possible injuries from trauma or submersion event (e.g., fractures, head injury) |
Initial Assessment — ABCDE Approach
| Step | Action |
|---|---|
| A – Airway | Assess airway patency. Suction water, secretions, or vomitus. Protect cervical spine if trauma suspected. |
| B – Breathing | Assess respiratory rate, effort, oxygen saturation. Administer high-flow oxygen via mask or nasal cannula. Support ventilation if apnoeic. |
| C – Circulation | Check pulse, heart rate, BP, capillary refill. Start IV access; give isotonic fluids for hypotension. Avoid hypotonic or glucose-containing fluids. Monitor for shock. |
| D – Disability | Assess neurological status (GCS), pupil size, limb movement, and seizure activity. |
| E – Exposure | Remove wet clothing, treat hypothermia with warm blankets, warmed IV fluids if necessary, monitor core temperature. |
Resuscitation and Supportive Care
| Intervention | Details |
|---|---|
| Cardiopulmonary resuscitation | Follow standard paediatric CPR guidelines. Emphasize oxygenation and ventilation. Consider prolonged resuscitation depending on submersion duration and initial rhythm. |
| Oxygen therapy | Administer high-flow oxygen (FiO₂ 1.0 initially) via mask, nasal cannula, or mechanical ventilation if needed. Avoid excessive oxygen in hyperoxic patients after stabilization. |
| Temperature management | Rewarm hypothermic patients gradually using warmed IV fluids, blankets, or heating devices. Avoid rapid rewarming. |
| Cardiac monitoring | Continuous ECG monitoring for arrhythmias; treat according to standard arrhythmia protocols. |
| Fluid management | Use isotonic crystalloids (0.9% NS or RL). Avoid hypotonic or dextrose-containing fluids initially. Correct hypovolemia carefully. |
| Pulmonary support | Monitor for pulmonary oedema or ARDS. Consider CPAP or intubation for severe respiratory compromise. |
| Neurological support | Observe for delayed neurological deterioration; serial GCS checks and supportive care. |
| Observation | All patients should be observed at least 6–8 hours, even if initially asymptomatic. Pulmonary oedema can develop 4–6 hours post-submersion. |
Investigations
| Test Type | Purpose / Findings |
|---|---|
| Pulse oximetry / ABG | Monitor oxygenation and acid-base status |
| Chest X-ray | Evaluate for pulmonary oedema, aspiration, pneumothorax, or pneumonia |
| Electrolytes, renal function | Monitor fluid balance, detect hyponatremia or acute kidney injury |
| Full blood count | Detect infection or hemoconcentration |
| Cardiac enzymes / ECG | Detect arrhythmias or myocardial injury if indicated |
| Neurological assessment | Monitor for hypoxic brain injury, seizures |
Summary
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Drowning leads to hypoxia-induced injury, predominantly affecting the lungs and brain.
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Immediate ABCs assessment and resuscitation are critical.
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Protect cervical spine and manage hypothermia carefully.
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Provide oxygen and supportive care, monitor cardiovascular and neurological status.
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Observe for at least 6–8 hours post-submersion, as pulmonary oedema or respiratory failure may be delayed.
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Fluid resuscitation with isotonic crystalloids is recommended; avoid hypotonic or glucose-containing fluids.
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ICU admission is warranted for severe cases requiring prolonged ventilation, cardiac monitoring, or neurological support.