Submersion, Drowning & Diving Emergencies
Comprehensive emergency protocol for drowning, immersion hypothermia, and scuba diving barotrauma. Details the pathophysiology of drowning and non-cardiogenic pulmonary edema, the 'not dead until warm and dead' hypothermic resuscitation rule, distinguishing Arterial Gas Embolism (AGE) from Decompression Sickness (DCS), and hyperbaric oxygen (HBO) indications.
Resuscitation Quick Ribbon (First 2 Minutes)
Bottom-Line Clinical Pearl
In drowning victims presenting in cardiac arrest, the primary insult is profound HYPOXIA, not primary arrhythmia. Resuscitation must prioritize immediate airway aeration and ventilations (traditional A-B-C or 2 rescue breaths before compressions), rather than compression-only CPR.
Drowning is a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium. The traditional distinction between fresh vs. salt water drowning is clinically irrelevant in humans; both cause surfactant washout, alveolar collapse, ventilation-perfusion mismatch, and ARDS:
| Szpilman Drowning Grade | Clinical Presentation & Auscultation | In-Hospital Mortality | Emergency Management Strategy |
|---|---|---|---|
| Grade 1 | Normal auscultation, coughing only | < 0.5% | Observe in ED for 6 hours; discharge if room air SpO2 > 95% and normal chest X-ray. |
| Grade 2 | Rales in some lung fields; mild dyspnea | 1 - 2% | Supplemental oxygen (target SpO2 92-96%), bronchodilators if wheezing; admit to observation unit. |
| Grade 3 | Severe pulmonary edema without arterial hypotension | 5 - 10% | High-Flow Nasal Cannula (HFNC) or BiPAP; admit to ICU/step-down; avoid prophylactic antibiotics. |
| Grade 4 | Severe pulmonary edema WITH hypotension / shock | 20 - 25% | Endotracheal intubation with lung-protective ARDS ventilation; IV crystalloid and vasopressors; ICU. |
| Grade 5 | Respiratory arrest with preserved pulse | 40 - 50% | Immediate Positive Pressure Ventilation via BVM/ETT; oxygenation restores spontaneous rhythm. |
| Grade 6 | Cardiopulmonary Arrest | > 90% | Full ACLS with priority on rescue ventilations + rewarming to > 32-35 C before terminating. |
| Parameter | Arterial Gas Embolism (AGE) | Decompression Sickness (DCS) |
|---|---|---|
| Underlying Physics | Boyle's Law (P1V1 = P2V2): Breath-holding on ascent leads to pulmonary barotrauma and alveolar rupture, allowing gas directly into pulmonary veins and arterial circulation | Henry's Law: Dissolved nitrogen gas comes out of solution forming bubbles in blood and tissues upon rapid decompression |
| Onset of Symptoms | RAPID: Within seconds to 10 minutes of surfacing from dive | DELAYED: Typically 1 to 24 hours after dive (rarely immediate) |
| Clinical Hallmarks | Sudden stroke-like focal deficits (hemiplegia, aphasia), seizures, sudden blindness, loss of consciousness, cardiac arrest, pneumothorax | Type I ('The Bends'): Deep, aching periarticular joint pain (shoulders, knees), cutis marmorata. Type II: Spinal cord paraplegia, sensory loss, labyrinthine vertigo ('the staggers'), pulmonary bubbles ('the chokes'). |
| Emergency Therapy | 100% Normobaric Oxygen (speeds nitrogen washout) + Supine positioning + IMMEDIATE HYPERBARIC OXYGEN (HBO) RECOMPRESSION (US Navy Treatment Table 6). | 100% Normobaric Oxygen + IV hydration + Transport to hyperbaric recompression chamber (maintain low flight altitude < 1,000 ft if air transfer). |
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