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CHAPTER 90 ■ ENVIRONMENTAL
EMERGENCIES, RADIOLOGICAL
EMERGENCIES, BITES AND STINGS
IOANNIS KOUTROULIS, DEWESH AGRAWAL

RELATED CHAPTERS
Resuscitation and Stabilization
Airway: Chapter 8
Cardiopulmonary Resuscitation: Chapter 9
Shock: Chapter 10
Pain: Abdomen: Chapter 53
Signs and Symptoms
Seizures: Chapter 72
Clinical Pathways

Shock: Chapter 10
Medical, Surgical, and Trauma Emergencies
Cardiac Emergencies: Chapter 86
Renal and Electrolyte Emergencies: Chapter 100
Burns: Chapter 104

DROWNING
Goals of Treatment
Treatment of submersion injuries aims to resuscitate and stabilize those who need
it, and prevent further cardiopulmonary and neurologic deterioration.
CLINICAL PEARLS AND PITFALLS


Outcome of submersion victims depends on duration of submersion,
degree of pulmonary damage by aspiration, and effectiveness of initial
resuscitative measures.
Supplemental O2 should be given as needed to victims of submersion
to maintain adequate oxygenation (SaO2 >92%).
Consider the early initiation of ECMO for hypothermic patients with
cardiorespiratory insufficiency.

Current Evidence
The World Congress on Drowning defines drowning as “the process of
experiencing respiratory impairment from submersion/immersion in liquid.” The
term near-drowning that was used to describe survival beyond 24 hours after
resuscitation created confusion, and today only two categories of drowning are
used—fatal or nonfatal.
Recently, dry drowning and secondary drowning were introduced to describe
cases in which autopsy did not reveal any water in the lungs of persons found
dead in water and delayed symptoms after aspirating small amounts of water,

respectively. Both terms can lead to misdiagnosis of sudden death as drowning or
failure to identify underlying conditions. The term submersion injury may be used
instead to describe injury from events where the entire body, particularly the
airway, is found below the liquid surface.
Drowning affects all age groups and males two to three times more often than
females. Individuals with epilepsy have a 15- to 19-fold higher risk of drowning
when compared to the general population.
Drowning is the leading cause of death worldwide in boys between the ages of
5 and 14 years, and in the United States drowning is the second leading cause of
injury death in children 1 to 14 years of age (after motor vehicle crashes). Older
infants and toddlers are disproportionately represented in drownings, with lower
survival rates. They are vulnerable to immersion in household buckets, baths, hot
tubs, swimming pools, and other bodies of water near their homes. Young
teenagers are also at greater risk because adult supervision decreases and
impulsive behavior increases. However, coexisting trauma (head and cervical
spine), drug or alcohol use, and especially suicidal intent must be considered in
each case.
Fresh water aspirated into the lungs is rapidly taken up into the circulation,
resulting in a transient rise in circulating blood volume and hemodilution. Saltwater aspiration causes decreased intravascular volume and hemoconcentration.