EnvC5 Environmental emergencies MRCEM syllabus
'respiratory impairment from submersion in liquid'
wet, dry, passive, active, near-drowning (...despite the curriculum) no longer used.

considerations - physiology and management principles

airway

immediately and prehospital: laryngospasm
in ICU: bronchoscopy and suction of aspirated material

breathing

hypoxia kills
aspiration of water/fluid is said to be <20ml/kg, i.e. not filling up lung volume
due to washing out surfactant → collapse of alveoli
in ICU: aspiration pneumonitis, negative pressure pulmonary oedema

circulation

hypoxia kills - bradycardia → asystolic arrest

disability

pathogenesis - from hypoxia

exposure

hypothermia - may be protective, but also changes cardiac arrest management
- Hypothermic cardiac arrest
- basically needs rapid cooling of the brain - more significant in children

prognostication

Szpilman et al 2012
Poorer outcomes if:

on scene
- immersion > 10 mins (or 5 mins?)
- CPR delayed > 10 mins
presentation to ED
- GCS 3
- fixed dilated pupils
on ICU admission
- GCS less than 6
- Arterial pH less than 7.00 upon arrival to ICU
- No spontaneous purposeful movement and the abnormal brainstem function after 48 hours
- Abnormal CT within 36 hours

#trauma #environmental-emergencies

sources/links

https://www.rcemlearning.co.uk/reference/drowning/#1568890491084-3a97dd39-a049
https://derangedphysiology.com/main/required-reading/environmental-injuries-and-toxicology/Chapter-407/immersion-submersion-and-drowning
Szpilman et al 2012 https://www.nejm.org/doi/full/10.1056/NEJMra1013317
https://litfl.com/cicm-saq-2015-2-q25/
https://litfl.com/drowning/
https://derangedphysiology.com/main/required-reading/paediatrics/Chapter-211/drowning-children