A 22 year old male is brought into the ED by EMS, after being pulled out of the lake in Central Park. He had been walking on the ice when it broke, and he fell into the water. His friends were able to drag him to shore. As per EMS, he was found to be in Vfib and was shocked once with ROSC, now with sinus bradycardia at a rate of 38 bpm. He was intubated in the field, current temperature is 28 degrees Celsius.
How would you continue care for this patient?
Cold water immersion syndrome is described as syncope resulting from cardiac dysrhythmia on sudden contact with water that is at least 5 degrees Celsius lower than body temperature. There are several proposed mechanisms, but the most probable is vagal stimulation causing asystole and/or ventricular fibrillation secondary to QT-interval prolongation and massive release of catecholamines on contact with cold water.
The risk of cold water immersion syndrome occurring is directly proportional to the difference between the temperature of the body and the temperature of the water. Ethanol consumption is a major risk factor in all types of submersion incidents.
Treatment consists of the ABCs, as well as vigorous rewarming of hypothermic patients to normothermia. Core rewarming with warmed oxygen, continuous bladder lavage with fluid at 40°C, and intravenous (IV) infusion of isotonic fluids at 40°C can be initiated during resuscitation. Warm peritoneal lavage has been used for core rewarming in patients with severe hypothermia.
Thoracotomy, with open heart massage and warm mediastinal lavage, has been used in refractory situations. The hypothermic heart is typically unresponsive to pharmacotherapy and countershock. Extracorporeal blood rewarming has been used in patients with severe hypothermia who did not respond to lavage/thoracotomy or who were in arrest.
It is suggested that resuscitation of a submersion victim not be abandoned until the patient has been warmed to a minimum of 30°C. However, newer literature based on case reports suggests that therapeutic hypothermia may be highly effective in reducing ischemic brain injury in the setting of cold water submersion injury.
The 2002 World Congress on Drowning made the following consensus recommendations on drowning management: “The highest priority is restoration of spontaneous circulation, subsequent to this continuous monitoring of core/and or brain (tympanic) temperatures is mandatory in the ED and intensive care unit and to the extent possible in the prehospital setting. Drowning victims with restoration of adequate spontaneous circulation who remain comatose should not be actively warmed to temperature values above 32-34°C. If core temperature exceeds 34°C, hypothermia should be achieved as soon as possible and sustained for 12 to 24 hours…”
[Credits to PEER VIII and Medscape]
