CE Solutions Student Zone

Water Related Injuries
Objectives:
At the conclusion of this chapter you should be able to:
1. Describe the treatment for drowning and near-drowning patients
2. Describe marine life injuries and the prehospital treatment
3. Describe the treatment for SCUBA accidents and hypothermia

Introduction
Water emergencies can be divided into three main
categories; drownings and near-drownings, traumatic
injuries due to water sports, and injuries due to
marine life. Drownings and near-drownings are
considered by the American College of Surgeons to be
trauma (American College of Surgeons, 2004), as they
clearly do not meet the description of a medical
problem. Traumatic injuries are complicated by the
presence of water. For example, a fractured clavicle on
land is a painful but manageable result of trauma, but
in the marine environment, it may be life-threatening
as the victim may be unable to swim effectively due to
the injury, resulting in a drowning or near-drowning
situation in addition to the initial trauma. Water
emergencies are also frequently complicated by the
issue of hypothermia. Hypothermia causes changes to
the chemistry of blood that can be extremely detrimental to the trauma patient.

Drowning and Near-Drowning
Drowning is defined as death by asphyxiation within 24 hours of submersion in a liquid. Near drowning describes
survival for greater than 24 hours following asphyxiation due to submersion (Fiore & Heidemann, 2004). According to
the Centers for Disease Control (CDC), unintentional injury is the leading cause of death for the 1-44 year-old age
group (CDC, 2002). Within the category of unintentional injury, drowning is the second leading cause of death in the
1-14 year-old age group. This results in more than 1500 drowning deaths in this pediatric population every year in the
United States (Fiore & Heidemann, 2004). Near drowning victims have a about a 70% survival rate (EMedicine, 2005).
Although freshwater and saltwater do have somewhat different effects on the lungs, they are both treated the same. Of
greater importance is the temperature of the water, with higher rates of survival occurring in very cold water
immersions, particularly among the pediatric population. This is thought to be due to the Mammalian Reflex, also
known as the Diving Reflex. This is thought to be a reflex inhibition of breathing, bradycardia, and vasoconstriction of
blood supply to non-critical areas of the body triggered when cold water touches the face.
This reflex is more pronounced in children and may explain their survival times of up to an hour underwater in freezing
water (Shepherd & Martin, 2005). When water enters the larynx, it typically causes a laryngospasm, which results in
occlusion of the airway. In 15% of cases, this results in the entry of very little water into the lungs. This condition is
known as "dry drowning". Unless an airway obstruction is suspected, no attempt should be made to clear water from
the victim's lungs using any subdiaphragmatic thrusts (Sanders, 2005 p. 995). Drowning episodes can be categorized as
primary and secondary. Primary causes refer to victims who are simply overcome by the water and do not have the
strength or ability to stay afloat. Seizures, drugs, cardiac arrest and alcohol are considered secondary causes of
drowning. Among adolescents, alcohol has been found to be a contributory factor in as many as half the drowning
deaths (US Department of Health & Human Services, n.d.). Entry of water into the lungs, or laryngospasm, result in
hypoxia due to lack of air exchange. This rapidly leads to hypoxemia, hypercapnia and acidosis, which result in cardiac
arrest (Sanders, 2005 p.994).

Traumatic Injuries Related to Watersports
Personal watercraft and boating accidents accounted for 3,888 injuries and 703 deaths in 2003 in the United States
(CDC, 2005). With these accidents, victims frequently suffer from traumatic injuries as well as drowning or
near-drowning. All drowning and near-drowning victims must be assumed to have suffered trauma. C-spine precautions
must be taken unless traumatic mechanism of injury can be definitively ruled out by eyewitnesses. Consider the
potential for traumatic injury in the following examples:
A 14 year old boy is being chased around the family yacht by his older brother. The boy jumps into the

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the rescuer needs to make a decision about the extent of the risk that he or she is willing to accept in effecting the rescue. 2005). Anaphylaxis may be severe enough to cause vascular collapse and airway compromise as swelling of soft tissue begins to occlude the pharynx and trachea. Treatment for jellyfish stings includes immersing the stinging tentacles in vinegar or alcohol to inactivate the stinging cells. In this way. Jellyfish deliver stings from cnidocysts. A 24 year old female scuba instructor is clearing a rope from the propeller of a dive boat. The throttle sticks and the Zodiac goes into a tight circle at max. She goes into cardiac arrest on the deck of the dive boat due to massive blood loss and cannot be resuscitated. By the time other crewmembers realize what has happened and get to the injured diver. Other marine life injuries that may result in serious bleeding include attacks from alligators. amputating the diver's leg at the hip with the spinning propeller. A dive rescue team later finds his body 20' below the surface. barracuda. Shark attacks attract disproportionate media attention. found in tropical waters. 2004). if a boat or dinghy is not available. Failing these techniques. Wounds incurred in water have an increased potential for infection. there were 1. both to prevent further attack and to begin definitive care for the victim. Elevating an affected limb above the heart will assist in bleeding control by mechanically lowering the blood pressure at the site. a fractured femur.CE Solutions Student Zone 2 of 6 Zodiac dinghy alongside the yacht and starts the powerful outboard engine just as his brother jumps in. stingrays. the most dangerous of these being the box jellyfish. and cone shells. even while the victim is still in the water. He does not surface. involving large loss of blood such as from shark attack. There are around 100 species of jellyfish that are toxic to humans. Statistically. It is preferable to use a boat to extricate a sharkbite victim for example. He is paralyzed for life.857 lightning deaths. there is no risk of cutting off circulation to the limb distal to the pressure point. Bleeding control must be initiated immediately. causing massive head injuries and a C1 fracture of the diver's neck. and a fractured left radius and ulna. An anaphylactic reaction is a life-threatening emergency and should be treated aggressively with IV fluid hydration to increase blood pressure and administration of subcutaneous epinephrine. Any wheezing or swelling of the lips or tongue should be treated aggressively by the rescuer before it progresses further. and food or fluids in the stomach greatly increase the risk of aspiration during surgery. He puts the boat in gear. Do not give anything by mouth as the victim will likely need surgery. A tourist on a rented Waverunner is using the dive flag as a turning buoy and hits the diver in the head at 30mph. killing him instantly. A 22 year old male on a party boat in Lake Powell does a back flip off the roof of the houseboat. applying pressure to pressure points such as the brachial artery in the arms and the femoral artery in the legs will assist in reducing the amount of bleeding. small sacs containing a coiled barbed filament that discharges when touched. It is important to remember that blood loss in water is very difficult to estimate. males are twice as likely to suffer trauma than females (NTDB. landing headfirst in six feet of water. water or sea snakes. if possible. thus allowing platelets to form a clot more rapidly. sea urchins. However. If a tourniquet must be used. or envenomations such as from jellyfish. running over the 14 year old three times and inflicting over 40 deep lacerations. as they do occlude all distal circulation and run the risk of causing ischemic injuries to the limb distal to the tourniquet. His friends jump in and pull him out of the water without any cervical spine precautions. rpm. Bleeding should be controlled first by direct pressure to the site of the wound with a dressing. The patient survives but has to endure many subsequent plastic surgeries. compared to 22 fatal shark attacks during the same period (University of Florida. remember to keep the victim warm. His leg has been wedged in a submerged tree. it should be at least wide so as not to cause localized nerve damage due to the high pressure generated by thin tourniquets at the site of their application. 2004). which have caused fatalities due to cardiorespiratory arrest (Cheng. Tourniquets should be used only as a last resort. Victims should be removed from the water as rapidly as possible. knocking them both into the water. These should then be . fracturing two cervical vertebra. Anaphylactic reactions have also resulted from relatively minor stings. Never enter the water without at the very minimum some form of flotation. moray eels and marine mammals such as seals and sealions. From 1959-2003. Note that the examples above refer overwhelmingly to male victims. This of course does not trivialize the seriousness of a shark bite which obviously has potential for large amounts of blood loss and must be treated aggressively. injecting the victim with a toxin. it is too late. due to the presence of bacteria and foreign matter in both salt and fresh water. Remember that the fish or animal that inflicted the initial trauma may pose a continuing danger to rescuers. The captain is told incorrectly that she is back on board. A 29 year old scuba diver in the Caribbean surfaces right next to the dive flag he is using to warn boaters of his presence. Once extricated. Marine Life Injuries Marine life injuries can be traumatic. In actual fact the incidence of fatal shark attacks in the US is far less than the number of fatalities from lightning strikes. A 30 year old male jumps 60' from a cliff into a deep swimming hole. Use of pressure points in the groin and the bicep occlude the major arteries while still allowing collateral circulation through minor arteries.

not rubbed off. paralysis and death can occur (Pulley. This venom usually results in localized swelling and severe pain and can also cause systemic problems such as nausea. The bubbles that form join together to make larger bubbles which then clog the circulation. resulting in continued envenomation of the victim. the highest point in the US. or pneumothorax.300'. unconsciousness. these airspaces begin to expand again as the pressure on them is reduced.000' exerts a pressure at sea level of 14. These include the sinuses. n. the nitrogen comes out of the tissues and enters the bloodstream in the form of microbubbles.CE Solutions Student Zone removed with tweezers or gloved fingers. or two atmospheres. muscle cramps and seizures (Meade. its volume is half what it was at the surface. As a freediver (a diver who is not using any kind of compressed air to dive with) descends in the water column. If the ischemia occurs in the brain. The problem occurs when a diver ascends too quickly or stays down too long and absorbs too much nitrogen. starting at the bite site and working upward and a splint applied to immobilize the affected area. They are found in the tropics and sub tropics. Boyle's Law states that as pressure increases. 3 of 6 . It is important that EMS personnel in areas where diving is conducted have at least a basic understanding of diving physics. So if a balloon full of air is taken down to 33' in salt water. if possible. SCUBA Diving Injuries Scuba diving is an increasingly popular sport in the United States. volume decreases according to the equation P1V1 = P2V2 (Blauch. from one atmosphere at the surface to two. At 100. This air column of 100. the middle and inner ear and the lungs. At 20. aphasia. which come frothing out of the bottle. Envenomation from sea snakes is much more rare as sea snakes are generally not an aggressive species. the nitrogen in the inhaled air is absorbed by various tissues in the body. What this means to the balloon is that at 33'. While divers are trained never to ascend without exhaling. the air in the diver's lungs will double in volume as the pressure changes from two atmospheres back to one. as rubbing causes the trigger hairs to fire. 2005). Medical care should be sought for stingray envenomations as x-rays may be needed to determine that no part of the stinger remains in the victim. Stingray venom is protein based. it only takes 33' of salt water to equal the pressure of the atmosphere. certainly not enough to sustain life.d. 1997). there is only an occasional molecule or two to be found. The victim should be taken immediately to an emergency department to get antivenin treatment. They should never be put back into the water for recompression as they could become unconscious and drown. 2005). with paralysis. Most of the molecules that make up our atmosphere sink to the bottom of the air column. This can be a lethal combination. Decompression sickness is a much less acute phenomenon than CAGE. including the Hawaiian islands. With regard to the freediver's lungs. the increasing weight of the water column above begins to compress the diver's airspaces. seizures. as well as multi organ failure. unconsciousness or cardiac arrest. ABCs should be closely monitored en-route (Foster. and soaking the affected site in water as hot as the victim can tolerate without causing burns usually brings rapid relief. Soaking in hot water should continue for 30-90 minutes. and results in formation of bubbles. The heat presumably changes the chemical composition of the venom (Meade.000'. they also compress to half their volume at 33'. A pressure dressing should be applied. much the same way as an egg white in boiling water changes its composition. Large bubbles can enter the arterial circulation causing emboli in the brain known as cerebral artery gas embolism or CAGE. 1995). A rapid ascent can be compared to quickly twisting the top off a soda bottle. This same treatment should be used for sea urchin impalements. then disorientation. The danger in this is that if a scuba diver ascends from 33' to the surface without exhaling. near sea level. Stingrays can inject venom from stingers at the base of their tails. ataxia. and to ensure that there is no systemic reaction to the stingray venom. The atmosphere. This would cause a rupture of the lung tissue. and symptoms may not present for up to 24 hours after a dive. This is possible because the regulator that the diver breathes from provides more air with each breath as the surrounding water pressure increases. The scuba diver's lungs always remain at their normal volume. vomiting. This rapidly reduces the pressure in the bottle. Scuba diving is very different from freediving however. then re-expand back to their normal volume as the freediver ascends to the surface. The same phenomenon occurs in a diver's blood during a rapid ascent. McKinley). with the number of recreational scuba divers estimated at over two million in the United States alone. As a diver breathes compressed air under pressure. These can manifest similar to a stroke. on top of Denali (also known as Mt. no matter how deep the diver descends. The atmosphere is generally accepted to be about 100. panic situations can cause rapid ascents and failure to exhale. Another danger of scuba diving is known as decompression sickness. They are extremely toxic and their venom causes rapid onset of neurological symptoms. As the freediver ascends. 2005). Victims of CAGE need immediate transport by ambulance to a recompression chamber. As the diver ascends. 2005). or air that we breathe consists of approximately 21% oxygen. 78% nitrogen and 1% trace gases (Lide.7 pounds per square inch. occluding blood flow and causing painful ischemia and physical stretching of nerves and blood vessels known as the "bends" or decompression sickness. 2000). diarrhea. It is then exhaled from the lungs.000' high (NASA. the atmospheric pressure is about 43% of what it is at sea level (Aerospaceweb.) . and stings from members of the scorpionfish family such as rock sculpins. Because water is so much denser than air. the pressure on the balloon doubles.

Immediate first aid for these patients includes administering high flow oxygen by non-rebreather mask. 980). the transfer of body heat to the surrounding water is inevitable. Think of cold water sitting in a pot. ultimately boiling. Their number is 1-800 446-2671. n. Hypothermia also causes cardiac dysrhythmias. These include conduction. flown by helicopter at as low an altitude as possible. Injuries due to pressure are known as barotrauma. the water begins to move around. There are some larger "multiplace" chambers capable of treating up to 20 divers at a time. An IV of isotonic fluid should be established. As you apply heat. It is caused by the increased partial pressure of nitrogen in the blood and disappears as the diver ascends to shallower depths (EMedicine. but many of these larger facilities are military and are not available to civilians. Hypothermia causes blood to become coagulopathic. and the victim should see a physician for follow up. especially if the bleed is internal. The Divers Alert Network (DAN) maintains a 24 hour hotline that provides information for victims and rescuers of diving injuries and is a valuable resource in identifying recompression facilities and guiding rescuers through the first aid for diving related injuries. with the patient intermittently breathing 100% oxygen. 1997). If there is a traumatic injury that is causing bleeding. p. Other than encouraging the victim not to swallow blood. as the reduced cabin pressure would further exacerbate their condition by allowing more dissolved nitrogen to come fizzing into their blood. and amnesia. These victims may not be flown. . 2005). so the molecules draining your body heat are far more numerous. 2005 p. at which point some of the molecules have so much energy that they are able to leap out of the pot and into the atmosphere as vapor or steam. This possibility exists because of the build up of toxic metabolites and cellular contents such as potassium from damaged cells in extremities that have greatly restricted circulation. This is one of the reasons that trauma victims should be kept as warm as possible. such as a lacerated liver. 2005. they absorb some of the heat produced by your body and carry it away. As the molecules of air come into contact with your skin. this is impractical. confusion. This can occur when the body's temperature reaches around 90ºF (Sanders. is a sign of barotrauma. These chambers are typically able to treat one person at a time with an attendant inside the chamber to provide direct patient care as needed. Imagine how quickly a breeze can cool you.). the doors are sealed and the pressure inside the chamber is gradually increased using compressed air until the desired "depth" is reached. are cooled rapidly. or. The victim is placed inside the chamber. Cool water acts as a sponge that sucks the warmth out of a body. or nose. Even with wetsuits or drysuits. This is said to be mild hypothermia. Most water that we come into contact with in the watersports context is considerably colder than this. according to the treatment tables being used. there is no real first aid for these conditions. if a recompression chamber is not available locally. or unable to clot. An airlock allows the attendant to leave and reenter the recompression chamber without altering the pressure in the patient treatment area. 91. Even partial immersion can cause hypothermia as the affected body parts. at least. relative to the outside or ambient pressure. usually the legs. elevation and/or pressure points. which is a feeling of euphoria typically felt at around 100'. n. Patients should be handled as gently as possible so as not to increase the risk of cardiac arrest.). Conduction is the transfer of energy from one molecule to another. Heat is carried away from a body by several mechanisms.4ºF is the temperature at which a nude individual's heat production balances heat loss (Shepherd & Martin. This is more pressure than it is reasonable to submit a victim to. experts state a survival time of under fifteen minutes before extreme hypothermia renders the body unconscious. Eustachian tubes. Hypothermia Hypothermia is a lowering of the body's temperature and occurs when the core temperature reaches 96. however.d.d. so the size of the bubbles in a routine treatment are not reduced by 50%. and cool your body 32 times faster than air (United States Search and Rescue Taskforce. According to the formula: volume = 4/3πr3 the pressure on the bubble must increase by a factor of eight (Diving Medicine Online. 2004) and transported. Always activate the local EMS system first. 2005). In water around freezing. this is obviously a big problem. Recompression chambers follow specific treatment plans originally developed by the US Navy.CE Solutions Student Zone 4 of 6 Treatment for decompression sickness and CAGE is essentially the same. Molecules of a lower temperature have less energy than similar molecules with a higher temperature. they must be transported in a portable chamber to the treatment center. such as the sinuses and inner and middle ear. whether their mechanism of injury is related to water or not. so that they are able to pass through the circulation and be exhaled in the lungs. Barotrauma can also affect airspaces besides the lungs. and cannot be controlled with direct pressure. It would be helpful to decrease the diameter of a bubble by 50%. The patient should be positioned in the left lateral recumbent position (Thalmann. Pain and bleeding from the ears. Recompression is the only way to reduce the size of the bubbles in the bloodstream and drive them back into solution in the blood and tissues of the body. The idea is to physically compress the bubbles inside the victim's body to a smaller size. Decompression sickness should not be confused with nitrogen narcosis. Failure of these airspaces to equalize pressure during an ascent can lead to painful trauma due to overexpansion of air inside these delicate structures. convection and radiation.991). Instead. A typical treatment would take the pressurize the victim to an equivalent depth of 60 feet for 285 minutes. according to treatment schedules developed by the US Navy (Campbell.8ºF (Sanders. and a one liter bolus delivered over 30-60 minutes to counteract the effects of dehydration and coagulation. A victim of decompression sickness or CAGE may require many sessions in the recompression chamber before relief of symptoms is obtained. The recompression chamber itself is an airtight container that is strong enough to withstand a pressure difference of several atmospheres of pressure. Water is 800 times denser than air.

once their wheels lose traction. p.shtml 2. such as by reaching the victim with a pole. from extrication to treatment. n. the patient should be handled very gently so as not to promote venous return of this cold blood by manipulation of the patient's limbs (Steinman. Watersports are becoming increasingly popular in the United States and elsewhere. 2005 from http://www. the size of a (small!) linebacker. envenomations.davidson. Retrieved on September 2. If the hypothermia victim is unresponsive. Scuba diving accidents involving barotrauma can be life-threatening in the case of CAGE.edu/ChemistryApplets /GasLaws/BoylesLawCalc.html 3. Cold water drowning victims should be aggressively resuscitated. Victims should be taken out of the water in a horizontal position if possible. For the same reason. 1500lbs of a vehicle's weight is displaced (NOAA.com/content 5 of 6 . a huge amount of force is applied by fast moving water. 2005 from http://www. are totally at the mercy of the current. All victims of water related accidents must be assumed to have spinal injuries unless this can absolutely be ruled out by eyewitnesses. Atmospheric pressure. 2005 from http://www.d.aerospaceweb. throw. or throwing a line to the victim. Because of the surface area of the side of a vehicle. Alcohol is a frequent factor in marine injuries involving watercraft. It is better to err on the side of caution and place all victims in C-spine precautions. or allergic reactions that may progress to life-threatening anaphylaxis. All rights reserved. even if it appears to be hopeless. Trying to cross a flooded creek in a vehicle often leads to the vehicle being swept away and the death or injury of the occupants. This tragedy resulted in the deaths of seven people. Copyright © CE Solutions. and exacerbates trauma by changing the blood's clotting abilities and chemistry and placing the victim at risk for lethal cardiac arrhythmias. and it is easy to see how a person's feet can be swept out from under them in relatively shallow. Sanders (2005. four adult rescuers died trying to rescue three boys who had fallen through the ice into the freezing water of the lake. n. M. then swimming. Decompression sickness and CAGE victims need to be treated in a recompression chamber as quickly as possible. Avoid becoming a victim. watersport injuries or marine life injuries at some point in their careers. Imagine that linebacker hitting your legs at 30mph. Gradual rewarming en route to an emergency department is preferred.org/question/atmosphere /q0049. A mnemonic used in swift water rescue is "Reach. helo" meaning the order of preference in a rescue is to reach for the victim with a hand or a pole. The chance of being involved in a water rescue is always a possibility. Blauch. (2000). Jellyfish tentacles can be neutralized with rubbing alcohol or vinegar in large quantities.rescuenet. (n. hypothermia does slow the metabolism. 996) describes an incident in which a child was resuscitated with good neurological outcome after being submerged for 66 minutes in 37ºF water. This will minimize further discharge of stinging cells. Calculations using Boyle's law. Victims of marine life injuries are more likely to have lacerations. after which they should be peeled off the skin and not rubbed off with a towel or hand. go. Brown. then taking a boat.d. and special training is highly recommended before any water rescue is attempted. Water provides a series of distinct challenges to the rescuer. then naturally this should be attempted. If a rescue can be effected without placing the rescuer at risk.d.). check the ABCs and begin CPR if indicated. or merely painful and inconvenient. adding to the burden on the remaining rescuers. to prevent a large drop in blood pressure in the vital organs.chm. A careful assessment is vital. and remarkable stories of survival after lengthy immersions have been reported. Remove all wet clothing and wrap the victim in warm blankets and place the victim in a heated environment (Sanders. acidotic blood from the extremities may cause lethal arrhythmias. 990). and victims may be distracted from the extent of their injuries by the alcohol. Learn water rescue techniques taught by groups such as the American Red Cross. or local search and rescue groups. then using a helicopter (Brown. Hypothermia is frequently a factor in water related emergencies. Warm IV fluids and warmed humidified oxygen are helpful in rewarming the hypothermic patient. at Convict Lake in California's Sierra Nevadas. D. EMS personnel should absolutely expect to deal with a victim of a water emergency. Rescuers may drown. Training is required for water rescues in order to ensure that rescuers do not become victims themselves. Therefore a fast moving creek two feet deep is more than sufficient to carry an average vehicle away. Rewarming with hot baths should be avoided in the field as the sudden return to circulation of cold.). For each foot of flood water. Author Chris Greenfield References: 1. Victims of watercraft injuries can have severe trauma and internal injuries. 2005 p. Retrieved on August 29.). Three cubic feet weigh about 190lbs. in the case of a sinus injury. While it may be hard for untrained rescuers to stand by while the victim cries for help.CE Solutions Student Zone On the positive side. Vehicles.d. Consider that a cubic foot of fresh water weighs 62. Swift water has tremendous energy that is often underestimated by victims and rescuers alike. 2004). Retrieved on September 2. followed by throwing a rope. Aerospaceweb (n. it will not help the situation if the rescuer becomes a victim too. In 1990. whether due to drowning or near-drowning. row. The same applies to many rescuers. fast moving water. Developing a swiftwater rescue plan. Water Rescues Many victims of water related injuries get into trouble when they underestimate the power of moving water.4lbs. or suffer injuries due to be crushed by or pinned against objects in the fast moving water.).

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