Patient Care

Improving the Index of Suspicion for Spinal Injuries in Drowning Victims

Cervical spine injuries have become the hot topic for EMS professionals over the past few years. New studies have proven the most fundamental treatment practices to be ineffective and sometimes harmful to patients. Today, a person who complains of minor neck pain from a low speed traffic collision is treated with a C-collar and placed in position of comfort on a gurney. This is a stark contrast to the previous practice, in which this same patient would have received full spinal immobilization with a backboard and minimal manipulation of the spine. The advancement in research-driven treatment practices has paved the way for better patient comfort, more advanced treatment and improved patient outcomes. This shift in focus however, may cause EMS providers to underestimate the occurrence of spinal injuries in less common emergencies such as in drowning victims. By maintaining a high index of suspicion in drowning victims, the EMS professional will be able to identify the risk factors of possible spinal injury and apply appropriate treatment practices.

EMS professionals must understand the different risk factors in relation to three age groups: toddlers (0–4 years), children (5–14 years), and adults (15+ years). Toddlers between 0–4 years old are a unique age group, as they are at risk for drowning in small bodies of water like a bathtub just as easily as they are in a pool.1 This age group is at highest risk when unsupervised near water even for short periods of time. Toddlers tend to slip underwater in bathtubs and drown due to their lack of muscle tone and inexperience in standing on their own. They can also easily fall into swimming pools if no barrier is in place to keep them out of the water.2 For this reason, trauma is not a common mechanism in toddlers (except in the case of suspected abuse) as discussed in a study published by JAMA Pediatrics.3 With this information, treatment of a toddler drowning victim should focus on airway management, as there is very little chance of trauma or spinal injury due to the mechanism most commonly associated with this age group.

Children ages 5–14 years old statistically have the lowest risk of drowning out of all age groups.2 This age group however, is most at risk for drowning in swimming pools and open bodies of water when unsupervised. Inexperienced swimmers and failure to wear life jackets while boating are common contributing factors in these drownings.2 The adolescent age group between the ages of 10–14 is the first age group where we find spinal injuries.3 These injuries are primarily associated with diving into swimming pools, as this age group tends to be reckless and commonly misjudges the water’s depth.

The prevalence of these injuries increases with adults ages 15 and up. Adults have the highest occurrence of spinal injuries due to higher mechanisms of injury and increased risk factors. Adults commonly misjudge the depth of the water when diving and take more risks when jumping from increased heights.4 Even being familiar with the body of water does not reduce these risk factors, according to a study out of South Africa which found the majority of injuries were in fact in bodies of water that the victim was familiar with.4 Adults also engage in high risk activities, such as water sports, that in turn produce higher mechanisms of injury. Finally, alcohol consumption further increases these risk factors by almost 50% and is associated with up to 70% of all water recreation fatalities.5,6

Diving into shallow water commonly results in striking the bottom of a body of water or upslope of a swimming pool, thereby causing compression and flexion of the cervical spine.4,5 This compression can cause subluxation, dislocation or burst fractures of the vertebrae and skull, allowing bone fragments to impinge on the spinal cord or brain.5 These injuries most commonly occur in C5–C7, with less common locations in C1 and C2.5 These injuries may or may not produce obvious visual injuries and require a detailed secondary exam (including a CT scan in the ED) of the spine and skull to help identify their presence.5 For this reason, it is important to take spinal precautions in the field for high-mechanism drowning victims.

Conversely, low-mechanism drowning victims have correspondingly low chances of spinal injury according to a 22-year-long study out of Washington State.7 The JAMA Pediatrics study reflects this conclusion, as only one patient in the study suffered spinal injury who did not have a history of diving or other high mechanism of injury. The patient’s medical history should be further evaluated in these cases as a possible cause for their drowning. Medical conditions that contribute to high-risk drownings include seizures, cardiac conditions and respiratory diseases that can incapacitate a person while swimming, causing them to drown. These risk factors become greater as the patient’s age increases.

Conclusion

When responding to a drowning victim, it is important for the EMS professional to assess the situation and identify risk factors that may have contributed to the drowning.

Ask yourself:

  • What were the circumstances leading up to the event?
  • Was it a high mechanism event, or does the patient have an underlying medical condition that may have incapacitated them?
  • What special risk factors does the patient have simply based on their age?
  • Was alcohol involved? 
  • Most importantly, did the patient know how to swim?

By maintaining a high index of suspicion in drowning victims and asking these types of questions, the EMS professional can develop a treatment plan that best suits the patient’s needs and provides for spinal stabilization when warranted.

References

1. Brenner R, Trumble A, Smith G, et. al. Where children drown, United States, 1995. Pediatrics. 2001;108 (1):85–89.

2. Quan L, Cummings P. Characteristics of drowning by different age groups. Inj Prev. 2003;9(2):163–168.

3. Hwang V, Shofer F, Durbin D, et. al. Prevalence of traumatic injuries in drowning and near drowning in children and adolescents. Arch Pediatric Adolescent Med. 2003;157(1):50–53.

4. Steinbrück K, Paeslack V. Analysis of 139 spinal cord injuries due to accidents in water sport. Paraplegia. 1980;18(2):86–93.

5. Borius P, Gouader I, Bousquet P, et. al. Cervical spine injuries resulting from diving accidents in swimming pools: outcome of 34 patients. Eur Spine J. 2010;19(4):552–557.

6. Centers for Disease Control and Prevention (n.d.). Web-based injury statistics query and reporting system (WISQARS). Retrieved Nov. 18, 2016, from http://www.cdc.gov/injury/wisqars/.

7. Watson R, Cummings P, Quan L, et. al. Cervical spine injuries among submersion victims. J Trauma. 2001;51(4):658–662.