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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Zodiac dinghy alongside the yacht and starts the powerful outboard engine just as his brother jumps in,
knocking them both into the water. The throttle sticks and the Zodiac goes into a tight circle at max. rpm,
running over the 14 year old three times and inflicting over 40 deep lacerations, a fractured femur, and a
fractured left radius and ulna. The patient survives but has to endure many subsequent plastic surgeries.
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. A tourist on a rented Waverunner is using the dive flag as a turning buoy and hits the
diver in the head at 30mph, causing massive head injuries and a C1 fracture of the diver's neck, 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, landing
headfirst in six feet of water, fracturing two cervical vertebra. His friends jump in and pull him out of the
water without any cervical spine precautions. He is paralyzed for life.
A 24 year old female scuba instructor is clearing a rope from the propeller of a dive boat. The captain is
told incorrectly that she is back on board. He puts the boat in gear, amputating the diver's leg at the hip
with the spinning propeller. By the time other crewmembers realize what has happened and get to the
injured diver, it is too late. She goes into cardiac arrest on the deck of the dive boat due to massive blood
loss and cannot be resuscitated.
A 30 year old male jumps 60' from a cliff into a deep swimming hole. He does not surface. A dive rescue
team later finds his body 20' below the surface. His leg has been wedged in a submerged tree.
Note that the examples above refer overwhelmingly to male victims. Statistically, males are twice as likely to suffer
trauma than females (NTDB, 2004).

Marine Life Injuries

Marine life injuries can be traumatic, involving large loss of blood such as from shark attack, or envenomations such as
from jellyfish, stingrays, water or sea snakes, sea urchins, and cone shells. Shark attacks attract disproportionate
media attention. In actual fact the incidence of fatal shark attacks in the US is far less than the number of fatalities from
lightning strikes. From 1959-2003, there were 1,857 lightning deaths, compared to 22 fatal shark attacks during the
same period (University of Florida, 2004). 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.
Other marine life injuries that may result in serious bleeding include attacks from alligators, barracuda, moray eels and
marine mammals such as seals and sealions. It is important to remember that blood loss in water is very difficult to
estimate. Bleeding control must be initiated immediately, even while the victim is still in the water, if possible. Bleeding
should be controlled first by direct pressure to the site of the wound with a dressing. Elevating an affected limb above
the heart will assist in bleeding control by mechanically lowering the blood pressure at the site, thus allowing platelets
to form a clot more rapidly. Failing these techniques, 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. Use of pressure points in the
groin and the bicep occlude the major arteries while still allowing collateral circulation through minor arteries. In this
way, there is no risk of cutting off circulation to the limb distal to the pressure point.
Tourniquets should be used only as a last resort, as they do occlude all distal circulation and run the risk of causing
ischemic injuries to the limb distal to the tourniquet. If a tourniquet must be used, 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.
Wounds incurred in water have an increased potential for infection, due to the presence of bacteria and foreign matter
in both salt and fresh water. Victims should be removed from the water as rapidly as possible, both to prevent further
attack and to begin definitive care for the victim.
Remember that the fish or animal that inflicted the initial trauma may pose a continuing danger to rescuers. It is
preferable to use a boat to extricate a sharkbite victim for example. However, if a boat or dinghy is not available, 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.
Never enter the water without at the very minimum some form of flotation. Once extricated, remember to keep the
victim warm. Do not give anything by mouth as the victim will likely need surgery, and food or fluids in the stomach
greatly increase the risk of aspiration during surgery.
Jellyfish deliver stings from cnidocysts, small sacs containing a coiled barbed filament that discharges when touched,
injecting the victim with a toxin. There are around 100 species of jellyfish that are toxic to humans, the most dangerous
of these being the box jellyfish, found in tropical waters, which have caused fatalities due to cardiorespiratory arrest
(Cheng, 2005). Anaphylactic reactions have also resulted from relatively minor stings. Anaphylaxis may be severe
enough to cause vascular collapse and airway compromise as swelling of soft tissue begins to occlude the pharynx and
trachea. 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. Treatment for jellyfish stings
includes immersing the stinging tentacles in vinegar or alcohol to inactivate the stinging cells. These should then be

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removed with tweezers or gloved fingers, not rubbed off, as rubbing causes the trigger hairs to fire, resulting in
continued envenomation of the victim.
Stingrays can inject venom from stingers at the base of their tails. This venom usually results in localized swelling and
severe pain and can also cause systemic problems such as nausea, vomiting, diarrhea, muscle cramps and seizures
(Meade, 2005). Stingray venom is protein based, 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. This
same treatment should be used for sea urchin impalements, and stings from members of the scorpionfish family such
as rock sculpins. The heat presumably changes the chemical composition of the venom (Meade, 2005), much the same
way as an egg white in boiling water changes its composition. 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, and to ensure that there is no
systemic reaction to the stingray venom.
Envenomation from sea snakes is much more rare as sea snakes are generally not an aggressive species. They are
found in the tropics and sub tropics, including the Hawaiian islands. They are extremely toxic and their venom causes
rapid onset of neurological symptoms, as well as multi organ failure. A pressure dressing should be applied, starting at
the bite site and working upward and a splint applied to immobilize the affected area, if possible. The victim should be
taken immediately to an emergency department to get antivenin treatment. ABCs should be closely monitored
en-route (Foster, 2005).

SCUBA Diving Injuries

Scuba diving is an increasingly popular sport in the United States, with the number of recreational scuba divers
estimated at over two million in the United States alone. It is important that EMS personnel in areas where diving is
conducted have at least a basic understanding of diving physics. As a freediver (a diver who is not using any kind of
compressed air to dive with) descends in the water column, the increasing weight of the water column above begins to
compress the diver's airspaces. These include the sinuses, the middle and inner ear and the lungs. As the freediver
ascends, these airspaces begin to expand again as the pressure on them is reduced.
The atmosphere is generally accepted to be about 100,000' high (NASA, 1995). The atmosphere, or air that we breathe
consists of approximately 21% oxygen, 78% nitrogen and 1% trace gases (Lide, 1997). Most of the molecules that
make up our atmosphere sink to the bottom of the air column, near sea level. At 20,300', on top of Denali (also known
as Mt. McKinley), the highest point in the US, the atmospheric pressure is about 43% of what it is at sea level
(Aerospaceweb, n.d.) . At 100,000', there is only an occasional molecule or two to be found, certainly not enough to
sustain life. This air column of 100,000' exerts a pressure at sea level of 14.7 pounds per square inch. Because water is
so much denser than air, it only takes 33' of salt water to equal the pressure of the atmosphere.
So if a balloon full of air is taken down to 33' in salt water, the pressure on the balloon doubles, from one atmosphere at
the surface to two. Boyle's Law states that as pressure increases, volume decreases according to the equation P1V1 =
P2V2 (Blauch, 2000). What this means to the balloon is that at 33', or two atmospheres, its volume is half what it was
at the surface. With regard to the freediver's lungs, they also compress to half their volume at 33', then re-expand
back to their normal volume as the freediver ascends to the surface.
Scuba diving is very different from freediving however. The scuba diver's lungs always remain at their normal volume,
no matter how deep the diver descends. This is possible because the regulator that the diver breathes from provides
more air with each breath as the surrounding water pressure increases. The danger in this is that if a scuba diver
ascends from 33' to the surface without exhaling, the air in the diver's lungs will double in volume as the pressure
changes from two atmospheres back to one. This would cause a rupture of the lung tissue, or pneumothorax.
Large bubbles can enter the arterial circulation causing emboli in the brain known as cerebral artery gas embolism or
CAGE. These can manifest similar to a stroke, with paralysis, ataxia, aphasia, unconsciousness or cardiac arrest. While
divers are trained never to ascend without exhaling, panic situations can cause rapid ascents and failure to exhale. This
can be a lethal combination. Victims of CAGE need immediate transport by ambulance to a recompression chamber.
They should never be put back into the water for recompression as they could become unconscious and drown.
Another danger of scuba diving is known as decompression sickness. As a diver breathes compressed air under
pressure, the nitrogen in the inhaled air is absorbed by various tissues in the body. As the diver ascends, the nitrogen
comes out of the tissues and enters the bloodstream in the form of microbubbles. It is then exhaled from the lungs. The
problem occurs when a diver ascends too quickly or stays down too long and absorbs too much nitrogen. A rapid ascent
can be compared to quickly twisting the top off a soda bottle. This rapidly reduces the pressure in the bottle, and results
in formation of bubbles, which come frothing out of the bottle.
The same phenomenon occurs in a diver's blood during a rapid ascent. The bubbles that form join together to make
larger bubbles which then clog the circulation, occluding blood flow and causing painful ischemia and physical stretching
of nerves and blood vessels known as the "bends" or decompression sickness. If the ischemia occurs in the brain, then
disorientation, unconsciousness, seizures, paralysis and death can occur (Pulley, 2005). Decompression sickness is a
much less acute phenomenon than CAGE, and symptoms may not present for up to 24 hours after a dive.

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Treatment for decompression sickness and CAGE is essentially the same. 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.
Recompression chambers follow specific treatment plans originally developed by the US Navy. 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. There are some larger "multiplace" chambers capable of treating up to 20 divers at a time, but many of these
larger facilities are military and are not available to civilians.
The recompression chamber itself is an airtight container that is strong enough to withstand a pressure difference of
several atmospheres of pressure, relative to the outside or ambient pressure. The victim is placed inside the chamber,
the doors are sealed and the pressure inside the chamber is gradually increased using compressed air until the desired
"depth" is reached, according to the treatment tables being used. An airlock allows the attendant to leave and reenter
the recompression chamber without altering the pressure in the patient treatment area. A typical treatment would take
the pressurize the victim to an equivalent depth of 60 feet for 285 minutes, with the patient intermittently breathing
100% oxygen, according to treatment schedules developed by the US Navy (Campbell, 1997). The idea is to physically
compress the bubbles inside the victim's body to a smaller size, so that they are able to pass through the circulation
and be exhaled in the lungs. A victim of decompression sickness or CAGE may require many sessions in the
recompression chamber before relief of symptoms is obtained. It would be helpful to decrease the diameter of a bubble
by 50%, however, this is impractical. According to the formula: volume = 4/3r3 the pressure on the bubble must
increase by a factor of eight (Diving Medicine Online, n.d.). This is more pressure than it is reasonable to submit a
victim to, so the size of the bubbles in a routine treatment are not reduced by 50%.
Immediate first aid for these patients includes administering high flow oxygen by non-rebreather mask. An IV of
isotonic fluid should be established, and a one liter bolus delivered over 30-60 minutes to counteract the effects of
dehydration and coagulation. The patient should be positioned in the left lateral recumbent position (Thalmann, 2004)
and transported. These victims may not be flown, as the reduced cabin pressure would further exacerbate their
condition by allowing more dissolved nitrogen to come fizzing into their blood. Instead, if a recompression chamber is
not available locally, they must be transported in a portable chamber to the treatment center, or, at least, flown by
helicopter at as low an altitude as possible. Decompression sickness should not be confused with nitrogen narcosis,
which is a feeling of euphoria typically felt at around 100'. It is caused by the increased partial pressure of nitrogen in
the blood and disappears as the diver ascends to shallower depths (EMedicine, 2005).
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. Their number is 1-800 446-2671. Always activate the local EMS system first.
Injuries due to pressure are known as barotrauma. Barotrauma can also affect airspaces besides the lungs, such as the
sinuses and inner and middle ear. Failure of these airspaces to equalize pressure during an ascent can lead to painful
trauma due to overexpansion of air inside these delicate structures. Pain and bleeding from the ears, Eustachian tubes,
or nose, is a sign of barotrauma. Other than encouraging the victim not to swallow blood, there is no real first aid for
these conditions, and the victim should see a physician for follow up.

Hypothermia
Hypothermia is a lowering of the body's temperature and occurs when the core temperature reaches 96.8F (Sanders,
2005 p. 980). This is said to be mild hypothermia. Heat is carried away from a body by several mechanisms. These
include conduction, convection and radiation. Conduction is the transfer of energy from one molecule to another.
Molecules of a lower temperature have less energy than similar molecules with a higher temperature. Think of cold
water sitting in a pot. As you apply heat, the water begins to move around, ultimately boiling, 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. Cool water acts as a sponge that sucks the warmth out of a body. 91.4F is the temperature at which a nude
individual's heat production balances heat loss (Shepherd & Martin, 2005). Most water that we come into contact with in
the watersports context is considerably colder than this. Even with wetsuits or drysuits, the transfer of body heat to the
surrounding water is inevitable. Imagine how quickly a breeze can cool you. As the molecules of air come into contact
with your skin, they absorb some of the heat produced by your body and carry it away. Water is 800 times denser than
air, so the molecules draining your body heat are far more numerous, and cool your body 32 times faster than air
(United States Search and Rescue Taskforce, n.d.). Even partial immersion can cause hypothermia as the affected body
parts, usually the legs, are cooled rapidly. In water around freezing, experts state a survival time of under fifteen
minutes before extreme hypothermia renders the body unconscious. This can occur when the body's temperature
reaches around 90F (Sanders, 2005, p.991).
Hypothermia causes blood to become coagulopathic, or unable to clot. If there is a traumatic injury that is causing
bleeding, this is obviously a big problem, especially if the bleed is internal, such as a lacerated liver, and cannot be
controlled with direct pressure, elevation and/or pressure points. This is one of the reasons that trauma victims should
be kept as warm as possible, whether their mechanism of injury is related to water or not. Hypothermia also causes
cardiac dysrhythmias, confusion, and amnesia. Patients should be handled as gently as possible so as not to increase
the risk of cardiac arrest. 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.

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On the positive side, hypothermia does slow the metabolism, and remarkable stories of survival after lengthy
immersions have been reported. Sanders (2005, p. 996) describes an incident in which a child was resuscitated with
good neurological outcome after being submerged for 66 minutes in 37F water. Cold water drowning victims should be
aggressively resuscitated, even if it appears to be hopeless. Victims should be taken out of the water in a horizontal
position if possible, to prevent a large drop in blood pressure in the vital organs. Remove all wet clothing and wrap the
victim in warm blankets and place the victim in a heated environment (Sanders, 2005 p. 990). Rewarming with hot
baths should be avoided in the field as the sudden return to circulation of cold, acidotic blood from the extremities may
cause lethal arrhythmias. Gradual rewarming en route to an emergency department is preferred. For the same reason,
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, 2004). Warm IV fluids and warmed humidified oxygen are helpful in rewarming the
hypothermic patient. If the hypothermia victim is unresponsive, check the ABCs and begin CPR if indicated.

Water Rescues
Many victims of water related injuries get into trouble when they underestimate the power of moving water. The same
applies to many rescuers. 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. Consider that a cubic foot of fresh water weighs 62.4lbs. Three cubic feet weigh
about 190lbs, the size of a (small!) linebacker. Imagine that linebacker hitting your legs at 30mph, and it is easy to see
how a person's feet can be swept out from under them in relatively shallow, fast moving water. Vehicles, once their
wheels lose traction, are totally at the mercy of the current. Because of the surface area of the side of a vehicle, a huge
amount of force is applied by fast moving water. For each foot of flood water, 1500lbs of a vehicle's weight is displaced
(NOAA, n.d.). Therefore a fast moving creek two feet deep is more than sufficient to carry an average vehicle away.
Training is required for water rescues in order to ensure that rescuers do not become victims themselves. Rescuers
may drown, or suffer injuries due to be crushed by or pinned against objects in the fast moving water. In 1990, at
Convict Lake in California's Sierra Nevadas, four adult rescuers died trying to rescue three boys who had fallen through
the ice into the freezing water of the lake. This tragedy resulted in the deaths of seven people. Avoid becoming a
victim. Learn water rescue techniques taught by groups such as the American Red Cross, or local search and rescue
groups. A mnemonic used in swift water rescue is "Reach, throw, row, go, helo" meaning the order of preference in a
rescue is to reach for the victim with a hand or a pole, followed by throwing a rope, then taking a boat, then swimming,
then using a helicopter (Brown, n.d.). While it may be hard for untrained rescuers to stand by while the victim cries for
help, it will not help the situation if the rescuer becomes a victim too, adding to the burden on the remaining rescuers.
If a rescue can be effected without placing the rescuer at risk, such as by reaching the victim with a pole, or throwing a
line to the victim, then naturally this should be attempted.
Watersports are becoming increasingly popular in the United States and elsewhere. EMS personnel should absolutely
expect to deal with a victim of a water emergency, whether due to drowning or near-drowning, watersport injuries or
marine life injuries at some point in their careers. The chance of being involved in a water rescue is always a possibility.
Water provides a series of distinct challenges to the rescuer, from extrication to treatment, and special training is highly
recommended before any water rescue is attempted. Swift water has tremendous energy that is often underestimated
by victims and rescuers alike.
Hypothermia is frequently a factor in water related emergencies, and exacerbates trauma by changing the blood's
clotting abilities and chemistry and placing the victim at risk for lethal cardiac arrhythmias.
All victims of water related accidents must be assumed to have spinal injuries unless this can absolutely be ruled out by
eyewitnesses. It is better to err on the side of caution and place all victims in C-spine precautions. Victims of watercraft
injuries can have severe trauma and internal injuries. Alcohol is a frequent factor in marine injuries involving
watercraft, and victims may be distracted from the extent of their injuries by the alcohol. A careful assessment is vital.
Victims of marine life injuries are more likely to have lacerations, envenomations, or allergic reactions that may
progress to life-threatening anaphylaxis.
Jellyfish tentacles can be neutralized with rubbing alcohol or vinegar in large quantities, after which they should be
peeled off the skin and not rubbed off with a towel or hand. This will minimize further discharge of stinging cells.
Scuba diving accidents involving barotrauma can be life-threatening in the case of CAGE, or merely painful and
inconvenient, in the case of a sinus injury. Decompression sickness and CAGE victims need to be treated in a
recompression chamber as quickly as possible.
Copyright CE Solutions. All rights reserved. Author Chris Greenfield
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