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Immersion, submersion, and crush injuries are related to conditions where the body is consumed by a medium, which may be liquid, semi-solid, or solid. Immersion injuries occur when the head is above the surface of the medium whereas submersion injuries refer to the body and head below the surface of the medium. Death due to liquid medium can be from asphyxia, laryngospasm, aspiration, surfactant failure, hemolysis due to hemodilution, hypothermia, and infection. In semi-solid or solid medium, death can be related to hypoxia, direct trauma to vital organs and/or crush injuries with rhabdomyolysis and electrolyte disturbances.


Death rates vary by country, medium, and context. In 2016, there were an estimated 320,000 annual drowning mortalities worldwide, which accounted for 75% of deaths from floods.1 In South Korea from 1990 to 2008, drowning (60.3%) caused the greatest number of deaths followed by landslide (19.7%), and structural collapse (10.1%).2 In Utah, United States, avalanche fatalities were secondary to asphyxia.3 During the eruption of Mount St. Helen in Washington, upper and lower airway injuries were the most common causes of death.4 In Uganda, landslides caused more death than floods.5 In Mali, mine landslides is an occupational hazard.6 A large number of patients can easily overwhelm the available relief channels.7

Earthquakes have been associated with crush injures: Armenia in 1988 had 25,000 deaths with 600 crush injuries; Kobe, Japan in 1995 had 5,000 deaths with 372 crush injures; Turkey in 1999 had > 17,000 deaths with 639 crush injuries; Taiwan in 1999 had 2,405 deaths with 52 crush injuries; India had 20,023 deaths with 35 crush injuries; Algeria 2,266 deaths with 20 crush injuries; Iraq had 26,000 deaths with 124 crush injuries; and Pakistan had > 80,000 deaths with 118 crush injuries.8


Cold immersion injury results in impaired circulatory control, direct microcirculatory damage with microvascular thrombosis and endothelial damage, and reperfusion injury.9,10 In warm water immersion injury, there is hyperhydration that allows water to travel in between the layers of skin if immersed > 72 hours.11

In immersion or submersion injuries related to landslide, sand and air can penetrate into the sinuses and subcutaneous tissues.12

In submersion injuries caused by liquid, the resultant aspiration of liquid and/or reflex laryngospasm can lead to hypoxia. Saltwater aspiration results in intrapulmonary shunting, while freshwater aspiration results in more washout of surfactant with both types ultimately causing profound hypoxia from decreased lung compliance, micro-atelectasis, and decreased lung volume.13

Most patients who present with submersion injuries have multi-organ dysfunction as a result of prolonged hypoxia. Clinical presentation may vary from cough, mild dyspnea and tachypnea to respiratory failure. Physical exam findings of rales, rhonchi, or wheezing are not uncommon. Fluid aspiration can result in varying degrees of hypoxemia which often produces noncardiogenic ...

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