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Three Part Question

In [patients who have nearly drowned] does [routine immobilization of the cervical spine] [improve neurological outcomes or reduce mortality]?

Clinical Scenario

A 20 year old man presents to the Emergency Department after being pulled from the canal. He fell into the canal while intoxicated, and on arrival is unconscious. There are no clinical signs of serious injury. You wonder whether his cervical spine should be immobilised until imaging rules out trauma.

Search Strategy

Medline 1946 to June week 2 2015 and Embase 1980 to 2015 week 25 using the OVID interface.
Medline: [exp Near Drowning/ OR exp Drowning/ OR drown$.mp. OR exp Immersion/ OR immers$.mp.] AND [exp Cervical Vertebrae/ OR exp Spinal Injuries/ OR C-Spine immobilisation.mp. OR exp Immobilization/ OR spinal immobilization$.mp. OR cervical collar$.mp OR neck collar$.mp OR hard collar$.mp.] LIMIT to human AND English Language.
Embase: : [exp Near Drowning/ OR exp Drowning/ OR drown$.mp. OR exp Immersion/ OR immers$.mp.] AND [exp Cervical Vertebrae/ OR exp Spinal Injuries/ OR C-Spine immobilisation.mp. OR exp Immobilization/ OR spinal immobilization$.mp. OR cervical collar$.mp OR neck collar$.mp OR hard collar$.mp.] LIMIT to human AND English Language.
The Cochrane Library Issue 6 of 12 date of searching 03/07/2015 : MeSH descriptor: [Drowning] explode all trees.

Search Outcome

Altogether 39 papers were identified by the Medline search strategy and 95 papers were identified by the Embase search strategy. Of these 3 papers were considered relevant to the three part question. No relevant reviews were found in the Cochrane library.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Watson RS et al 2001 USA	2,224 submersion victims who were submerged in and/or received medical care in, King, Pierce, and Snohomish counties in Washington State between January 1, 1974, and August 31, 1996.	Multicentre retrospective analysis	C-Spine Injury	11 of 2,224 submersion victims sustained a C-Spine injury (0.49%). Of these, all had a history of high impact submersion or physical signs of severe injury. No C-spine injuries in 880 low impact submersions (95% CI 0-0.4%)	Retrospective. Data not originally collected to study c-spine injury so some cases could be missed.
Hwang V et al 2003 USA	143 children with codes for fatal/nonfatal drowning, fall into water, accidental drowning or submersion over 10 years	Single centre retrospective chart review	Traumatic injury	7 of 143 children sustained traumatic injury (4.9%, 95% CI 0-28%). All injuries were to the cervical spine and all but one had a clear history of diving.	Retrospective Single Centre
Heming N et al 2012 France	37 consecutive admissions to ICU following cardiac arrest due to drowning in the Seine River after a witnessed jump from a bridge.	Single centre retrospective chart review	Traumatic injury	Of 37 patients 14 had radiological examination. 5 patients had suffered traumatic injury, and just 2 of these involved the cervical spine.	Retrospective. Small number of patients. Single centre. 23 patients had no radiological examination – true incidence of injury is unknown. No standardised investigation or management.

Comment(s)

The only relevant papers were retrospective studies, of which one was a multicentre analysis of a large number of patients. The remaining two were single centre studies of a small number of patients. Two papers both found that the incidence of C-Spine injury in submersion victims is low, and recommend avoiding C-Spine immobilization in the absence of clinical signs of trauma or a history of high impact submersion. This is to avoid interference with airway management or physical examination of the patient. The third paper has a small number of patients, but recommends C-Spine immobilization in patients experiencing a high velocity impact with water.

Editor Comment

BF

Clinical Bottom Line

Immobilisation of the cervical spine is not necessary in patients who have nearly drowned except in patients with a history of high impact submersion or physical signs of injury.

References

1. Watson RS, Cummings P, Quan L et al. Cervical Spine injuries amongst submersion victims. J Trauma-Injury Inf Crit Care 2001; 51(4): 658-6
2. Hwang V, Shofer FS, Durbin DR et al. Prevalence of traumatic injuries in drowning and near drowning in children and adolescents. Archives of Pediatrics and Adolescent Medicine 2003; 157(1): 50-53.
3. Heming N, Serve E, Weiss N et al. Drowning after falling from a medium-height bridge: multiple trauma victims. Prehospital Emergency Care 2012; 16(3): 356-60