Cervical Spine Injury and Submersion Injuries

Water + C-Spine Injury = Badness


I’m not sure if you have noticed, but the weather is starting to get a little warm.  It almost makes you want to go swimming… and that brings to mind the second leading cause of accidental deaths in pediatric patients: submersion injuries.  We’ve all, unfortunately, dealt with patients who have had submersion events: some mild and some quite severe.  For those that present to you in the ED via EMS, I can almost guarantee that those patients all had one thing in common – they were boarded and collared.  The question is, “do they need to be?” And the answer is, “Yes!”  But that “yes” is specifically for the pre-hospital environment.   Swimming pools and Life-Guards have protocols.  Paramedics and First-Responders have protocols.  These are for the benefit of the patient certainly, but then the real question is, “Do I have to keep the C-Collar on once the patient arrives in the ED?

Submersion Basics

  • Submersion Injuries are the Second leading cause of accidental death in kids 1-19yrs
  • For each Fatality, there are 1 to 4 nonfatal submersions requiring hospitalization.
  • 98% involve Fresh Water (even next to the ocean… have you ever noticed how many people in Florida own pools?)

Submersion and Trauma

  • Having a C-Collar on the patient potentially complicates the patient’s management.
  • Air and Breathing are certainly not benefiting from the restrictive plastic collar.
  • Fortunately, the prevalence of C-Spine Injuries in Submersion Victims is VERY LOW (~0.5%).
  • What you need to ascertain is whether this Submersion Event was a Traumatic Event.
    • Studies looking at C-Spine Injuries associated with Submersions show that not only are they rare, but they are associated with HIGH IMPACT events or had Clinical Signs of Trauma.
    • High Impact Events:
      • Diving
      • Boating (kind of like an out of control car in which no one wears seatbelts)
      • Water Sports (Skiing, Body Surfing {I’ve personally seen two of these}, etc)
      • Assault (beat up an tossed in the water).
      • Journal of Trauma 2001
        • Of 2,244 Submersion Patients, 0.5% had C-Spine injuries
        • All 11 had clinical signs of serious injury, had history of open body of water, history of diving, or history of fall from height (literally, an airplane crash).
        • Most did not make it to the ED.
        • No C-spine Injury in 880 Low-impact events (swimming, bathing, wading, fishing, SCUBA).
        • No C-Spine injuries in kids <13yrs.
          • Not that young kids can’t have C-Spine Injuries… this speaks more to the fact that teenagers do dumb things and involve themselves in HIGH IMPACT events more than younger kids.
        • Recommendation: “Routine Immobilization does not appear to be warranted solely on the basis of history of submersion.
  • What it boils down to:
    • They will arrive in a C-Collar (this is probably appropriate).
    • Perform thorough exam – signs of Trauma?
    • History of ETOH or Drugs or are they teenagers (some reason to not trust the patient and your exam)?
    • Get a history of the event. Was it a Trauma? If yes,… then maintain C-Spine precautions. If no, … do yourself and the patients a favor and take the collar off.


Hope your Spring and Summer are enjoyable and don’t make you have to recall this Morsel.


Watson RS, Cummings P, Quan L, Bratton S, Weiss NS. Cervical spine injuries among submersion victims. J. Trauma. 2001 Oct; 51(4):658-62.

Hwang V, Shofer FS, Durbin DR, Baren JM. Prevalence of traumatic injuries in drowning and near drowning in children and adolescents. Arch Pediatr Adolesc Med. 2003 Jan;157(1):50-3.

Sean M. Fox
Sean M. Fox

I enjoy taking care of patients and I finding it endlessly rewarding to help train others to do the same. I trained at the Combined Emergency Medicine and Pediatrics residency program at University of Maryland, where I had the tremendous fortune of learning from world renowned educators and clinicians. Now I have the unbelievable honor of working with an unbelievably gifted group of practitioners at Carolinas Medical Center. I strive every day to inspire my residents as much as they inspire me.

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