HPI
63-year-old male surfer in Northern California was found floating in shore break by fellow surfers. He was wearing a full wetsuit and last seen riding a 5-foot wave, perhaps 5 minutes before the incident. When other surfers arrived to assist, the victim was not breathing spontaneously, had limp muscle tone and was blue. He was dragged to the beach where bystander CPR was administered and 911 was called. During CPR, white frothy liquid emanated from the victim’s mouth and nose. After approximately 2 minutes of CPR the surfer started breathing spontaneously and regained a pulse, but did not regain consciousness. Paramedics arrived, suctioned the patient’s airway, administered high flow oxygen via bag-valve-mask, established IV access and transported patient to the ER.
Past Medical Hx, Surgical, Social (from prior medical records)
Surgery: appendectomy
Meds: ASA 81 mg daily, multivitamins, Omega 3 fatty acids
Social: Non-smoker, occasional Alcohol
ROS
Unable to provide
Physical exam
Vital Signs BP:100/55 Pulse:130 Respiratory Rate:24 Temp 36.50 C O2 Sat 89%
General Appearance: Fit male appears younger than stated age in severe respiratory distress being assisted with bag-valve-mask.
HEENT: Stellate laceration 3x4cm to mid parietal scalp. Minimal bleeding
White frothy sputum from mouth and nose. Pupils 4 mm sluggish
No hemotympanum
Neck: No bony stepoffs
Lungs: Coarse rales in all lung fields
Heart: Tachycardia ~120 bpm regular. No murmurs.
Abdomen: Soft, non-distended
Pelvis: Stable
Extremities: No deformities
Skin: Cool to touch
Neuro: Comatose, non-responsive. Decorticate to painful stimuli. GCS 5. Eyes: 0 Verbal: 2 (Grunting noises) Motor: 3 (Decorticate)
Labs: CBC – WBC 18k, Hemoglobin 15, Hct 47%
Chem 7 – Na 144, K 5.6, CO2 16, CL 100, BUN 40, Cr 2.2 Glucose 134
VBG pH 7.11, PCO2 50, Bicarb 18 Lactic Acid 8.4
Imaging: CXR: Diffuse, severe pulmonary edema. ETT tube 4cm above carina. No bony abnormalities
CT Brain: Severe cerebral edema with loss of grey/white interface. Concern for impending uncal herniation. Soft tissue swelling
CT Spine: Normal alignment no fractures
CT Brain shortly after arrival
Post-intubation CXR
ER Course
Patient was intubated emergently using rapid sequence intubation for airway protection and hypoxia. After intubation patient was aggressively suctioned via endotracheal tube. Vent setting included tidal volume 600cc, PEEP of 10, RR 14 and 60% FiO2. Oxygen saturation was maintained at 98%. Patient was brought to CT for imaging of brain and c-spine. After intubation sedation was withheld to monitor neurologic status. GCS remained at 5.
Hospital Course
Patient was admitted to medical intensive care and monitored. The patient’s lactic acidosis normalized and renal function improved on hospital day 1. There was no improvement of neurologic function and a repeat CT of the brain revealed worsening cerebral edema with brainstem herniation on hospital day 2. After neurologic consultation and further testing the patient was declared brain dead. After a long family discussion both kidneys and heart were harvested for donation, patient was terminally extubated on hospital day 3 and expired.
Discussion
Fatal surfing accidents are uncommon but not unheard of. It is likely that the majority of deaths are the result of drowning, though trauma from shark attacks, fin injuries, and cervical spine injuries have also been reported. Lightning strikes are also known to have caused surfing fatalities.
A number of factors contribute to drowning among surfers. Certainly, prolonged submersion in very large surf can result in drowning, though this much-feared event is surprisingly rare given the interest in big-wave surfing over the last decade. Loss of consciousness (LOC) from head trauma is known to have caused fatal drownings in numerous cases as a spontaneously breathing unconscious victim will continue to breathe underwater, aspirate, and rapidly drown. In cold water, hypothermia and resultant muscle fatigue and altered mental status can result in “swim failure” causing a victim to drown. Surfers have also drowned as a result of the leash being snagged on a coral head, kelp, or crab trap, tethering the surfer underwater.
Although the mechanism of injury was not witnessed in the case presented, it is very likely that the surfer hit his head on his board or the sea-floor, lost consciousness, and subsequently drowned. The surf was of modest size, and the patient was a well-conditioned strong swimmer and experienced surfer, so it is unlikely that he was forcefully held under-water, or panicked. Although head CT showed no intracranial pathology, the patient had a visible scalp hematoma and stellate laceration consistent with blunt-force trauma which likely caused a concussion with LOC.
Studies of injured surfers presenting to emergency departments by Hay, Chang, and Tanaguchi, have all found head injuries to be common (34%-42%). Head, facial, and scalp lacerations, fractures and contusions were reported in all 3 studies, although the number of concussions resulting in LOC is unknown. Even pro surfers are not immune to head injuries, with Tom Carroll, Owen Wright, and others having suffered severe head injuries that nearly ended their careers. For a full discussion on concussions among surfers see Dr. Donlon’s article on concussions in the fall 2013 issue of Surfing Medicine.
Clearly protecting ones’s head during a wipeout is important. This author prefers to cross his arms overhead until surfacing and visualizing his surfboard. Taylor, Nathanson, and others have suggested that helmets might prevent some of these injuries, but helmets have not been widely adopted by surfers. Taylors study found that many surfers do not use helmets because they are perceived to restrict hearing and balance and may impede duck-diving. However, it is likely that had the surfer in question been wearing a helmet he would not have been knocked unconscious and drowned. It is unlikely that the surfers will modify equipment in favor of safety if it alters the performance, aesthetics, or image of the surfer. Use of personal protective equipment will come about only if these measures are perceived as fashionable by style-conscious young adults. Mandatory use of helmets, noseguards, and blunt tipped boards in competition may be a way to foster change in the behavior of recreational surfers because they often look to professional surfers as role models.