Drowning

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Chapter 64 Drowning

Linda Quan, MD, Brian Coleman, MD, MS

1 How should the terms near drowning and drowning be applied to submersion victims? What is a drowning?

In 2002, the World Congress on Drowning developed universal terminology to improve interpretation and comparison of reported data. Previously used terminology, such as near-drowning, secondary, wet, dry, and silent drowning have been abandoned. Drowning is immersion in a liquid medium that results in some degree of primary respiratory impairment and may result in survival or death. The term drowning should not reflect clinical course or final outcome.

Bierens J: Handbook on Drowning. Springer, Netherlands, 2004.

Idris AH: Recommended guidelines for uniform reporting of data from drowning: The “Utstein style.” Resuscitation 59:45–57, 2003.

Zuckerbraun NS: Pediatric drowning: Current management strategies for immediate care. Clin Pediatr Emerg Med 6 49–56, 2005.

2 Is cardiopulmonary resuscitation indicated for every patient in cardiac arrest following a drowning?

Survival rates from cardiac arrest following drowning are among the highest, 20–31%, reported in pediatric cardiac arrest, although it is unclear why. To be effective, resuscitation should begin as soon as possible after retrieval from the water, at the scene. However, survival from prolonged (> 25 minutes) non–icy water drownings is essentially zero, as is survival following cardiopulmonary resuscitation for > 25 minutes without return of spontaneous circulation (a perfusing blood pressure). There are clearly some patients who are dead at the scene for whom efforts are futile.

Orlowski JP: Prognostic factors in pediatric cases of drowning and near-drowning. JACEP 8:176–179, 1979.

3 What is a cold water drowning?

The term cold water should be abandoned for the evidence-based predictor icy water. While there are rare, isolated cases of successful resuscitation and intact survival after long drowning in cold waters, these dramatic cases usually occurred in waters colder than 10° C. Nonicy cold water, unfortunately, is still too warmly defined by some enthusiastic resuscitators and is assigned greater powers than are supported by well-done studies.

Wollenek G: Cold water submersion and cardiac arrest in treatment of severe hypothermia with cardiopulmonary bypass. Resuscitation 52:255–263, 2002.

4 Is hypothermia protective?

Hypothermia can dramatically decrease the cerebral metabolic rate, with a resultant decrease in the oxygen requirements of the brain and greater tolerance of hypoxia. However, for hypothermia to be protective, it must precede the onset of hypoxic injury. The very rapid cooling required to produce protective hypothermia is usually not accomplished in the usual nonicy water drowning; in these patients, hypothermia upon arrival to the emergency department (ED) predicts a bad, not a good, outcome.

Biggart MJ: Effect of hypothermia and cardiac arrest on outcome of near-drowning accidents in children. J Pediatr 117:179–183, 1990.

5 How should an icy cold water drowning be managed differently from a warm water drowning?

A patient who has had a truly icy water drowning should be managed aggressively because of the possibility of intact survival. Prolonged and maximal resuscitative efforts, including cardiopulmonary bypass or extracorporeal membrane oxygenation, may be indicated for the icy water submersion but have not been effective for warm water submersion patients. Because icy water drownings are anecdotal reports, predictors and likelihood ratios for survival from icy water submersions are not available. Most would agree, however, that for nonicy water drownings, failure to restore a circulating cardiac rhythm within about 30 minutes after rewarming to 32–35° C suggests that further efforts are unlikely to be successful.

Wollenek G, Honarwar N, Golej J, Marx M: Cold water submersion and cardiac arrest in treatment of severe hypothermia with cardiopulmonary bypass. Resuscitation 52:255–263, 2002.

6 Is there a clinical difference between a salt water AND fresh water drowning?

There is none. A large clinical study showed no real difference in the clinical presentation of adults who drowned in salt or fresh waters, thus invalidating the mythic physiologic changes reported in one animal study. Clinical experience dictates that both salt water– and fresh water–drowned patients may develop pulmonary edema, anemia is rare, and electrolytes are usually normal. The explanation may lie in the fact that most humans do not aspirate large volumes of water. Furthermore, the pulmonary response to drowning, especially the development of pulmonary edema, relates to other factors besides the salinity of the aspirated fluid.

Modell JH: Drowning. N Engl J Med 328:253–256, 1993.

7 What are the tenets of management in resuscitation of the unresponsive drowning patient?

The injury of drowning is hypoxia, and the goal of resuscitation should be directed toward the ABCs. Those who are unconscious or who have respiratory compromise should undergo rapid sequence intubation and endotracheal intubation to protect their airway from vomiting and aspiration. Positive-pressure ventilation is the single most effective method for reversing hypoxemia. Poor perfusion is usually the result of significant myocardial hypoxia. It should first be treated with one to two boluses of normal saline (20 mL/kg body weight) for the possibility of hypovolemia; if this fails to restore adequate perfusion, cardiac dysfunction should be treated with inotropic agents. Additionally, regardless of the water temperature in which the drowning occurred, all drowning patients should be assumed to be at risk for hypothermia. Management includes continuous monitoring of core body temperature and careful rewarming to achieve and maintain a core temperature between 32–34° C as part of present mild hypothermia cerebral resuscitation protocols.

After successful resuscitation, attention must be directed toward preventing secondary brain injury. This can be achieved by monitoring for hypoxia, hypercapnia, and hypothermia.

Zuckerbraun NS: Pediatric drowning: Current management strategies for immediate care. Clin Pediatr Emerg Med 6:49–56, 2005.

KEY POINTS: DROWNING

1 Failure to restore a perfusing rhythm within about 30 minutes of resuscitation in a patient with a core temperature of 32–35 ° C, following a nonicy water drowning, suggests that further efforts are unlikely to be successful.

2 Patients who had a drowning but are asymptomatic after 6–8 hours of observation can be safely sent home if the social situation permits.

3 Social work involvement is important in the evaluation of any drowning patient for possible abuse, homicide, suicide, or risk-taking behaviors, especially alcohol use.

8 Should prophylactic antibiotics be given to the drowning patient?

No. The only indication for the prophylactic use of antibiotics is drowning in grossly contaminated water (e.g., sewage, retention pond). Instead, antibiotics should be initiated once signs of sepsis or pneumonia become apparent.

Orlowski JP: Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am 48:627–646, 2001.

9 Which tests are helpful in managing the drowning patient?

The patient’s clinical examination should guide what tests are needed. The full work-up panel of blood gas, chest radiography, complete blood count, and electrolytes can be reserved for the unresponsive patient; full evaluation is needed if this patient incurred a more serious hypoxic injury and is at great risk for complications and bad outcome. Additionally, a glucose level should be included because it is a useful prognostic factor. Hyperglycemia (glucose level > 250 mg/dL) portends a poor outcome. It is unclear if hyperglycemia should be treated. On the other hand, hypoglycemia must be treated. For the alert patient with no or mild respiratory distress, oximetry monitoring may be all that is needed and is a more reliable treatment guide than chest radiography. Several studies have recommended against using an abnormal radiograph as the sole criterion for hospital admission. Electrolytes are usually normal.

Noonan L: Freshwater submersion injuries in children: A retrospective review of seventy-five hospitalized patients. Pediatrics 98:368–371, 1996.

10 What is the most common cause of death and disability in hospitalized drowning victims?

Cerebral edema secondary to hypoxic ischemia is the usual cause of death and becomes a clinical challenge at 6–18 hours after the drowning event. Hypoxic encephalopathy in survivors of severe drownings usually results in severe neurologic sequelae, including loss of self-help skills.

Orlowski JP, Szpilman D: Drowning: Rescue, resuscitation, and reanimation. Pediatr Clin North Am 48:627–646, 2001.

11 Can some drowning patients be sent home from the ED?

Some postsubmersion patients arrive looking cheery but wet. They have usually had a short submersion interval, have minimal signs (mild metabolic acidosis) of a hypoxic insult, and are asymptomatic. These patients should be observed in the ED for a minimum of 6–8 hours with evaluation of neurologic and pulmonary status, including cardiorespiratory monitoring. Some initially asymptomatic, alert patients can develop mild respiratory distress (tachypnea, mild hypoxia) and cough at the scene or within a few hours of the submersion. In many cases, their symptoms respond to a brief period of low-flow oxygen and do not mandate hospital admission if they are asymptomatic at 8 hours.

Causey AL: Predicting discharge in uncomplicated near-drowning. Am J Emerg Med 18:9–11, 2000.

Noonan L, Howrey R, Ginsburg CM: Freshwater submersion injuries in children: A retrospective review of seventy-five hospitalized patients. Pediatrics 98:368–371, 1996.

Quan L: Near-drowning. Pediatr Rev 20:255–259, quiz 260, 1999.

12 Does every drowning patient need evaluation for cervical spine injury?

No. Routine cervical spine imaging is not indicated for the overwhelming majority of patients. Cervical spine injury is very rare (< 1%) in drowning patients, and is almost never seen in preadolescent children. It occurs when there has been a high-velocity injury and when concern for multiple major trauma coexists, such as drowning associated with motor vehicle, boating, or personal watercraft accidents; diving; or surfing. In two large retrospective studies of over 2000 patients, all cases of cervical spine injury had a history consistent with high-speed mechanism, or clinical signs of serious injury on physical examination. A careful history and examination of the neck are sufficient screening for cervical spine injury for most patients.

Hwang V: Prevalence of traumatic injuries in drowning and near drowning in children and adolescents. Arch Pediatr Adolesc Med 157:50–53, 2003.

Watson RS: Cervical spine injuries among submersion victims. J Trauma 51:658–662, 2001.

13 Who will survive a drowning?

The victim whose drowning interval is less than 5 minutes will most likely (90%) survive. Following longer drowning intervals, survival drops precipitously. Young children are more likely to survive than adolescents, who are more likely to be declared dead at the scene. The marked difference in survival between young children and adolescents or adults is explained by their different submersion scenarios. Young children tend to drown where supervision is nearby but has lapsed; they also tend to drown in bodies of water, such as bathtubs or swimming pools, where rescue is easy. On the other hand, adolescents and adults get to larger, deeper, murkier bodies of water, such as lakes and rivers, where rescue is more difficult and the drowning interval is lengthy. When these factors are controlled for, age is not a predictor of outcome.

Quan L: Characteristics of drowning by different age groups. Inj Prev 9:163–168, 2003.

14 What are predictors of outcome in drowning?

The key predictor is the patient’s mental status after the drowning. Patients who are alert on arrival to the ED or at hospital admission will survive with normal neurologic status. In patients arriving unresponsive to the ED, ultimate neurologic outcome is more difficult to predict. Factors upon presentation that will identify patients who will remain in a persistent vegetative state or die include duration of submersion > 10 min., absent pupillary reflexes, Glasgow Coma Scale score ≤ 5, hyperglycemia after resuscitation (glucose level > 250 mg/dL), acidosis (pH < 7.10), and duration of cardiopulmonary resuscitation greater than 25 minutes until return of spontaneous circulation. A poor prognosis is most likely when all of these bad prognostic factors are present. However, no single factor or combination of factors at the time the patient arrives in the ED has achieved greater than 96% accuracy in predicting poor outcome (persistent vegetative state or death), so some recommend resuscitation attempts for all drowning victims on arrival in the ED. As the time interval from the drowning event increases, predicting outcome becomes more reliable; most of those who remain comatose at 24 hours will die or survive with severe neurologic sequelae.

Ashwal S: Prognostic implications of hyperglycemia and reduced cerebral blood flow in childhood near-drowning. Neurology 40:820–823, 1990.

Causey AL, Tilelli JA, Swanson ME: Predicting discharge in uncomplicated near-drowning. Am J Emerg Med 18:9–11, 2000.

Graf WD: Predicting outcome in pediatric submersion victims. Ann Emerg Med 26:312–319, 1995.

Jacinto SJ: Predicting outcome in hypoxic-ischemic brain injury. Pediatr Clin North Am 48:647–660, 2001.

Lavelle JM: Near drowning: Is emergency department cardiopulmonary resuscitation or intensive care unit cerebral resuscitation indicated? Crit Care Med 21:368–373, 1993.

Quan L: Outcome and predictors of outcome in pediatric submersion victims receiving prehospital care in King County, Washington. Pediatrics 86:586–593, 1990.

Suominen PK: Does water temperature affect outcome of nearly drowned children? Resuscitation 35:111–115, 1997.

KEY POINTS: POOR PROGNOSTIC SIGNS

1 Duration of submersion > 10 minutes

2 Absent pupillary reflexes

3 Glasgow Coma Scale score ≤ 5

4 Hyperglycemia (glucose level > 250 mg/dL)

5 Acidosis (pH < 7.1)

6 No spontaneous circulation after 25 minutes of cardiopulmonary resuscitation

15 How does one recognize child abuse as the etiology for drowning?

Drowning as child abuse or homicide is most often recognized in the young child whose submersion occurred in the bathtub. Drowning may be the primary injury as well as a secondary injury when the abuser attempts to revive the child or to conceal other physical injury by placing the child in the tub. The physical examination must include a careful search for signs of physical abuse and signs of multiple traumas. However, radiographs for fractures are usually not helpful. The key to recognition of intentional trauma is usually in the history. A caregiver’s explanation for the injury that is not compatible with the child’s developmental status or a changing or vague history should prompt consideration of child abuse. A critical part of any childhood drowning, regardless of the concern for abuse, is evaluation by social services.

Gillenwater JM: Inflicted submersion in childhood. Arch Pediatr Adolesc Med 150:298–303, 1996.

Kemp AM: Accidents and child abuse in bathtub submersions. Arch Dis Child 70:435–438, 1994.

16 How can pediatric drowning be prevented?

Drownings are preventable with active and passive interventions. For children younger than 5 years of age, falling into swimming pools is the most common cause of drowning. Four-sided, isolation fencing with self-closing, self-latching gates around residential pools is effective in preventing more than 50% of these drownings. Adult supervision of young children around any water is essential and can prevent all bath tub–related drownings. Infant bath seats, supporting rings, or the care provided by another young child are not suitable substitutes for adult supervision. Adequate supervision entails that the adult be constantly present, focused on the child, and within an arm’s length. The American Academy of Pediatrics also recommends swimming lessons as soon as the child is developmentally ready, after the age of 4 years, and caregiver training in cardiopulmonary resuscitation. For adolescents, drownings occur while swimming with friends or while boating. Many of these deaths could be prevented by wearing life vests and avoiding alcohol.

Prevention of drowning in infants, children, and adolescents. Pediatrics 112:437–439, 2003.

Quan L, Liller K, Bennett E. Water-related injuries of children and adolescents. In: Liller K. Injury Prevention for Children and Adolescents: Research, Practice and Advocacy. Washington DC, American Public Health Association, 2006.

17 Should patients with seizures be allowed to participate in water-related activities?

Seizures are the most common predisposing event for drowning in all age groups, and drowning is the major cause of death in patients with epilepsy. This group of patients has 10 times the risk for drowning and death from drowning of those without seizures. In these children, the bath tub actually is the highest risk site. Health care providers should advise patients with seizures to take showers, not baths. Involvement in water sports should include wearing of life jackets when by and in the water and swimming in pools where lifeguards supervise and are notified of the patient’s increased risk.

Diekema DS: Epilepsy as a risk factor for submersion injury in children. Pediatrics 91:612– 616, 1993.

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