All other organs and tissues may exhibit signs of hypoxic-ischemic injury. In the lung, damage to the pulmonary vascular endothelium can lead to acute respiratory distress syndrome (ARDS; Chapter 65). Aspiration may also compound pulmonary injury. Myocardial dysfunction (so-called stunning), arterial hypotension, decreased cardiac output, arrhythmias, and cardiac infarction may also occur. Acute tubular necrosis, cortical necrosis, and renal failure are common complications of major hypoxic-ischemic events (Chapter 529). Vascular endothelial injury may initiate disseminated intravascular coagulation (DIC), hemolysis, and thrombocytopenia. Many factors contribute to gastrointestinal damage; bloody diarrhea with mucosal sloughing may be seen and often portends a fatal injury. Serum levels of hepatic transaminases and pancreatic enzymes are often acutely increased. Violation of normal mucosal protective barriers predisposes the victim to bacteremia and sepsis.

Pulmonary Injury

Pulmonary aspiration (Chapter 65) occurs in a majority of drowning victims, but the amount aspirated is usually small. Aspirated water does not obstruct airways and is readily moved into the pulmonary circulation with positive pressure ventilation. It can wash out surfactant and cause alveolar instability, ventilation-perfusion mismatch, and intrapulmonary shunting. In humans, aspiration of small amounts (1-3 mL/kg) can lead to marked hypoxemia and a 10-40% reduction in lung compliance. The composition of aspirated material can affect the patient’s clinical course: Gastric contents, pathogenic organisms, toxic chemicals, and other foreign matter can injure the lung or cause airway obstruction. Clinical management is not significantly different in saltwater and freshwater aspirations, because most victims do not aspirate enough fluid volume to make a clinical difference. A few children may have massive aspiration, increasing the likelihood of severe pulmonary dysfunction.

Hypothermia

Hypothermia (Chapter 69) is common after submersion. It is often categorized, according to core body temperature measurement, as mild (34-36°C), moderate (30-34°C), or severe (<30°C). Drowning should be differentiated from cold water immersion injury, in which the victim remains afloat, keeping the head above water without respiratory impairment. The definition of cold water varies from 60 to 70°F.

Heat loss through conduction and convection is more efficient in water than in air and, if the water is cool, cannot be matched by the body’s thermogenic mechanisms (shivering and nonshivering thermogenesis, vasoconstriction, active movements). Children are at increased risk for hypothermia because they have a relatively high ratio of body surface area to mass, decreased subcutaneous fat, and limited thermogenic capacity. Hypothermia can develop as a result of prolonged surface contact with cold water while the head is above water (immersion) or after submersion, which involves the potential additional impact of swallowing or aspirating large quantities of very cold fluid. Hypothermia may develop more quickly with immersion in fast-flowing water as a result of increased convection.

Depending on water and air temperature, insulation, body surface area, thermogenic capacity, and physical condition, heat loss can lead to significant core temperature decreases. As core temperature drops to <35°C, cognition, coordination, and muscle strength become progressively impaired. The likelihood of self-rescue decreases at this point. With progressive hypothermia, there may be loss of consciousness, water aspiration, decreases in heart rate and cardiac output, ineffective breathing, and cardiac arrest.

Immediate effects of cold water immersion are respiratory and cardiovascular. Victims who drown in water <60-70°F also experience cold water shock, a dynamic series of cardiorespiratory physiologic responses. In human adults, immersion in icy water results in intense involuntary reflex hyperventilation and to a decrease in breath-holding ability to <10 seconds, which leads to fluid aspiration, contributing to more rapid and deep hypothermia. Severe bradycardia occurs in adults but is transient and rapidly followed by supraventricular and ectopic tachycardias and hypertension. There is no evidence that the diving reflex, or bradycardia that may occur in children after submersion, has any protective effect.

It may theoretically be possible for the brain to rapidly cool to a neuroprotective level, if the water is cold enough, the cooling process is quick, and cardiac output lasts long enough for sufficient heat exchange to occur. Once submersion-associated hypoxia, apnea, and cardiovascular compromise decrease blood circulation, the effect of hypothermia’s neuroprotection is mitigated.

After the child is removed from the water, body temperature may continue to fall as a result of cold air, wet clothes, hypoxia, and hospital transport. Hypothermia in pediatric drowning victims is observed even after drowning in relatively warm water and in warm climates. Unrecognized progressive hypothermia can lead to further decompensation. In hypothermic victims, compensatory mechanisms usually attempt to restore normothermia at body temperatures >32°C; at lower temperatures, thermoregulation may fail and spontaneous rewarming will not occur.

With moderate to severe hypothermia, progressive bradycardia, impaired myocardial contractility, and loss of vasomotor tone contribute to inadequate perfusion, hypotension, and possible shock. At body temperature <28°C, extreme bradycardia is usually present, and the propensity for spontaneous ventricular fibrillation (VF) or asystole is high. Central respiratory center depression with moderate to severe hypothermia results in hypoventilation and eventual apnea. A deep coma, with fixed and dilated pupils and absence of reflexes at very low body temperatures (<25-29°C), may give the false appearance of death.

The theoretical benefits, implications, and consequences of hypothermia in drowning victims are areas of controversy. Known adverse effects are associated with hypothermia, and these must be balanced against the potential benefits observed in experimental data. One should clearly differentiate among: (1) controlled hypothermia, such as that used in the operating room before the onset of hypoxia or ischemia, (2) accidental hypothermia, such as occurs in drowning, which is uncontrolled and variable, with onset during or shortly after hypoxia-ischemia, and (3) therapeutic hypothermia, involving the purposeful and controlled lowering and maintenance of body (or brain) temperature at some time after a hypoxic-ischemic event.

In drowning victims with uncontrolled accidental hypothermia associated with icy water submersion, there are a few case reports of good neurologic recovery after prolonged (10-150 min) cardiopulmonary arrest. Almost all of these rare survivors have been in freezing water (<5°C) and had core body temperatures <30°C, often much lower. Presumably, very rapid and sufficiently deep hypothermia developed in these fortunate survivors before irreversible hypoxic-ischemic injury occurred.

Most often hypothermia is a poor prognostic sign, and a neuroprotective effect has not been demonstrated. In King County, Washington, where the water is cold but rarely icy, 92% of drowning survivors with good neurologic outcomes had initial body temperatures ≥34°C, whereas 61% of those who died or had severe neurologic injury had temperatures <34°C. In another study of comatose drowning patients admitted to pediatric intensive care units (PICUs), 65% of hypothermic patients (body temperature <35°C) died, compared with a 27% observed mortality rate in nonhypothermic victims. Similarly, in Finland (where the median water temperature was 16°C), a beneficial effect of hypothermia is not seen in pediatric submersion victims; submersion duration <10 min was most strongly related to good outcome.

Management

The clinical course and outcome for a submersion victim are primarily determined by the circumstances of the incident, the duration of submersion, the speed of the rescue, and the effectiveness of resuscitative efforts. Two groups may be identified on the basis of responsiveness at the scene. The first group consists of children who require minimal resuscitation at the scene and quickly regain spontaneous respiration and consciousness. They have good outcomes and minimal complications. These victims should be transported from the scene to the ED for further evaluation.

The second group comprises children in cardiac arrest who require aggressive or prolonged resuscitation and have a high risk of multiorgan system complications, major neurologic morbidity, or death. Compared with cardiac arrest from other causes, cardiac arrest from drowning has a higher survival rate.

Initial management of drowning victims requires coordinated and experienced prehospital care following the ABCs of emergency resuscitation (Chapter 62). These children often remain comatose and lack brainstem reflexes despite the restoration of oxygenation and circulation. Subsequent ED and PICU care often involve advanced life support strategies and management of multiorgan dysfunction.

Initial Evaluation and Resuscitation

(See Chapter 62.)

Once a submersion has occurred, immediate institution of CPR efforts at the scene is imperative. The goal is to reverse the anoxia from submersion and prevent secondary hypoxic injury after submersion. Every minute that passes without the reestablishment of adequate breathing and circulation dramatically decreases the possibility of a good outcome. When safe for the victim and the rescuer, institution of in-water resuscitation for nonbreathing victims by trained personnel may improve the likelihood of survival. Victims usually need to be extricated from the water as quickly as possible so that effective CPR can be provided. Common themes in children who have good recovery are a short duration of event and initiation of CPR as soon as possible, prior to arrival of emergency medical services (EMS).

Initial resuscitation must focus on rapidly restoring oxygenation, ventilation, and adequate circulation. The airway should be clear of vomitus and foreign material, which may cause obstruction or aspiration. Abdominal thrusts should not be used for fluid removal, because many victims have a distended abdomen from swallowed water; abdominal thrusts may increase the risk of regurgitation and aspiration. In cases of suspected airway foreign body, chest compressions or back blows are preferable maneuvers.

The cervical spine should be protected in anyone with potential traumatic neck injury (Chapters 63 and 66). Cervical spine injury is a rare concomitant injury in drowning; only approximately 0.5% of submersion victims have cervical spine injuries. History of the event and victim age guide suspicion of cervical spine injury. Drowning victims with cervical spine injury are usually preteens or teenagers whose drowning event involved diving, a motorized vehicle crash, a fall from a height, a water sport accident, child abuse, or other clinical signs of serious traumatic injury. In such cases, the neck should be maintained in a neutral position and protected with a well-fitting cervical collar. Patients rescued from unknown circumstances may also warrant cervical spine precautions. In low-impact submersions, spinal injuries are exceedingly rare, and routine spinal immobilization is not warranted.

If the victim has ineffective respiration or apnea, ventilatory support must be initiated immediately (Chapter 62). Mouth-to-mouth or mouth-to-nose breathing by trained bystanders often restores spontaneous ventilation. As soon as it is available, supplemental oxygen should be administered to all victims. Positive pressure bag-mask ventilation with 100% inspired oxygen should be instituted in patients with respiratory insufficiency. If apnea, cyanosis, hypoventilation, or labored respiration persists, trained personnel should perform endotracheal tube (ET) intubation as soon as possible. Intubation is also indicated to protect the airway in patients with depressed mental status or hemodynamic instability. Hypoxia must be corrected rapidly to optimize the chance of recovery.

Concurrent with securing of airway control, oxygenation, and ventilation, the child’s cardiovascular status must be evaluated and treated according to the usual resuscitation guidelines and protocols. Heart rate and rhythm, blood pressure, temperature, and end-organ perfusion require urgent assessment. CPR should be instituted immediately in pulseless, bradycardic, or severely hypotensive victims. Continuous monitoring of the electrocardiogram (ECG) allows appropriate diagnosis and treatment of arrhythmias. Slow capillary refill, cool extremities, and altered mental status are potential indicators of shock (Chapter 64). Recognition and treatment of hypothermia are the unique aspects of cardiac resuscitation in the drowning victim. Core temperature must be evaluated, especially in children, because moderate to severe hypothermia can depress myocardial function and cause arrhythmias.

Often, IV fluids and cardioactive medications are required to improve circulation and perfusion. Vascular access should be established as quickly as possible for the administration of fluids or pressors. Intraosseous catheter placement is a potentially lifesaving vascular access technique that avoids the delay usually associated with multiple attempts to establish intravenous (IV) access in critically ill children. Epinephrine is usually the initial drug of choice in victims with cardiopulmonary arrest (the IV dose is 0.01 mg/kg of 1 : 10,000 solution given q3-5min as needed). Epinephrine can be given intratracheally (ET dose is 0.1-0.2 mg/kg of 1 : 1,000 solution) if no IV access is available. An intravascular bolus of lactated Ringer solution or 0.9% normal saline (10-20 mL/kg) is often used to augment preload; repeated doses may be necessary. Hypotonic or glucose-containing solutions should not be used for intravascular volume administration of drowning victims.

Hospital-Based Evaluation and Treatment

Pediatric drowning victims probably should be observed for at least 6-8 hr, even if they are asymptomatic on presentation to the ED. At a minimum, serial monitoring of vital signs (respiratory rate, heart rate, blood pressure, and temperature) and of oxygenation by pulse oximetry, repeated pulmonary examination, and neurologic assessment should be performed in all drowning victims. Other studies may also be warranted, depending on the specific circumstances (possible abuse or neglect, traumatic injuries, or suspected intoxication). Almost half of asymptomatic or minimally symptomatic alert children (those who do not require advanced life support in the prehospital setting or who have an initial ED Glasgow Coma Scale [GCS] score of ≥13) experience some level of respiratory distress or hypoxemia progressing to pulmonary edema, usually during the 1st 4-8 hr after submersion. Most alert children with early respiratory symptoms respond to oxygen and, despite abnormal initial radiographs, become asymptomatic with a return of normal room air SaO₂ and pulmonary examination by 4-6 hr. Subsequent delayed respiratory deterioration is extremely unlikely in such children. Selected low-risk patients who are alert and asymptomatic with normal physical findings and oxygenation levels may be considered for discharge after 6-8 hr of observation, as long as appropriate follow-up can be ensured.

Cardiorespiratory Management

For children who are not in cardiac arrest, the level of respiratory support should be appropriate to the patient’s condition and is a continuation of prehospital management. Frequent assessments are required to ensure that adequate oxygenation, ventilation, and airway control are maintained (Chapter 65). Hypercapnia should generally be avoided in potentially brain-injured children. Patients with actual or potential hypoventilation or markedly elevated work of breathing should receive mechanical ventilation to avoid hypercapnia and decrease the energy expenditures of labored respiration.

Measures to stabilize cardiovascular status should also continue. Conditions contributing to myocardial insufficiency include hypoxic-ischemic injury, ongoing hypoxia, hypothermia, acidosis, high airway pressures during mechanical ventilation, alterations of intravascular volume, and electrolyte disorders. Heart failure, shock, arrhythmias, or cardiac arrest may occur. Continuous ECG monitoring is mandatory for recognition and treatment of arrhythmias (Chapter 429).

The provision of adequate oxygenation and ventilation is a prerequisite to improving myocardial function. Fluid resuscitation and inotropic agents are often necessary to improve heart function and restore tissue perfusion (Chapter 62). Increasing preload with IV fluids may be beneficial through improvements in stroke volume and cardiac output. Overzealous fluid administration, especially in the presence of poor myocardial function, can worsen pulmonary edema.

For patients with persistent cardiopulmonary arrest on arrival in the ED after non–icy water drowning, the decision to withhold or stop resuscitative efforts can be addressed by review of the history and the response to treatment. Death or severe neurologic sequelae are quite likely in patients with deep coma, apnea, absence of papillary responses, and hyperglycemia in the ED, with submersion durations >10 min, and with failure of response to CPR given for 25 min. In one comprehensive case series, 100% of children with resuscitation durations >25 min either died or had severe neurologic morbidity, and all victims with submersion durations >25 min died. Because there are reports of good outcome following ongoing CPR in the ED, most drowning victims should be treated aggressively upon presentation. However, for children who do not show ready response to aggressive resuscitative efforts, the need for prolonged ongoing CPR after non–icy water submersion almost invariably predicts death or persistent vegetative state. Consequently, in most cases, discontinuation of CPR in the ED is probably warranted for victims of non–icy water submersion who do not respond to aggressive advanced life support within 25-30 min. Final decisions regarding whether and when to discontinue resuscitative efforts must be individualized, with the understanding that the possibility of good outcome is generally very low with protracted resuscitation efforts.

Neurologic Management

Drowning victims who present to the hospital awake and alert usually have normal neurologic outcomes. In comatose victims, irreversible CNS injury is highly likely. The most critical and effective neurologic intensive care measures after drowning are rapid restoration and maintenance of adequate oxygenation, ventilation, and perfusion. Core body temperature and glucose management may also be important modulators of neurologic injury after hypoxia-ischemia.

Comatose drowning patients are at risk for intracranial hypertension. Although ICP monitoring and therapy to reduce intracranial hypertension would seem likely to preserve cerebral perfusion and prevent herniation, there is little evidence that these measures improve outcomes for drowning victims. Patients with elevated ICP usually have poor outcomes—either death or persistent vegetative state—regardless of ICP management. Children with normal ICP can also have poor outcomes, although less frequently. Conventional neurologic intensive care therapies, such as fluid restriction, hyperventilation, and administration of muscle relaxants, osmotic agents, diuretics, barbiturates, and steroids, have not been shown to benefit the drowning victim, either individually or in combination. Indeed, there is some evidence that these therapies may reduce overall mortality, but only by increasing the number of survivors with severe neurologic morbidity.

Electroencephalographic monitoring has only limited value in the management of drowning victims and is generally not recommended, except to detect seizures or as an adjunct in the clinical evaluation of brain death (Chapter 63). Seizures should be treated if possible, although they tend to be very refractory. There is no evidence that treatment of seizures after drowning improves outcome. Fosphenytoin or phenytoin (loading dose of 10-20 mg of phenytoin equivalents [PE]/kg, followed by maintenance dosing with 5-8 mg of PE/kg/day in 2-3 divided doses; levels should be monitored) may be considered as an anticonvulsant; it may have some neuroprotective effects and may mitigate neurogenic pulmonary edema. Benzodiazepines, barbiturates, and other anticonvulsants may also have some role in seizure therapy.

With optimal management, many initially comatose children can have impressive neurologic improvement, but usually do so within the 1st 24-72 hr. Unfortunately, almost half of deeply comatose drowning victims admitted to the PICU die of their hypoxic brain injury or survive with severe neurologic damage. Many children become brain dead. Deeply comatose drowning victims who do not show substantial improvement on neurologic examination after 24-72 hr and whose coma cannot be otherwise explained should be seriously considered for limitation or withdrawal of support.

Other Management Issues

A few drowning victims may have traumatic injury (Chapter 66), especially if they were participating in water sports involving personal watercraft, boating, diving, or surfing. A high index of suspicion for such injury is required. Spinal precautions should be maintained in victims with altered mental status and suspected traumatic injury. Significant anemia suggests trauma and internal hemorrhage.

Hypoxic-ischemic injury can have multiple systemic effects, although protracted organ dysfunction is uncommon in the absence of severe CNS injury. Hyperglycemia is associated with a poor outcome in pediatric drowning victims. Its etiology is unclear but it is possibly a stress response.

Manifestations of acute renal failure may be seen after hypoxic-ischemic injury (Chapter 529). Diuretics, fluid restriction, and dialysis are occasionally needed to treat fluid overload or electrolyte disturbances; renal function usually normalizes in survivors. Rhabdomyolysis after drowning has been reported.

Profuse bloody diarrhea and mucosal sloughing usually portend a grim prognosis; conservative management includes bowel rest, nasogastric suction, and gastric pH neutralization. Nutritional support for most drowning victims is usually not difficult, because the majority of children either die or recover quickly and resume a normal diet within a few days; enteral tube feeding or parenteral nutrition is occasionally indicated in children who do not recover quickly.

Almost half of drowning victims have a fever during the 1st 48 hr after submersion. Hyperthermia is usually not due to infection and resolves without antibiotics in approximately 80% of patients. Generally, prophylactic antibiotics are not recommended.

Psychiatric and psychosocial sequelae in the family of a pediatric drowning victim are common. Grief, guilt, and anger are common among family members, including siblings. Divorce rates of up to 80% within a few years of the injury have been reported, and parents often report difficulties with employment or substance abuse. Friends and family may blame the parents for the event. Professional counseling, pastoral care, or social work referral should be considered for drowning victims and their families.

Hypothermia Management

Damp clothing should be removed from all drowning victims. Attention to core body temperature starts in the field and continues during transport and in the hospital. The goal is to prevent or treat moderate or severe hypothermia. Rewarming measures are generally categorized as passive, active external, or active internal (Chapter 69). Passive rewarming measures can be applied in the prehospital or hospital setting; they include the provision of dry blankets, a warm environment, and protection from further heat loss. Rewarming measures should be instituted as soon as possible for hypothermic drowning victims who have not had a cardiac arrest.

Full CPR with chest compressions is indicated for hypothermic victims if no pulse can be found or if narrow complex QRS activity is absent on ECG (Chapters 62 and 69). When core body temperature is <30°C, resuscitative efforts should proceed according to the current American Heart Association guidelines for CPR, but IV medications may be given at a lower frequency in moderate hypothermia because of decreased drug clearance. When VF is present in severely hypothermic victims (core temperature <30°C), up to 3 defibrillation attempts should initially be delivered, but further defibrillation attempts should be held until the core temperature is ≥30°C, at which time successful defibrillation may be more likely.

There is significant controversy regarding the discontinuation of prolonged resuscitative efforts in hypothermic drowning victims. Body temperature should be taken into account before resuscitative efforts are terminated. Other considerations include whether the water was icy or the cooling was very rapid with fast-flowing cold water. Victims with profound hypothermia may appear clinically dead, but full neurologic recovery is possible, although rare. Attempts at lifesaving resuscitation should not be withheld on the basis of initial clinical presentation unless the victim is obviously dead (dependent lividity or rigor mortis). Rewarming efforts should usually be continued until the temperature is 32-34°C; if the victim continues to have no effective cardiac rhythm and remains unresponsive to aggressive CPR, then resuscitative efforts may be discontinued.

Complete rewarming is not indicated for all arrest victims before resuscitative efforts are abandoned. Discontinuing resuscitation in victims of non–icy water submersion who remain asystolic despite 30 minutes of CPR is probably warranted. Physicians must use their individual clinical judgment about deciding to stop resuscitative efforts, taking into account the unique circumstances of each incident, including evaluation of the rapidity with which cooling occurred.

Once a drowning victim has undergone successful CPR after a cardiac arrest, temperature management should be carefully considered, and body temperature should be continuously monitored. In victims in whom resuscitation duration was brief and who are awake soon after resuscitation, attempts to restore and maintain normothermia are warranted. Careful monitoring is necessary to prevent unrecognized worsening hypothermia, which can have untoward consequences.

Victims in whom resuscitation duration has been longer are more likely to remain comatose; temperature management in these individuals is an area of controversy. Fever commonly develops within the 1st 24-48 hr of drowning. There is general consensus that fever or hyperthermia (core body temperature >37.5°C) in comatose drowning victims resuscitated from cardiac arrest should be prevented at all times in the acute recovery period (at least the 1st 24-48 hr). Hyperthermia after drowning or other types of brain injury may increase the risk of mortality and exacerbate hypoxic-ischemic CNS damage.

For drowning victims who remain comatose after successful CPR, more contentious issues include: (1) rewarming of hypothermic victims and (2) controlled application of therapeutic hypothermia. There are no human trials indicating that hypothermia improves the outcome of drowning patients.

Although there is no consensus of opinion, many investigators now cautiously recommend that hypothermic drowning victims who remain unresponsive because of hypoxic-ischemic encephalopathy after restoration of adequate spontaneous circulation should not be actively rewarmed to normal body temperatures. Active rewarming should be limited to victims with core body temperatures <32°C, but temperatures 32-37.5°C should be allowed without further rewarming efforts.

More controversial is the induction of therapeutic hypothermia in drowning victims who remain comatose because of hypoxic-ischemic encephalopathy after CPR for cardiac arrest. The 2002 World Congress on Drowning recommended that hypothermia (32-34°C) be instituted as soon as possible after resuscitation and sustained for 12-24 hr. These patients should be intubated, mechanically ventilated, and treated with sedatives and/or analgesics (with or without neuromuscular blocking agents) as necessary to prevent shivering and maintain hypothermia. Rewarming after this period should be very gradual.

A specific recommendation for therapeutic hypothermia, especially in children, is not yet generally accepted. The Advanced Life Support Task Force of the International Liaison Committee on Resuscitation (2002) did not recommend therapeutic hypothermia in children resuscitated after cardiopulmonary arrest, citing insufficient evidence and older studies demonstrating a potential deleterious effect in pediatric drowning victims.

Prognosis

The outcomes for drowning victims are remarkably bimodal: The great majority of victims either have a good outcome (intact or mild neurologic injury) or a bad outcome (persistent vegetative state or death), with very few exhibiting intermediate neurologic injury. Of hospitalized pediatric drowning victims, 15% die and as many as 20% survive with severe permanent neurologic damage.

Intact survival or mild neurologic impairment has been seen in 91% of children with submersion duration <5 min and in 87% with resuscitation duration <10 min. Children with normal sinus rhythm, reactive pupils, or neurologic responsiveness at the scene virtually always had good outcomes (99%). For cases requiring advanced CPR, death or severe neurologic morbidity occurred in 93% of patients with submersion duration >10 min and in 100% of victims requiring resuscitation for >25 min. In one study, all victims with submersion duration >25 min died. Similarly, a Finnish study of pediatric drowning showed submersion duration was the best predictor of outcome and water temperature was not. However, there are rare case reports of intact recovery following non–icy water drowning with longer submersion or resuscitation duration. Other studies have looked at factors such as ambulance response time, serum potassium level, gender, rate of rewarming, and initial ECG rhythm. In small numbers of patients, these factors appear to have an association with outcome, but the data are not conclusive, highlighting the difficulty in assigning absolute prognostic classifications the basis of prehospital and ED variables alone.

The GCS score has some limited utility in predicting recovery. Children with a score ≥6 on hospital admission generally have a good outcome, whereas those with a score ≤5 have a much higher probability of poor neurologic outcome. Occasionally, children with a GCS score of 3 or 4 in the ED have complete recovery. Improvement in the GCS score during the first several hours of hospitalization may indicate a better prognosis. Overall, early GCS assessments fail to adequately distinguish children who will survive intact from those with major neurologic injury.

Neurologic examination and progression during the 1st 24-72 hr are currently the best prognosticators of long-term CNS outcome. Children who regain consciousness within 48-72 hr, even after prolonged resuscitation, are unlikely to have serious neurologic sequelae. In a small series of comatose victims of non–icy water submersion, all survivors with a good outcome had spontaneous purposeful movements and normal brainstem function within 24 hr; good recovery did not occur in any child with abnormal brainstem function or absence of purposeful movements at 24 hr. In another small series of drowning victims who remained unconscious >24 hr and survived for at least 1yr, 73% remained in a persistent vegetative state and the rest had severe neurologic impairment. These victims continued to have many complications and a high mortality rate: 45% died during the study’s 1-yr follow-up period.

The prognostic value of neurologic responsiveness during the 1st 48-72 hr of hospitalization was also observed in a larger retrospective series of 274 pediatric drowning victims. Of the victims who had an initial GCS score of 3 in the ED, only 14% survived intact. Overall, 67.5% survived intact. Of these, 95% demonstrated purposeful neurologic function within 48 hr. Patients with a documented first purposeful neurologic response within 6 hr all survived intact. Conversely, in only 5.6% of children with poor outcomes (persistent vegetative state or death) was “purposeful” movement documented in the 1st 48 hr. Laboratory and technologic methods to improve prognostication have not yet proved superior to neurologic examination.

Early prognostic certainty in drowning can often be elusive. Serial neurologic evaluations after CPR should be performed over the ensuing 48-72 hr, with consideration given to limitation or withdrawal of support in patients who do not have significant neurologic recovery, even though this may occur before absolute prognostic certainty is achieved.

Prevention

The most effective way to decrease the injury burden of drowning is prevention. Drowning is a multifaceted problem, but several preventive strategies are effective. The pediatrician has a prime opportunity to identify and inform families at risk through anticipatory guidance.

A family-centered approach to anticipatory guidance for water safety is to explore and identify the water hazards that each family is exposed to in their environment, with water-related activities, and because of the developmental stage of their child. The practitioner can then discuss the best tools and strategies for prevention that are relevant for the particular family. It is important to identify the risks both in and around the home and in other locations they may frequent, often when vacationing, such as vacation or relatives’ homes. For some families the focus may be on bathtubs and bucket safety; for others, home pools or hot tubs may be the major hazards. If the family recreates near or on open water, they also need to learn about safety around boats and open water. In a rural environment, water collection systems and natural bodies of water may pose great risk.

Parents must build layers of water protection around their children. Table 67-1 provides an approach to the hazards and preventive strategies relevant to the most common sources of water involved in childhood drowning. A common preventive strategy for exposure to all water types and all ages is ensuring appropriate supervision. Pediatricians should define for parents what constitutes appropriate supervision at the various developmental levels of childhood. Many parents either underestimate the importance of adequate supervision or are simply unaware of the risks associated with water. Even parents who say that constant supervision is necessary will often admit to brief lapses while their child is alone near water. Parents also overestimate the abilities of older siblings; many bathtub drownings occur when an infant or toddler is left with a child younger than 5 yr.

Table 67-1 APPROACH TO DROWNING-PREVENTION STRATEGIES

Supervision of infants and young children means that a responsible adult should be with the child every moment. The caregiver must be alert, must not be consuming alcohol or other drugs, and must be attentive and focused entirely on watching the child. Even a brief moment of inattention, such as to answer a phone, get a drink, or hold a conversation, can have tragic consequences. If the child does not swim, “touch supervision” is required, meaning that the caregiver should be within arm’s reach at all times. Many parents believe that swimming lessons can teach infants and toddlers how to protect themselves in water. However, parents must understand that although such lessons may offer many benefits, they do not result in the need for less supervision of their children near water. Furthermore, a supervising caretaker should be aware of where and how to get help and know how to safely rescue a child in trouble. Because only those trained in water rescue can safely attempt it, families should be encouraged to swim in designated areas only when and where a lifeguard is on duty.

Learning to swim offers another layer of protection. Most children are developmentally ready to learn to swim by age 4 yr. At an earlier age, children may start swim lessons that are developmentally appropriate and aimed at the individual child’s readiness and skill level. It is not clear whether lessons provide some level of protection to young children by teaching them swim skills, safer behaviors around water, or simply water awareness. It is also unclear how much risk reduction swim lessons provide. As with any other water safety intervention, parents need to know that swimming lessons and acquisition of swim skills cannot be solely relied on to prevent drowning. No child can be “drown-proof.” Children and adolescents should never swim alone regardless of their swimming abilities. Even as they become more independent and participate in recreational activities without their parents, they should be encouraged to seek areas that are watched by lifeguards. It is important to emphasize that even if the child is considered a strong swimmer, the ability to swim in a pool does not translate to being safe in open water, where different water temperature, currents, and underwater obstacles can present additional and unfamiliar challenges. For swimmers, supervision by lifeguards reduces drowning risk, because lifeguards monitor risk behaviors and are trained in the difficult and potentially dangerous task of rescuing drowning victims.

Two of the preventive strategies listed in Table 67-1 deserve special mention. The most vigorously evaluated and effective drowning intervention applies to swimming pools. Isolation fencing that completely surrounds a pool, with a secure, self-locking gate, reduces the risk of drowning. Guidelines for appropriate fencing, provided by the U.S. Consumer Product Safety Commission, are very specific; they were developed through testing of active toddlers in a gymnastics program on their ability to climb barriers of different materials and heights. In families who have a pool on their property, caregivers often erroneously believe that if a child falls into the water there will be a loud noise or splash to alert them. Sadly, these events are usually silent, increasing the time until the child is discovered. This finding highlights the importance of the guideline that the fence actually separate the pool from the house, not just surround the entire property.

The use of U.S. Coast Guard–approved lifejackets or PFDs should be discussed with all families spending time around open water, not just those who consider themselves boaters. This issue is also particularly important for families who will participate in aquatic activities on a vacation. A PFD should be chosen with respect to the weight of the child and the proposed activity. Young children should wear PFDs that will float them head up. Parents should be urged to wear PFDs, too, as their use is associated with greater use by their children. Toys such as water wings and “floaties” should not be relied upon as drowning prevention measures.

Effective preventive efforts must also consider cultural practices. Different ethnic groups may have certain attitudes, beliefs, dress, or other customs that may affect their water safety. The higher drowning risk of minority children needs to be addressed by community-based prevention programs.

In addition to anticipatory guidance, pediatricians can play an active role in drowning prevention by participating in advocacy efforts to improve legislation for pool fencing, PFD use, and alcohol consumption in various water activities. Several counties in the USA, Australia, and New Zealand have laws requiring isolation fencing for pools. Their effectiveness has been limited by a lack of enforcement. Similarly, all states have boating-under-the-influence laws but, similarly, rarely enforce them. Furthermore, efforts at the community level may be needed to ensure the availability of swimming lessons for underserved populations and lifeguarded swim areas.

Bibliography

Brenner RA, Taneja GS, Haynie DL, et al. Association between swimming lessons and drowning in childhood: a case-control study. Arch Pediatr Adolesc Med. 2009;163:203-210.

Centers for Disease Control and Prevention (CDC). Nonfatal and fatal drownings in recreational water settings—United States, 2001–2002. Morbid Mortal Wkly Rep. 2004;53:447-452. http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5321a1.htm.

Cohen RH, Matter KC, Sinclair SA, et al. Unintentional pediatric submersion-injury-related hospitalizations in the United States, 2003. Inj Prev. 2008;14:131-135.

Committee on Injury, Violence, and Poison Prevention. Policy Statement—prevention of drowning. Pediatrics. 2010;126:178-185.

Committee on Sports Medicine and Fitness and Committee on Injury and Poison Prevention. Swimming programs for infants and toddlers. Pediatrics. 2000;105:868-870.

Diplock S, Jamrozik K. Legislative and regulatory measures for preventing alcohol-related drownings and near-drownings. Aust N Z J Public Health. 2006;30:314-317.

Garssen MJ, Hoogenboezem J, Bierens JJ. Reduction of the drowning risk for young children, but increased risk for children of recently immigrated non-westerners. [See comment.]. Ned Tijdschr Geneeskd. 2008;152:1216-1220.

Jonkman SN, Kelman I. An analysis of the causes and circumstances of flood disaster deaths. Disasters. 2005;29:75-97.