Drowning

DROWNING
SUBMERSION INJURIES
INTRODUCTION
Drowning accounts for at least 500,000 deaths / year
(worldwide).
US : +/- 4000 fatalities.
Nonfatal drowning statistics are more difficult to obtain.
Nonfatal drowning events may occur several hundred

times as frequently as reported drowning deaths.
INTRODUCTION
Nonfatal drowning : survival, at least temporarily, after
suffocation by submersion in a liquid medium, include the
loss of consciousness while submerged.
Since pulmonary complications may follow the aspiration of

water without the loss of consciousness,
Nonfatal drowning : survival, at least temporarily, after

aspiration of fluid into the lungs ("wet nonfatal
drowning") or after a period of asphyxia secondary to
laryngospasm ("dry nonfatal drowning")
INTRODUCTION
According to the Utstein guidelines
Drowning refers to: "a process resulting in primary

respiratory impairment from submersion or
immersion in a liquid medium”
Ambiguous or confusing terms such as "near-

drowning," "secondary drowning," and "wet
drowning" should not be used.
EPIDEMIOLOGY
Drowning :
common cause of accidental death (US)
an important cause of childhood fatalities

(worldwide).
highest rates : Low / middle-income countries.

EPIDEMIOLOGY
In US, drowning is
a major cause of accidental death among persons < 45 yo.
a leading cause in children < 5 yo (in states where

swimming pools or beaches are more accessible).
Males, African-Americans, children 1 - 5 yo, low-

socioeconomic status.
Summer months.
EPIDEMIOLOGY
Age distribution : bimodal.
1st peak : < 5 yo,
who are inadequately supervised (in swimming pools,

bathtubs, or around other liquid-filled containers);
+/- 7 % : related to child abuse or neglect.
2nd peak : males, 15 - 25 yo,
occur at rivers, lakes, and beaches.

RISK FACTORS
Inadequate adult supervision.
Inability to swim or overestimation of swimming capabilities.
Risk-taking behavior.
Use of alcohol and illicit drugs (more than 50 percent of adult drowning deaths are
believed to be alcohol-related).
Hypothermia, which can lead to rapid exhaustion or cardiac arrhythmias
Concomitant trauma, stroke, or myocardial infarction.
Seizure disorder or developmental/behavioral disorders in children
Undetected primary cardiac arrhythmia (may be a more common cause of drowning

than generally appreciated)
Hyperventilation prior to a shallow dive.

PATHOPHYSIOLOGY
Fatal and nonfatal drowning typically begins with a period of panic,
loss of the normal breathing pattern,
breath-holding,
air hunger,
a struggle by the victim to stay above the water.
Reflex inspiratory efforts,
leading to hypoxemia and either aspiration or reflex

laryngospasm that occurs when water contacts the lower
respiratory tract.
PATHOPHYSIOLOGY
Hypoxemia affects every organ system.
Morbidity and mortality related to cerebral hypoxia

END ORGAN EFFECTS
Hypoxemia produces tissue hypoxia,
affects virtually all tissues and organs within the body.
Pulmonary
Neurologic
Cardiovascular
Acid-base and electrolytes
Renal
Coagulation
PULMONARY EFFECTS
Fluid aspiration results in hypoxemia.
Salt water and fresh water wash out surfactant,
producing noncardiogenic pulmonary edema and

the ARDS.
Pulmonary insufficiency (shortness of breath, crackles,

and wheezing).
Chest xray or CT : normal or localized - diffuse

pulmonary edema.
NEUROLOGIC EFFECTS
Hypoxemia and ischemia cause neuronal damage
produce cerebral edema and elevations in

intracranial pressure.
CV EFFECTS
Arrhythmias secondary to hypothermia and hypoxemia.

ACID-BASE EFFECTS
Metabolic and/or respiratory acidosis.
Significant electrolyte imbalances : submerged in

unusual media, such as the Dead Sea,
hypernatremia,
hypermagnesemia, and
hypercalcemia
due to absorption of swallowed seawater.

RENAL EFFECTS
Renal failure (rare)
due to acute tubular necrosis (resulting from

hypoxemia, shock, hemoglobinuria, or myoglobinuria).
COAGULATION
EFFECTS
Hemolysis and coagulopathy (rare in nonfatal drowning)

MANAGEMENT
Rescue and immediate resuscitation improves the

outcome.
CPR is determined as soon as possible (without

compromising the safety of the rescuer or delaying the
removal of the victim from the water).
MANAGEMENT
Ventilation : most important initial treatment for victims of
submersion injury.
Rescue breathing should begin as soon as the rescuer reaches

shallow water or a stable surface.
Note : that the priorities of CPR in the drowning victim differ from
those in the typical adult cardiac arrest patient, which emphasize
immediate uninterrupted chest compressions.
If the patient does not respond to the delivery of two rescue breaths
—> immediately begin performing high-quality chest compressions.
CPR (including automated external defibrillator) is then performed

according to standard guidelines.
MANAGEMENT
Life-threatening arrhythmias : ACLS protocols.
High-flow oxygen-delivery : to ensure adequate

oxygenation of spontaneously breathing patients;
Intubation : in apneic patients and in respiratory

distress or unable to protect airway.
Rewarming hypothermic patients.

MANAGEMENT
ED MANAGEMENT :
Prehospital resuscitative efforts should be continued and the

airway secured.
CPAP / BPAP
frequent vital sign measurements and clinical reassessment,
monitoring :
continuous oxygen saturation, end-tidal CO (Capnography)

2
and cardiac telemetry.
blood glucose
MANAGEMENT
ED MANAGEMENT :
Trauma evaluation and appropriate imaging studies.
Wet clothing should be removed and rewarming.
Methods :
passive and active external rewarming (eg, application of warm

blankets, plumbed garments, heating pads, radiant heat, forced
warm air), and
active internal core rewarming (eg, warmed humidified oxygen

via tracheal tube, heated irrigation of peritoneal and pleural
cavities).
MANAGEMENT
Repeat chest radiographs only when indicated by signs

and symptoms of
increased respiratory distress, declining pulse

oximetry, or hypercarbia.
Bronchospasm : management is treated similarly to

acute asthma.
MANAGEMENT
Pts with hypothermia :
"cold diuresis" —> significant hypovolemia and

hypotension
because during the early phase of vasoconstriction,

blood moves to the core, causing central volume
receptors to sense fluid overload and resulting in
decreased antidiuretic hormone production.
MANAGEMENT
Poor prognosis :
Duration of submersion >5 minutes (most critical factor)
Time to effective BLS >10 minutes
Resuscitation duration >25 minutes
Age >14 years
GCS <5 (ie, comatose)
Persistent apnea and requirement of CPR in ED
Arterial blood pH <7.1 upon presentation

MANAGEMENT
Poor prognosis :
Duration of submersion >5 minutes (most critical factor)
Time to effective BLS >10 minutes
Resuscitation duration >25 minutes
Age >14 years
GCS <5 (ie, comatose)
Persistent apnea and requirement of CPR in ED
Arterial blood pH <7.1 upon presentation

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DROWNING

US : +/- 4000 fatalities.

Nonfatal drowning statistics are more diﬃcult to obtain.

Nonfatal drowning events may occur several hundred

Since pulmonary complications may follow the aspiration of

Nonfatal drowning : survival, at least temporarily, after

Drowning refers to: "a process resulting in primary

Ambiguous or confusing terms such as "near-

common cause of accidental death (US)

an important cause of childhood fatalities

highest rates : Low / middle-income countries.

a major cause of accidental death among persons < 45 yo.

a leading cause in children < 5 yo (in states where

Males, African-Americans, children 1 - 5 yo, low-

1st peak : < 5 yo,

who are inadequately supervised (in swimming pools,

+/- 7 % : related to child abuse or neglect.

2nd peak : males, 15 - 25 yo,

occur at rivers, lakes, and beaches.

Inability to swim or overestimation of swimming capabilities.

Hypothermia, which can lead to rapid exhaustion or cardiac arrhythmias

Concomitant trauma, stroke, or myocardial infarction.

Seizure disorder or developmental/behavioral disorders in children

Undetected primary cardiac arrhythmia (may be a more common cause of drowning

Hyperventilation prior to a shallow dive.

loss of the normal breathing pattern,

a struggle by the victim to stay above the water.

Reflex inspiratory eﬀorts,

leading to hypoxemia and either aspiration or reflex

Hypoxemia aﬀects every organ system.

Morbidity and mortality related to cerebral hypoxia

aﬀects virtually all tissues and organs within the body.

Acid-base and electrolytes

Salt water and fresh water wash out surfactant,

producing noncardiogenic pulmonary edema and

Pulmonary insuﬃciency (shortness of breath, crackles,

Chest xray or CT : normal or localized - diﬀuse

Hypoxemia and ischemia cause neuronal damage

produce cerebral edema and elevations in

Arrhythmias secondary to hypothermia and hypoxemia.

Significant electrolyte imbalances : submerged in

due to absorption of swallowed seawater.

Renal failure (rare)

due to acute tubular necrosis (resulting from

Hemolysis and coagulopathy (rare in nonfatal drowning)

Rescue and immediate resuscitation improves the

CPR is determined as soon as possible (without

Rescue breathing should begin as soon as the rescuer reaches

CPR (including automated external defibrillator) is then performed

Life-threatening arrhythmias : ACLS protocols.

High-flow oxygen-delivery : to ensure adequate

Intubation : in apneic patients and in respiratory

Rewarming hypothermic patients.

Prehospital resuscitative eﬀorts should be continued and the

frequent vital sign measurements and clinical reassessment,

continuous oxygen saturation, end-tidal CO (Capnography)

and cardiac telemetry.

Trauma evaluation and appropriate imaging studies.

Wet clothing should be removed and rewarming.