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Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 8e

Chapter 215: Drowning Stephen John Cico; Linda Quan

FIGURE 215-1.

INTRODUCTION AND EPIDEMIOLOGY

Drowning is submersion in a liquid medium resulting in respiratory di�iculty or arrest.1 As with other causes of accidentaldeath, drowning injury typically involves otherwise healthy, young individuals, but can involve individuals of any age orbackground.

Worldwide, drowning accounts for >500,000 deaths annually and is the leading cause of injury death among children <15years of age. In the United States, there are >500,000 drowning events each year and 1100 deaths, which makes drowning

the second leading cause of unintentional death of individuals from birth to age 19 years old.2,3 However, the rate ofdrowning deaths has decreased over the past 40 years. In 1970, there were nearly 8000 deaths due to drowning in the United

States,4 and education with public awareness has been the major contributor to the decreased incidence. The vast majorityof victims survive submersion events, with e�ects ranging from minimal or transient injury to profound neurologic insult.

Drowning incidence peaks in three age groups: The highest is in children <5 years old, the second peak is in those aged 15 to24 years, and the third peak is in the elderly. Toddlers drown primarily a�er falling into swimming pools or open water, butthey also drown in bathtubs and buckets in the home. Physicians also need to evaluate for intentional drowning (childabuse) or factitious disorder by proxy (formerly Munchausen's by proxy). In teenagers and adults, suicide, homicide, anddomestic violence can be causes of drowning. The elderly also have an increased risk of bathtub drowning, o�en related tocomorbid medical conditions or medications. Even in coastal areas, most drownings take place in warm, freshwater bodiesof water (especially swimming pools).

Additional injuries or disorders that either precipitate or are associated with drowning events are shown in Table 215-1.

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Table 215-1

Disorders and Injuries Associated with Drowning

Disorders Associated with Drowning

Alcohol or other intoxicants

Syncope (e.g., due to hyperventilation prior to underwater diving)

Seizures

Cardiac conditions (e.g., dysrhythmias including prolonged QT syndromes, Brugada's syndrome, ischemic heart disease)

Dementia

Intentional (suicide, homicide, child abuse or neglect in young children)

Injuries Associated with Drowning

Spinal cord injuries due to diving into shallow water, significant falls from heights, or boating/personal watercra� mishaps

Hypothermia

Aspiration

Respiratory failure, insu�iciency, or distress

PATHOPHYSIOLOGY

A�er submersion, the degree of hypoxic insult to the central nervous system determines the ultimate outcome. It waspreviously thought that parasympathetic activation of the diving reflex (i.e., bradycardia, apnea, peripheralvasoconstriction, and central shunting of blood flow) provided transient protection during submersion. The diving reflex is

strongest in infants <6 months of age, but the e�ects decrease with age.5 In adults, vertical immersion (head out) andvertical submersion (head under) activate both the sympathetic and parasympathetic systems, which blunts any e�ect of

the diving reflex.6 Furthermore, physiologic stress associated with submersion also activates the sympathetic nervoussystem. Thus, the diving reflex is not protective. Cerebral protection in cold water submersions most likely results from rapidcentral nervous system cooling before significant hypoxic damage occurs.

Physiologic scoring systems7,8 to predict drowning outcome have been devised but are not clinically helpful. The vastmajority of patients who arrive at the hospital with sTable cardiovascular signs and awake, alert neurologic function survivewith minimal disability, whereas those who arrive with unsTable cardiovascular function and coma do poorly because of thehypoxic-ischemic insult. Predictors are not accurate for the 15% to 20% of drowning victims whose condition on arrival is

between these two extremes.9

End organs can also be a�ected by hypoxemia and metabolic acidosis. Aspiration of substances such as contaminatedforeign material, particulate matter, bacteria, vomitus, or chemical irritants can a�ect eventual pulmonary recovery.Electrolyte abnormalities are seldom significant and are usually transient unless there is significant hypoxia, central nervous

system depression, renal injury from hemoglobinuria, or myoglobinuria.8,9 Hematologic values are usually normal unlessthere has been massive hemolysis. Disseminated intravascular coagulation can be a complicating factor in drowningoutcome but usually occurs following severe hypoxic insult.

TREATMENT

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PREHOSPITAL CARE

Rapid resuscitation of a drowning victim (quickly restoring ventilation and oxygenation) optimizes outcome. A�er saferemoval of the victim from the water, CPR should be initiated as quickly as possible. Trauma as a cause of drowning is

uncommon, and most injured drowning patients have a history of trauma or signs of injury on examination.10 Cervical spineinjury is rare (0.5%) in drowning unless there is a history of diving, falling from a significant height, or motorized vehicle

crash.11 Use cervical spine precautions if the history warrants it.

Administer high-flow oxygen by facemask if the patient is breathing or by positive-pressure bag-valve mask ventilation if thepatient is not breathing. For patients who do not recover spontaneous respiratory e�ort, endotracheal intubation andpositive-pressure ventilation are necessary.

All patients with drowning amnesia for the event, loss of or depressed consciousness, or an observed period of apnea, aswell as those who require a period of artificial ventilation, should be transported to an ED for evaluation, even if they areasymptomatic at the scene. The patient should be warmed and monitored, and IV access should be established (Figure 215-1).

FIGURE 215-1.

Drowning event algorithm. CBC = complete blood count; CK = creatine kinase; CPAP = continuous positive airway pressure;CVP = central venous pressure; CXR = chest radiograph; GCS = Glasgow Coma Scale score; ICU = intensive care unit; PEEP =positive end-expiratory pressure; PT = prothrombin time; PTT = partial thromboplastin time; SaO2 = oxygen saturation (via

pulse oximetry); U/A = urinalysis.

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ED MANAGEMENT

Upon the patient's arrival at the ED, assess and secure the airway, provide oxygen, determine core temperature, and assistventilation as necessary. If the patient is hypothermic, administer warmed isotonic IV fluids and apply warming adjuncts(e.g., blankets, overhead warmers, warming devices). Address any associated injuries. Because cervical injury is rare without

a history of diving or associated trauma, routine cervical immobilization and CT of the brain are not necessary.11

Patients who present to the ED with a Glasgow Coma Scale score of >13 and an oxygen saturation of ≥95% are at low risk forcomplications (Figure 215-1) and should be observed for 4 to 6 hours. If the pulmonary examination does not reveal rales,rhonchi, wheezing, or retractions and arterial oxygen saturation on room air remains ≥95%, the patient can be safely

discharged home. Laboratory studies and radiographs are unnecessary and are not predictive of discharge.12 The patientshould be told to return if fever, mental status changes, or pulmonary symptoms occur. If, a�er 4 to 6 hours, the patientdevelops an oxygen requirement, the findings on pulmonary examination are abnormal (rales, rhonchi, wheeze, retractions,etc.), or the patient's condition deteriorates, reassessment and admission or transfer to a monitored bed are needed.

Patients who present to the ED with a Glasgow Coma Scale score of <13 should be maintained on supplemental oxygen andventilatory support as needed. If high-flow oxygen (fraction of inspired oxygen of 40% to 60%) cannot maintain an adequate

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partial pressure of arterial oxygen (>60 mm Hg in adults, >80 mm Hg in children), then intubate the patient and providepositive-pressure ventilation. Chest radiography and laboratory studies should be done to evaluate for pulmonaryaspiration and other complications (Figure 215-1). Although aspiration is common, prophylactic antibiotics have not been

shown to improve outcome and may be associated with resistant infections.13 Continuous cardiac monitoring, pulseoximetry, temperature monitoring, and frequent reassessments should be performed for all patients. Hypothermia is aconcern in patients who have been submerged in cold water (see chapter 209, Hypothermia).

If the patient is normothermic upon arrival in the ED and in cardiopulmonary arrest or asystole, serious thought should be

given to discontinuing resuscitation e�orts because recovery without profound neurologic complications is rare.14,15

CONTINUED MANAGEMENT

Hospital management of drowning victims is largely supportive.16 All drowning victims who require ED resuscitation shouldbe admitted to an intensive care unit for continuous cardiopulmonary and frequent neurologic monitoring. Most victims ofsignificant submersion injury benefit from mechanical ventilation. Supernormal levels of positive end-expiratory pressuremay be used to recruit fluid-filled lung units and aid oxygenation. Most patients demonstrate rapid improvement inoxygenation in the first 24 hours. Patients presenting with a significant aspiration pattern or cardiovascular collapse arepredisposed to develop acute respiratory distress syndrome. Although prophylactic antibiotics lack supporting evidence,delayed pulmonary infection, particularly among patients requiring mechanical ventilation, is a risk, and unusualorganisms, including Aeromonas species, should be considered if treatment is initiated. Care should be taken to avoid lungoverdistention and ventilator-associated barotrauma.

For patients who have been resuscitated from cardiac arrest, the hemodynamic response to exogenously administeredepinephrine is frequently short-lived, and most require a continuous infusion of dopamine or epinephrine in the ED orintensive care unit. Invasive (pulmonary artery catheter) or noninvasive (echocardiogram) measurement of ventricularfunction is o�en instructive. Hemodynamic recovery, when it occurs, can be expected within 48 hours. Patientsdemonstrating no hemodynamic recovery a�er 48 hours may slowly improve over the first week but are more likely to have

long-term neurologic damage.17

Results of "brain resuscitation" a�er significant warm water drowning have been disappointing.9,16 The degree of cerebraledema is largely determined by the duration of the anoxic or ischemic insult at the time of submersion. E�orts to controlcerebral edema, including the use of mannitol, loop diuretics, hypertonic saline, fluid restriction, and mechanical

hyperventilation, have not shown benefit.16 Controlled hypothermia, barbiturate "coma," and intracranial pressure

monitoring do not improve outcome in pediatric drowning victims.9 Although rare, complete or near-complete neurologicrecovery a�er asystole has been reported in both children and adults a�er icy water submersion episodes.

PROGNOSIS, DISPOSITION, AND FOLLOW-UP

Family members should be counseled about likely outcome. Based on initial presentation, resuscitation, laboratory data,and serial examinations, experienced practitioners should be able to provide accurate predictions of outcomes in most

cases.17 There are no standardized terms for describing drowning incidents.1 This chapter uses the terms asymptomatic andsymptomatic drowning.

ASYMPTOMATIC DROWNING

Drowning victims who are asymptomatic or mildly symptomatic can be observed for 4 to 6 hours. If the findings ofpulmonary examination and oxygen saturation on room air remain normal, patients can be discharged home. If

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deterioration is going to occur, it will do so within the 4- to 6-hour observation period.12,18,19 No data are available regardinglong-term outcomes, but it is unlikely that there are any measurable adverse e�ects. Patients and/or parents should beadvised to seek medical care for any respiratory complaints or fever.

SYMPTOMATIC DROWNING

Because submersion duration is frequently unknown or only estimated, the extent of required resuscitation is o�en themost objective measure of the degree of anoxic or ischemic insult (Table 215-2). Details of initial presentation andresuscitation are frequently strong prognostic indicators.

Table 215-2

Factors Associated with Poor Resuscitation Prognosis in Near-Drowning

Need for bystander CPR at scene

CPR in the ED

Asystole at scene or in ED a�er warming

For patients who require hospital admission, if the submersion victim does not require cardiopulmonary resuscitation at thescene or in the ED, complete recovery within 48 hours is expected. A small fraction of patients with significant aspirationmay develop severe, even life-threatening acute respiratory distress syndrome.

Victims requiring bystander CPR at the scene have a guarded prognosis. Of scene-resuscitated pediatric victims, about 20%

later die in the hospital, and about 5% are le� with severe hypoxic-ischemic encephalopathy.15,20 Those victims whodemonstrate continuous neurologic and cardiovascular improvement a�er hospital admission generally make a goodrecovery. Frequently, neurologic and cardiovascular examinations are normal within 24 hours of the drowning event.Victims who later die in the hospital usually demonstrate deteriorating cardiovascular and neurologic status.

Victims undergoing CPR in the ED have a poor prognosis. Prolonged (>30 minutes) CPR in drowning victims indicatessignificant anoxic or ischemic insult to the heart, brain, and other vital organs. Complete neurologic recovery is rare, withonly anecdotal reports of neurologic recovery a�er ED CPR of pediatric drowning victims. Asystole, whether noted at the

scene or in the ED, is a near-universal sign of poor prognosis in both adult and pediatric drowning injury.16,21

For the emergency physician, the answers to the questions of whom and how vigorously to resuscitate remain

challenging.16,20 Complete or near-complete neurologic recovery a�er asystole has been reported in both children andadults a�er drowning in icy water, although such occurrences are rare and documented mostly in case reports or smallseries. A large series of 1377 open-water drowning victims found no intact survivors among the group submerged for more

than 15 minutes, whether in warm or cold water, and there were no survivors of submersion greater than 60 minutes.22

There was also no di�erence in survival for children compared with adults in several studies, which contradicts the common

belief that pediatric patients do better than adults.7,21 For asystolic victims of drowning with short submersion durations

(i.e., a few minutes) and short transport times who receive CPR en route, a vigorous resuscitation attempt is reasonable.23

CPR should be abandoned if no response is noted. Conversely, because of the poor prognosis for intact neurologic survival,ED resuscitation attempts can reasonably be withheld from asystolic victims of drowning with longer submersion and

transport times.15,20

PREVENTION

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1. 

2. 

3. 

4. 

5. 

6. 

Submersion episodes in children <1 year of age are best prevented by parental vigilance during bathing. Child abuse or

neglect, particularly bathtub drownings in young children, and those with atypical presentations, should be considered.24

Bath seats may give parents a false sense of reassurance. Parents should never leave infants in bath seats unattended.25

Bathtub drownings are rare outside of the toddler age range, so abuse or seizures should be suspected.26 Among preschoolchildren, adult supervision in conjunction with properly installed and maintained four-sided pool fences that completely

isolate the pool could prevent 50% to 90% of drownings.27,28

Teen and young adult drownings may be reduced by avoiding alcohol and illicit drug use, which has been implicated in 40%

of all adult drownings and 75% of boating-related adult drownings.29 The use of personal flotation devices decreases

boating-related drowning deaths.30 Practical experience suggests that the ability to swim protects against teen and adult

drowning, but evidence only supports the e�icacy of swimming lessons for decreasing drowning death in young children.31

E�orts to decrease risk-taking behavior in the high-risk adolescent and young adult age groups need to be developed.

Swimmers with seizure disorders must be constantly monitored by an experienced professional or competent bystanderwhile they are in the water.

In the elderly, drowning locations closely parallel those of infant and toddler drowning. Adequate pool fencing and bathtubhandrails are important preventive measures for the elderly population and patients with premorbid conditions.

Acknowledgment: The authors gratefully acknowledge that portions of this chapter are based on previous work by Bruce E.Haynes, Alan L. Causey, and Mark A. Nichter (dec.)

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USEFUL WEB RESOURCES

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Water-Related Injuries: Centers for Disease Control and Prevention—http://www.cdc.gov/SafeChild/Drowning/;http://www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html;http://www.cdc.gov/Features/DrowningPrevention/; http://www.cdc.gov/Features/dsDrowningRisks/

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