Nonfatal Drowning

Joseph L. Steele, APA-C and Natasha J. Pyzocha, DO Reviewed 06/2017
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Subject: Nonfatal Drowning

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BASICS

DESCRIPTION

  • Survival at least temporarily after suffocation by submersion in a liquid medium or rescue from drowning at any time; drowning defined as respiratory impairment from submersion/immersion in liquid 1

  • System(s) affected: cardiovascular, nervous, pulmonary, renal

  • Synonym(s): submersion injury; according to the Utstein guidelines terms such as “near-drowning,” “secondary drowning,” and “wet drowning” should not be used.

EPIDEMIOLOGY

Incidence

  • From 2005 to 2014, an average of 3,536 fatal unintentional drownings in the United States 2.

  • Three age-related peaks: toddlers and young children (1 to 5 years), adolescents and young adults (15 to 25 years), and the elderly

  • 80% of people who die from drowning are male 2.

  • Greater incidence in minorities; African Americans age 5 to 19 years old are affected at 5.5 times the Caucasian rate 2.

Prevalence

  • Most common injury-related cause of death for children 1 to 4 in the United States 3

  • For every child age ≪15 years who dies from drowning, five more children are seen in the emergency room for nonfatal submersion injuries.

ALERT

Proper water supervision and safety techniques are critical in avoiding morbidity and mortality from drowning.

 

ETIOLOGY AND PATHOPHYSIOLOGY

Hypoxemia via aspiration and/or reflex laryngospasm causing cerebral hypoxia and multisystem organ involvement 
  • 10-20% of victims drown without aspiration; likely due to prolonged laryngospasm, previously termed “dry lungs.”

  • Bathtub and bucket drowning in children ≪1 year of age

  • Swimming pool drowning in children and young adults

  • Motor vehicle accidents (e.g., automobile submerged in water)

  • Head trauma while swimming or diving

  • Suicide

  • Pulmonary: morbidity primarily as a result of hypoxia. Aspiration also causes dilution of surfactant with decreased gas transfer across alveoli, atelectasis, development of intrapulmonary right-to-left shunting; acute respiratory distress syndrome (ARDS); obstruction due to laryngospasm and bronchospasm

  • Cardiac: hypoxic-ischemic injury and arrhythmia (primary or secondary)

  • Renal: acute tubular necrosis from hypoxemia, shock, hemoglobinuria, myoglobinuria

  • Neurologic: hypoxic-ischemic brain injury with damage especially to the hippocampus, insular cortex, and basal ganglia; cerebral edema

  • Coagulation: hemolysis and coagulopathy

RISK FACTORS

  • Risk-taking behavior

  • Inadequate physical barriers surrounding pools

  • Alcohol ingestion

  • Male sex

  • Low socioeconomic status

  • Use of illicit drugs

  • Seizure disorder

  • Inability to swim

  • Hyperventilation prior to underwater swimming

  • Boating mishaps and trauma during water sports, particularly when not wearing a life jacket

  • Scuba diving

  • Inadequate adult supervision of children

  • Concomitant stroke or myocardial infarction (MI)

  • Hypothermia

  • Cardiac arrhythmias: familial long QT and polymorphic ventricular tachycardia (VT)

  • Residence within sunbelt states

  • African Americans

  • Lack of instruction regarding swimming and supervision

GENERAL PREVENTION

  • Periodic education/reinforcement of supervision with an emphasis on drowning prevention for caretakers of young children

  • Consistent practice of proper adult supervision of children

  • Knowledge of water safety guidelines

  • Mandatory physical barriers surrounding pools

  • Pool alarms

  • Fences higher than 54 inches (137 cm) for home pools (four-sided)

  • Avoidance of alcohol or recreational drugs around water

  • Swimming instruction at an early age

  • Cardiopulmonary resuscitation (CPR) instruction for pool owners and parents

  • Boating safety knowledge

  • Personal flotation device (e.g., preserver, if necessary)

Pediatric Considerations

Children should never be left alone near water. Young children can drown in very small amounts of water, such as in bathtubs, buckets, and toilets. 

COMMONLY ASSOCIATED CONDITIONS

  • Trauma

  • Seizure disorder

  • Alcohol or illicit drug use

  • Hypothermia

  • Concomitant stroke or MI

  • Cardiac arrhythmias: familial long QT and familial polymorphic VT

  • Hyperventilation

DIAGNOSIS

HISTORY

The Utstein approach to the evaluation of drowning victims standardizes reporting data and provides guidance for the history, physical exam, and appropriate management. 
  • Gender, age, birthdate, event date

  • Time call received and emergency medical services (EMS) starts resuscitation.

  • Precipitating event

  • Location of drowning

  • Duration of submersion

  • Loss of consciousness

  • Period of apnea

  • Artificial ventilation/CPR performed

  • History of associated trauma

  • Approximate water temperature (hypothermia)

  • Recent use of alcohol or drugs

  • Known seizure disorder, cardiac disease, syncopal event

PHYSICAL EXAM

  • Airway status and degree of respiratory effort and/or distress

  • Pulse: absent, weak, or normal

  • Vital signs, including pulse oximetry

  • Glasgow Coma Scale (GCS)

  • Wheezing

  • Evidence of trauma

DIFFERENTIAL DIAGNOSIS

Syncopal event, head trauma, arrhythmia, seizure, MI, stroke, alcohol or other substance overdose, nonaccidental trauma 

DIAGNOSTIC TESTS & INTERPRETATION

Initial Tests (lab, imaging)

May be unnecessary if initial GCS and pulse oximetry are normal and remain that way for 6 to 8 hours 
  • CBC with differential

  • Arterial blood gases (ABGs): hypoxia, hypercarbia, acidosis

  • Electrolytes: hypokalemia, hyponatremia, hypernatremia

  • Blood glucose: may be low if the cause of neardrowning; increased levels may impair neurologic recovery after ischemic brain injury.

  • BUN, creatinine: acute tubular necrosis

  • ECG, cardiac monitoring, and serial troponin: MI

  • Creatine kinase (CK) and urine myoglobin: rhabdomyolysis

  • Coagulation studies: coagulopathy

  • Urinalysis/urine drug screen

  • Blood alcohol level

  • A chest x-ray (CXR) may be unnecessary for patients with all of the following:

    • ▪ Normal initial GCS and pulse oximetry
    • ▪ No evidence of respiratory distress
    • ▪ No change after 6 to 8 hours of observation
  • For others, a CXR may show evidence of aspiration, atelectasis, pneumothorax, or ARDS.

  • Head CT and/or C-spine imaging as needed for associated trauma

Follow-Up Tests & Special Considerations
  • Patients with an initial GCS of 15 and pulse oximetry >95% should be observed for 6 to 8 hours in the emergency department (ED).

  • CXR findings may be minimal or absent on early imaging.

Diagnostic Procedures/Other

  • Continuous cardiac monitoring

  • Continuous pulse oximetry

  • Continuous core temperature monitoring if hypothermic

  • ECG

  • Central venous pressure (CVP) monitoring for critically ill patients with hypotension refractory to IV fluids

  • Electroencephalogram (EEG) if suspect seizure as cause

TREATMENT

Early resuscitation and reversal of hypoxemia optimizes outcome. 

GENERAL MEASURES

  • Prehospital

    • ▪ Never approach a struggling victim alone.
    • ▪ Initially evaluate as per Basic Life Support (BLS) and Advanced Cardiovascular Life Support (ACLS) 4.
    • ▪ Rescue breathing may be helpful while the victim is in the water and not able to be immediately removed from the water, but chest compressions in the water may not be effective and may even harm the rescuer and the victim 4[C].
    • ▪ Remove the victim from the water and begin effective resuscitation as quickly as possible 5.
    • ▪ Early CPR that emphasizes effective chest compressions and rapid defibrillation as indicated
    • ▪ Start CPR if pulse is not definitely felt within 10 seconds, even in the hypothermic victim whose heart rate may be severely bradycardic 4[C].
    • ▪ Routine cervical collar use and spinal precautions are not needed unless a high suspicion for trauma exists 5[C].
    • ▪ Supplemental oxygen and early intubation with mechanical ventilation, as needed 1[A]
    • ▪ Rapid crystalloid infusion if hypotension not corrected by oxygenation 1[A]
    • ▪ If patient is breathing on his or her own and does not need spinal precautions, consider placing in the right lateral decubitus position to prevent aspiration of vomit or gastric contents 1.
  • ED

    • ▪ Oxygen, as needed, to maintain saturation between 92% and 96%, ensuring chest rise 1
    • ▪ Continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), or intubation if supplemental O2 alone is unsuccessful
    • ▪ If intubation is indicated, employ lung-protective vent settings (lower end-inspiratory airway pressures, lower tidal volumes of 6 mL/kg, higher positive end-expiratory pressures of 6 to 12 cm H2O) to avoid lung barotrauma 4[A].
    • ▪ Indications for intubation
      • * Neurologic deterioration
      • * Inability to protect the airway
      • * Inability to maintain oxygen saturation >90% or PaO2 >60 mm Hg on high-flow supplemental oxygen
      • * PaCO2 >50 mm Hg
    • ▪ Remove wet clothing and initiate rewarming.
    • ▪ Core temperature reading for possible hypothermia
    • ▪ Rewarming with minimally invasive core rewarming such as warm IV fluids, warm/humidified oxygen, and external rewarming
    • ▪ Active core rewarming reserved for refractory cases and only when extracorporeal blood warming is unavailable, depending on physician comfort level, due to major complications that can develop including core temperature after drop, rewarming acidosis, and rewarming shock

MEDICATION

First Line

  • High-flow oxygen, as needed 1[A]

  • For bronchospasm: aerosolized bronchodilator 3[C]: albuterol (Proventil, Ventolin), 3 mL of 0.083% solution or 0.5 mL of 0.5% solution diluted in 3 mL of saline

  • Pressors, as needed, for hypotension refractory to IV fluid resuscitation

  • Prophylactic antibiotics are not recommended 1[B].

Second Line

For pneumonia: antibiotics based on sputum or endotracheal lavage culture 1[A

ADMISSION, INPATIENT, AND NURSING CONSIDERATIONS

  • All symptomatic patients

  • Patients with abnormalities in vital signs, mental status, oxygenation, CXR, or laboratory analysis

  • Continuous cardiac monitoring

  • Continuous pulse oximetry monitoring

  • Frequent monitoring of vital signs and clinical reassessment

  • Careful monitoring of neurologic status

  • Induced hypothermia with core temp maintained between 32ºC and 34ºC for 24 hours may be neuroprotective 1.

  • Patients can be discharged from the ED after 6 to 8 hours of observation if the following criteria are met:

    • ▪ GCS = 15
    • ▪ Normal CXR, if indicated
    • ▪ Lack of clinical evidence of respiratory difficulty
    • ▪ Normal lung exam
    • ▪ Normal vital signs
    • ▪ Oxygen saturation ≥95% on room air 5

ONGOING CARE

FOLLOW-UP RECOMMENDATIONS

Appropriate follow-up with primary care provider, orthopedic, neurologic, cardiac, pulmonary, and additional specialists as indicated 

Patient Monitoring

  • Continuous cardiac monitoring

  • Continuous pulse oximetry monitoring

  • Frequent monitoring of vital signs and clinical reassessment

  • Careful monitoring of neurologic status

  • ABG monitoring, as indicated

  • A pulmonary artery catheter may be needed for hemodynamic monitoring in unstable patients 3[C].

  • Intracranial pressure monitoring in selected patients 3[C]

  • Serum electrolyte determinations

DIET

NPO until mental status normalizes 

PATIENT EDUCATION

Reemphasize preventive measures on discharge from hospital. Educate parents regarding supervision and preventive practices. 

PROGNOSIS

  • 75% of drowning victims survive; 6% of these with residual neurologic deficits

  • Patients with an initial GCS ≥13 and an oxygen saturation ≥95% have a low risk of complications and an excellent chance for a full recovery.

  • Patients who are comatose or receiving CPR at the time of presentation as well as those who have dilated and fixed pupils and no spontaneous respiratory activity have a more guarded and often poor prognosis, often secondary to neurologic sequelae.

  • Neurogenic pulmonary edema may occur within 48 hours of initial presentation.

COMPLICATIONS

  • Early

    • ▪ Bronchospasm
    • ▪ Vomiting/aspiration
    • ▪ Hypoglycemia
    • ▪ Hypothermia
    • ▪ Seizure
    • ▪ Hypovolemia
    • ▪ Electrolyte abnormalities
    • ▪ Arrhythmia from hypoxia or hypothermia (rarely from electrolyte imbalance)
    • ▪ Hypotension
  • Late

    • ▪ ARDS
    • ▪ Anoxic encephalopathy
    • ▪ Pneumonia
    • ▪ Lung abscess/empyema
    • ▪ Renal failure
    • ▪ Coagulopathy
    • ▪ Sepsis
    • ▪ Barotrauma
    • ▪ Seizure

REFERENCES

Szpilman  D, Bierens  J, Handley  AJ, et al. Drowning. N Engl J Med.  2012;362(22):2102–2110.  [View Abstract]
Centers for Disease Control and Prevention. Unintentional drowning: get the facts. http://www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html/. Accessed September 13, 2016.
Mott  T, Latimer  K. Prevention and treatment of drowning. Am Fam Physician.  2016;93(7): 576–582.  [View Abstract]
Berg  R, Hemphill  R, Abella  BS, et al. Part 5: adult basic life support: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation.  2010;122(18)(Suppl 3):S685–S705.  [View Abstract]
Salomez  F, Vincent  JL. Drowning: a review of epidemiology, pathophysiology, treatment and prevention. Resuscitation.  2004;63(3):261–268.  [View Abstract]

CODES

ICD10

  • T75.1XXA Unsp effects of drowning and nonfatal submersion, init

  • T75.1XXD Unsp effects of drowning and nonfatal submersion, subs

  • T75.1XXS Unsp effects of drowning and nonfatal submersion, sequel

ICD9

994.1 Drowning and nonfatal submersion 

SNOMED

87970004 Nonfatal submersion (disorder) 

CLINICAL PEARLS

  • The single most important treatment for near-drowning victims is prompt reversal of the hypoxic state. This should form the cornerstone for all other treatment modalities. Without oxygenation, other treatment is futile.

  • Focus water safety counseling on prevention measures targeting epidemiologic concerns that combine physical, behavioral, medical, and community areas of interest for greatest effect (4).

  • Family physicians and pediatricians should review water safety tips and guidelines with parents and children at yearly visits. Encourage pool owners and parents with young children to become CPR certified. Prevention of drowning can save many lives each year.

  • Despite successful resuscitation, patients are at risk for ARDS due to delayed pulmonary edema that may start hours after their submersion incident. For this reason, careful monitoring of every resuscitated patient is essential.

  • Patients requiring intubation should be treated with lung-protective vent settings to prevent barotrauma.

  • Patients with an initial GCS ≥13 and an oxygen saturation ≥95% have a low risk of complications and an excellent chance for a full recovery.

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