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Subject: Nonfatal Drowning
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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.
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.
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.
Proper water supervision and safety techniques are critical in avoiding morbidity and mortality from drowning.
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
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
Inadequate physical barriers surrounding pools
Low socioeconomic status
Use of illicit drugs
Inability to swim
Hyperventilation prior to underwater swimming
Boating mishaps and trauma during water sports, particularly when not wearing a life jacket
Inadequate adult supervision of children
Concomitant stroke or myocardial infarction (MI)
Cardiac arrhythmias: familial long QT and polymorphic ventricular tachycardia (VT)
Residence within sunbelt states
Lack of instruction regarding swimming and supervision
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
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)
Alcohol or illicit drug use
Concomitant stroke or MI
Cardiac arrhythmias: familial long QT and familial polymorphic VT
Gender, age, birthdate, event date
Time call received and emergency medical services (EMS) starts resuscitation.
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
Airway status and degree of respiratory effort and/or distress
Pulse: absent, weak, or normal
Vital signs, including pulse oximetry
Glasgow Coma Scale (GCS)
Evidence of trauma
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:
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
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.
Continuous cardiac monitoring
Continuous pulse oximetry
Continuous core temperature monitoring if hypothermic
Central venous pressure (CVP) monitoring for critically ill patients with hypotension refractory to IV fluids
Electroencephalogram (EEG) if suspect seizure as cause
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].
All symptomatic patients
Patients with abnormalities in vital signs, mental status, oxygenation, CXR, or laboratory analysis
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:
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
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.
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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.