Basics
Description
- Definitions:
- Drowning: "A process resulting in primary respiratory impairment from submersion or immersion in a liquid medium"
- Fatal drowning: Death at any time as a result of drowning
- Nonfatal drowning: If the victim is rescued at any time and the process of drowning is interrupted
- Water rescue: Any submersion or immersion incident without evidence of respiratory impairment
- Scenario of drowning:
- Now thought all drowning victims aspirate some amount of liquid
- Previously classified as "wet" and "dry" drowning:
- "Wet" drowning (90%): Aspiration of small amount of liquid into the lungs
- "Dry" drowning (10%): Laryngospasm secondary to the presence of liquid in the oropharynx or larynx
- End result: Hypoxia
- No significant difference between freshwater and saltwater submersion
- Pathophysiology:
- Aspiration:
- Small volume of water
- Decreased lung compliance causing ventilation/perfusion mismatch and intrapulmonary shunting
- No significant electrolyte changes
- Grossly contaminated water: Risk for pulmonary infection
- Hypoxemia:
- Metabolic lactic acidosis
- Multisystem organ dysfunction
- Noncardiogenic pulmonary edema
- Myocardial dysfunction (arrhythmias)
- Coagulation abnormalities (disseminated IV coagulation)
- Renal failure (usually acute tubular necrosis)
- Cerebral hypoxia: Cerebral edema, increased intracranial pressure
- Hypothermia:
- More common in young children
- Larger body surface-to-mass ratio
- Decreases the metabolic rate
- Survival with full recovery is possible (neuroprotective)
- Diving reflex:
- Young children are more susceptible
- Triggered by submersion of face in cold water
- Bradycardia ensues: Redistribution of blood flow to the heart and brain
- Delays onset of hypoxia-related damage
Risk factors:
- Lack of proper supervision
- Alcohol or other drug abuse
- Limited swimming ability or exhaustion
- Trauma
- Seizure disorder
- Risky behavior
- Pre-existing medical problem
- Attempted suicide
- Poor education
Diagnosis
Signs and Symptoms
- Cardiopulmonary arrest
- Cyanosis
- Dyspnea
- Copious pulmonary secretions
- Loss of consciousness
- Cerebral edema/injury
- Evidence of trauma:
- Intracranial hemorrhage
- Cervical spine injury rare (<0.5%)
- Hypothermia
Essential Workup
- Information from witnesses or emergency medical services personnel at the scene
- Early airway management and CPR
- Rectal temperature for hypothermia
Diagnosis Tests & Interpretation
Lab
- Arterial blood gas (pH)
- CBC
- Electrolytes, BUN, creatinine, glucose:
- Usually normal (>85%)
- Hypernatremia or hyponatremia
- Alcohol and toxicology screen
Imaging
- CXR:
- Diffuse or focal infiltrates, acute respiratory distress syndrome
- May be normal initially
- ECG:
- Long QT interval
- Sinus bradycardia
- Sinus tachycardia
- Atrial fibrillation
- CT scan:
- Brain: Abnormality at any time during hospitalization is associated with poor neurologic outcome
- Cervical spine: Traumatic injury
Differential Diagnosis
- Consider reason for submersion:
- Dysrhythmia (long QT syndrome, familial polymorphic ventricular tachycardia)
- Myocardial infarction
- Seizure
- Syncope
- Trauma
- Suicide attempt
Consider child abuse/neglect:
- Especially infants in bathtub near drowning
Treatment
Pre-Hospital
- Attention to ABCs:
- Avoid further aspiration
- Secure airway-intubate
- Early CPR
- Cervical spine precautions if injury suspected or concerning mechanism
- Early rewarming attempts
- 90% survival with appropriate intervention
- All drowning victims need ED evaluation
- Abdominal thrust to remove water not recommended:
- Useful only if foreign body in airway
- Increases risk for aspiration
- Delays effective CPR
Initial Stabilization/Therapy
- ABCs
- Core temperature:
- Initiate rewarming (see "Hypothermia")
- Remove wet clothing
Ed Treatment/Procedures
- Correct hypoxemia:
- Titrate to oxygen saturation
- Intubate and provide mechanical ventilation with positive end-expiratory pressure
- Evaluate and treat traumatic injuries
- Correct acidosis
- Cardiopulmonary arrest:
- Initiate advanced cardiac life support measures
- Continue rewarming efforts:
- Passive: Blankets, insulators
- Active external: Warm blankets, radiant heat, warm baths
- Active internal: Pleural or peritoneal lavage, cardiopulmonary bypass
- Continue resuscitation until core temperature >32 °C or until spontaneous pulse and respirations return
- No value to steroids
- Poor prognostic signs:
- Prolonged submersion time
- Severe acidosis (pH â¤7.0)
- Need for CPR
- Low oxygen saturation
- Low Glasgow Coma Score (GCS)
Medication
- Epinephrine: 1 mg (peds: 0.01 mg/kg) IV
- Vasopressin: 40 U (peds: 0.04 U/kg) IV
- Lidocaine: 1 mg/kg IV
- Sodium bicarbonate: 1 mEq/kg IV
- Hypothermia may be protective:
- Aggressive rewarming
- Aggressive resuscitation
- Evaluate for abuse/neglect
- Family history: Sudden death, similar episode:
- Long QT syndrome
- Familial polymorphic ventricular tachycardia
- Prevention is key to treatment:
- Supervision around water
- Empty pails and buckets
Controversial: Therapeutic hypothermia
- Widely accepted in adult population after cardiac arrest with return of spontaneous circulation, still controversial in pediatrics
- Optimize neurologic outcome
- Suppress reperfusion injury
Follow-Up
Disposition
Admission Criteria
- Delayed symptomatology occurs:
- Pulmonary edema (up to 12 hr later)
- Neurologic abnormalities
- ICU:
- Patients who required CPR or artificial ventilation
- Abnormal chest radiograph
- Arterial blood gas abnormalities
- GCS <13
- Admit observation status:
- All symptomatic patients
- Submersion for >1 min
- History of cyanosis or apnea
- Patients who required brief assisted ventilation
Discharge Criteria
- Questionable history of submersion:
- Observe in ED for 8 hr:
- No respiratory distress
- No neurologic impairment
- Discharge to reliable home
- Home-going instructions:
- Return for shortness of breath or mental status changes
Followup Recommendations
Close primary care follow-up for all patients discharged from ED
Pearls and Pitfalls
- All patients with drowning incident require at least 8 hr of observation
- Indicators of poor prognosis:
- Acidemia (pH <7.1 on presentation)
- Age <3 yr
- Submersion >10 min
- Time to basic life support care >10 min
- GCS ⤠5
- Long transportation time to ED
- Persistent apnea or need for cardiopulmonary resuscitation in the ED
- Water temperature >10 °C
Additional Reading
- Burford AE, Ryan LM, Stone BJ, et al. Drowning and near-drowning in children and adolescents: A succinct review for emergency physicians and nurses. Pediatr Emerg Care. 2005;21(9):610-619.
- Layon AJ, Modell JH. Drowning: Update 2009. Anesthesiology. 2009;110(6):1390-1401.
- Szpilman D, Bierens JJ, Handley AJ, et al. Drowning. N Engl J Med. 2012;366(22):2102-2110.
- Wagner C. Pediatric submersion injuries. Air Med J. 2009;28(3):116-119.
- Youn CS, Choi SP, Yim HW, et al. Out-of-hospital cardiac arrest due to drowning: An Utstein Style report of 10 years of experience from St. Marys Hospital. Resuscitation. 2009;80(7):778-783.
See Also (Topic, Algorithm, Electronic Media Element)
Hypothermia
Codes
ICD9
- 507.0 Pneumonitis due to inhalation of food or vomitus
- 991.6 Hypothermia
- 994.1 Drowning and nonfatal submersion
- 799.02 Hypoxemia
ICD10
- J69.0 Pneumonitis due to inhalation of food and vomit
- T68.XXXA Hypothermia, initial encounter
- T75.1XXA Unsp effects of drowning and nonfatal submersion, init
- R09.02 Hypoxemia
SNOMED
- 87970004 Nonfatal submersion (disorder)
- 116277006 Pulmonary aspiration of fluid (finding)
- 241968001 Immersion hypothermia (disorder)
- 389086002 Hypoxia (disorder)