II. Definition

  1. Drowning (WHO Definition)
    1. Respiratory Impairment from submersion or immersion in liquid

III. Epidemiology

  1. Deaths per year
    1. Worldwide: 140,000-300,000
    2. United States: 4,000 to 8,000
  2. Incidence peaks May to August in United States
  3. Most cases in age <14 years old in the United States
  4. Males account for 80% of Drowning deaths

IV. Causes

  1. Home pools (50% of Drowning cases in United States)
    1. Age under 5 years accounts for 90% of cases
  2. Bathtub
    1. Second most common site for preschool Drowning cases
    2. Majority ages 7 to 15 months old
  3. Occupations
    1. Fishing industry (especially Alaska)
  4. Personal Water Craft (e.g. Seadoo)
    1. Relative Risk (compared with other boats): 8.5
    2. References
      1. Branche (1997) JAMA 278(8):663-5 [PubMed]
  5. Alcohol and Illicit Drugs
    1. Involved in over 50% adolescent Drowning cases
  6. Developmental or neurologic Impairment
  7. Epilepsy
  8. Rural Hazards
    1. Ponds
    2. Ditches
    3. Old septic tanks
    4. Water filled buckets
      1. Accounts for 24% of preschool Drowning cases
      2. Toddlers unable to right themselves
  9. Physical Abuse
    1. Accounts for 8% of childhood Drowning cases
    2. References
      1. Gillenwater (1996) Arch Pediatr Adolesc Med 150:298 [PubMed]

V. Mechanism

  1. Aspirated water disrupts alveolar-capillary membrane
    1. Results in Atelectasis, surfactant loss and Ventilation-Perfusion Mismatch (V-Q Mismatch)
    2. Causes severe hemorrhagic pulmonary edema and bronchospasm
    3. Asphyxia leads to Hypoxemia and Metabolic Acidosis
    4. Cardiac rhythm degenerates over minutes from Tachycardia to Bradycardia to PEA to Asystole
  2. Dry Drownings on autopsy (no lung water): 10-20%
  3. Small-moderate amount water aspirated (<22 ml/kg): 85%
  4. Freshwater and Saltwater Drownings are treated the same

VI. Complications

  1. Adult Respiratory Distress Syndrome
  2. Persistent anoxic-ischemic encephalopathy
  3. Aspiration Pneumonia, Lung Abscess, empyema
    1. Especially if water contaminated
  4. Pneumothorax, Barotrauma from high Ventilatory pressure
  5. Traumatic Myoglobinuria or Hemoglobinuria
  6. Renal Failure (Acute Tubular Necrosis)
  7. Coagulopathy (associated with Hypothermia)
  8. Sepsis
  9. Hypothermia
  10. Hyperglycemia (from Catecholamine release)
  11. Seizures

VII. Evaluation: No response to verbal or tactile stimuli (prehospital)

  1. Open airway and check for ventilations
    1. No breathing
      1. Give 5 initial breaths
      2. Check carotid pulse
    2. Breathing
      1. Lung auscultation
  2. Pulse absent
    1. Submersion >1 hour or signs of death (Death)
      1. Survival probability: 0%
      2. Pronounce patient and cease efforts
    2. Submersion <1 hour and no signs of death (Grade 6)
      1. Initiate CPR
      2. Move to Grade 5 or 4 management (if ROSC achieved)
      3. Survival probability: 7-12%
  3. Pulse present (Grade 5)
    1. Rescue Breathing until return of spontaneous ventilation or Mechanical Ventilation
    2. Move to grade 4 management
    3. Admit to medical ICU
    4. Survival probability: 56-69%

VIII. Evaluation: Responds to verbal or tactile stimuli (prehospital)

  1. Abnormal breath sounds
    1. Rales in all pulmonary fields
      1. General management
        1. High Flow Oxygen via face mask
        2. Intubate for GCS 8 or less, respiratory failure or other Advanced Airway indications
        3. Admit to medical ICU
      2. Hypotension or shock (Grade 4)
        1. Risk of delayed respiratory arrest
        2. Fluid Resuscitation with crystalloid and consider Vasopressors
        3. Survival probability: 78-82%
      3. Normal Blood Pressure (Grade 3)
        1. Survival probability: 95-96%
    2. Rales in some pulmonary fields (Grade 2)
      1. Low Flow Oxygen
      2. Transfer to emergency department
      3. Survival probability: 99%
  2. Normal breath sounds (94% of lifeguard rescues)
    1. Cough (Grade 1)
      1. Further evaluation as needed
      2. Survival probability: 100%
    2. No cough (Rescue)
      1. No comorbid conditions and asymptomatic
      2. May be discharge from accident scene

IX. Imaging

  1. Chest XRay
    1. Initial XRay is typically normal (ARDS findings delayed)

X. Management: Initial

  1. Accident site
    1. Do NOT clear airway of aspirated water
      1. Delays ventilation
      2. Use Heimlich/Abdominal thrust ONLY IF obstruction
    2. Cervical Spine precautions
      1. Controversial unless diving or other injury with suspected C-Spine Injury
      2. Cervical Spine injuries occur in <1% of cases
    3. Rescue Breathing and CPR
      1. Ventilation is paramount and should be started while still in water
      2. Start with 5 ventilations and then every 6-8 seconds until on land
      3. Chest Compressions obviously are delayed until on land at which time initiate 2 breaths per CPR cycle
    4. Keep patient horizontal to maximize brain perfusion
  2. Initial ACLS management
    1. ACLS protocol
    2. Respiratory management is paramount
      1. Intubation for apnea or unconscious patient
      2. Non-Invasive Positive Pressure Ventilation for conscious patients
        1. Move to intubation if not improving in first 10-30 minutes
    3. C-Spine precaution indications
      1. Altered Level of Consciousness or intoxicated
      2. Head, face, neck Trauma findings
      3. History consistent with neck injury (e.g. diving or boating accident, fall from height)
    4. Observation for Vomiting and aspiration risk
      1. Occurs in 30-85% of Drowning victims who swallow large water volumes
    5. Intravenous Fluids
      1. Persistent Hypotension is associated with worse outcomes
    6. Hypothermia
      1. Cold water Drownings are protective of neurologic status
        1. Cerebral oxygen consumption drops by 5% per every 1 C below 37 C
        2. Drowning victims are "not dead unless warm and dead"
      2. Mild Hypothermia (Brief immersion in warm water)
        1. Initiate rewarming en route to facility
      3. Severe Hypothermia (T <30C or 86F) - Most cases
        1. Initiate rewarming at medical facility
    7. Empiric antibiotics are not typically indicated
      1. Consider if grossly contaminated water
      2. Gram Stain and culture directed antibiotics are preferred over empiric, prophylactic antibiotics
  3. Medical facility management
    1. Continue ACLS protocol
    2. Reevaluate airway and consider intubation
    3. Glasgow Coma Scale
    4. Nasogastric Tube (decompress swallowed water)
    5. Evaluate C-Spine for suspected injury
    6. Freshwater and Saltwater Drownings are treated the same
    7. Core Rewarming (for severe Hypothermia)
      1. Avoid drugs or stimuli that can trigger Ventricular Fibrillation
      2. Administer warm humidified oxygen endotracheally
      3. Administer warm fluid by central IV
      4. Peritoneal or Chest Tube lavage
      5. Esophageal rewarming tube
      6. Cardiopulmonary bypass or Extracorporeal Membrane Oxygenation (ECMO)

XI. Management: Disposition

  1. Criteria for early discharge from ED after 4-8 hours observation (Grade 1, benign cases only)
    1. Children and young adults AND
    2. No symptoms AND
    3. No preexisting Neurologic or cardiopulmonary disease AND
    4. GCS 14 or 15
  2. Criteria for routine hospital ward observation for 24 hours
    1. Patients with minimal symptoms (mild cough) AND
    2. Normal Oxygen Saturation
  3. Criteria for ICU admission
    1. Above criteria not met
    2. Any signs of respiratory distress

XII. Management: ICU

  1. Monitoring
    1. Continuous O2 Sats and frequent lung auscultation
    2. Urine output
    3. Electrolytes and Glucose
    4. CXR
    5. ABG
  2. Specific Management stratagies
    1. Bronchospasm
      1. Inhaled Beta Agonists
    2. Pulmonary edema from freshwater immersion
      1. Loop Diuretics
    3. Airway protection from aspiration as indicated
      1. Intubation
      2. Nasogastric suction
    4. Hypoxia
      1. CPAP
      2. Mechanical Ventilation indications
        1. pCO2, mental status, work of breathing
    5. Unstable patients require aggressive management
      1. Intubation and Mechanical Ventilation
      2. IV fluids and Pressors (Dopamine) for Hypotension
    6. Metabolic Acidosis
      1. Maximize oxygenation and fluid Resuscitation
      2. Sodium Bicarbonate ONLY for severe acidosis (<7.10)
    7. Hyperglycemia
      1. Pathophysiology
        1. Associated with Catecholamine release
        2. May worsen encephalopathy
      2. Management
        1. Insulin drip to lower Glucose <300 mg/dl
    8. Mental status depression
      1. Induced Therapeutic Hypothermia
        1. Controversial in Drowning due to lack of evidence and underwhelming outcomes
      2. Evaluation
        1. Neuro status usually improves with Resuscitation
        2. If Mental status depression/Seizure continues:
          1. Consider CT Head (r/o Head Injury)
          2. Consider Alcohol and Illicit Drug testing
      3. Management Seizures
        1. Supportive care
        2. Prolonged Seizure
          1. Diazepam or Ativan (0.1 mg/kg)
          2. Consider Dilantin loading

XIII. Prognosis

  1. Predictors of survival and good neurologic outcome
    1. Pulse and detectable Blood Pressure on admit
    2. Young age
    3. Early rescue breaths by life guards or rescuers while patient still in water (often not feasible)
    4. Hypothermia (Core temp <95F or 35C)
      1. Diving reflex to very cold water is protective
        1. Breath holding, Bradycardia, redistribution
      2. Protection depends on rapid onset Hypothermia
      3. Child submerged 66 min in ice cold water survived neurologically intact (case report)
      4. In at least one 2014 study, water Temperature did not impact survival (see Quan reference below)
  2. Predictors of poor prognosis
    1. pH < 7.10
    2. GCS < 5
    3. Pupils fixed and dilated on admit
    4. Persistent acidosis and coma 4 hours after Resuscitation
    5. Submersion for 6 minutes or longer (7.4% with good outcomes compared with 88% if <6 minutes)
      1. Water Temperature did not impact survival
      2. Quan (2014) Resuscitation 85(6):790-4 +PMID: 24607870 [PubMed]
    6. Resuscitation >30 minutes (even in children with cold water drowing)
      1. Kieboom (2015) BMJ 350:h418 [PubMed]
  3. Outcomes
    1. Children requiring PICU admit for near Drowning
      1. 30% mortality
      2. 10-30% severe brain injury (e.g. persistent vegetative state, spastic quadriplegia)
    2. Overall
      1. 92% Near-drowning survivors recover completely

XIV. Prevention

  1. Avoid swimming under influence of Alcohol, Illicit Drug
    1. Alcohol is found in 30-70% of Fatal Drowning victims
    2. Even small amounts of Alcohol increase risk, and risk increases in relationship to amount consumed
  2. Never swim alone
  3. Swim in areas with lifeguards
    1. Rescues by lifeguards require medical attention in only 6% of cases and CPR in 0.5% of cases
  4. Home swimming pool safety
    1. Install drain covers, vacuum release systems and multiple drains to displace pressure
    2. Install rescue equipment around pool (reaching pole, life buoys, working telephone)
    3. Install fence around home swimming pool
      1. At least 5 feet high with vertical openings <4 inches, and <4 inch opening at ground level
      2. Fence completely encloses pool on 4 sides (not attached to house on one side)
      3. Self closing and lockable gate (latching Mechanism at least 58 inches above ground)
      4. Fence should not be climbable (e.g. not chain link)
  5. All family members should learn to swim
  6. Learn Cardiopulmonary Resuscitation (CPR)
  7. Safe proof home for infants and toddlers
    1. Never leave infants unsupervised in bath (do not substitute bath stands for direct supervision)
    2. Avoid leaving standing water in buckets, containers
    3. Do NOT leave water in home plastic wading pools
  8. Water sport participants
    1. Practice standard boating safety
    2. Avoid Alcohol while operating vehicles
    3. Wear personal floatation devices (floatable, air-inflated aids are not a substitute)
  9. Open water precautions
    1. Rip currents (away from beach) should be countered by swimming parallel to current until cleared
    2. Swift currents under rocks or trees can trap swimmers
  10. References
    1. Griffith (1994) Patient Instructions

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Ontology: Drowning (C0013142)

Definition (MEDLINEPLUS)

People drown when they get too much water in their lungs. You can drown in as little as an inch or two of water. Babies can drown in a sink or bathtub. Preschoolers are most likely to drown in a swimming pool. People who have seizure disorders are also at risk in the water. Drowning can happen quickly and silently.

Drowning precautions should include

  • Fences around pools
  • Supervising children near any body of water, including tubs
  • Not swimming or boating when under the influence of alcohol or sedatives
  • Wearing life jackets when boating
  • Learning CPR
Definition (MSH) Death that occurs as a result of anoxia or heart arrest, associated with immersion in liquid.
Concepts Injury or Poisoning (T037)
MSH D004332
ICD10 W74
SnomedCT 157739005, 40947009
LNC LA17057-3
English Drowning, Drownings, DROWNING, Drowning [Disease/Finding], drown, drowned, drowns, drowning, drowning findings, drownings, Drowning NOS, Drowning (disorder), Fatal submersion-immersion, Drowning, NOS, Drowning (finding), Drowning (event)
French NOYADE, Noyade
Portuguese AFOGAMENTO, Afogamento
German ERTRINKEN, Ertrinken
Spanish ahogamiento (evento), ahogamiento (hallazgo), ahogamiento, Ahogamiento
Japanese 溺死, デキシ
Swedish Drunkning
Czech utonutí, Utonutí
Finnish Hukkuminen
Russian UTOPLENIE, УТОПЛЕНИЕ
Italian Incidenti da annegamento, Annegamento
Polish Utonięcie
Hungarian Vízbefúlás
Norwegian Drukningsulykker, Drukning
Dutch verdrinking, Verdrinking

Ontology: Near Drowning (C0027516)

Definition (MSH) Non-fatal immersion or submersion in water. The subject is resuscitable.
Concepts Injury or Poisoning (T037)
MSH D015701
SnomedCT 304457009, 87970004
English Drowning, Near, Drownings, Near, Near Drowning, Near Drownings, Near-Drowning, Near-Drownings, Near Drowning [Disease/Finding], drowning near, near-drowning, near drowning, Non-fatal immersion (disorder), Near drowning, Nonfatal submersion, Non-fatal immersion, Non-fatal submersion, Nonfatal submersion (disorder), Nonfatal submersion, NOS
Swedish Nära-drunkning
Japanese デキスイ, 溺水
Czech utonutí neúplné, tonutí, Krátké tonutí
Finnish Melkein hukkuminen
Russian UTOPLENIE, OBRATIMYI ISKHOD, НЕПОЛНОЕ УТОПЛЕНИЕ, УТОПЛЕНИЕ НЕСОСТОЯВШЕЕСЯ, УТОПЛЕНИЕ БЕЗ ЛЕТАЛЬНОГО ПОСЛЕДСТВИЯ, NEPOLNOE UTOPLENIE, УТОПЛЕНИЕ, НЕЛЕТАЛЬНЫЕ ПОСЛЕДСТВИЯ, УТОПЛЕНИЕ, ОБРАТИМЫЙ ИСХОД, UTOPLENIE, NELETAL'NYE POSLEDSTVIIA, UTOPLENIE BEZ LETAL'NOGO POSLEDSTVIIA, UTOPLENIE NESOSTOIAVSHEESIA, СЛУЧАИ НА ГРАНИ УТОПЛЕНИЯ, SLUCHAI NA GRANI UTOPLENIIA
Italian Incidenti da semiannegamento, Semiannegamento
Polish Podtopienie
Hungarian Majdnem vízbefulladás
Norwegian Nesten-drukning, Nestendrukning
Spanish casi ahogamiento, preahogamiento, sumersión no fatal (trastorno), sumersión no fatal, Cuasi-ahogamiento, Ahogamiento Inminente
Portuguese Quase afogamento, Afogamento Iminente
Dutch bijna gebeurde verdrinking, Bijna-verdrinking
German Fastertrinken, Beinahe-Ertrinken
French Noyade sublétale, Quasi-noyade