Background

Submersion injuries are a significant cause of death and disability in children, second only to unintentional trauma. At least one third of survivors sustain moderate to severe neurologic sequelae. Although no uniform classification for submersion injuries is noted, drowning is usually defined as death from asphyxia within 24 hours of submersion in water. Near drowning refers to survival (even if temporary) beyond 24 hours after a submersion episode. Submersion injuries may be further classified as cold-water or warm-water injuries. Warm-water drowning occurs at water temperatures of 20C or higher, and cold-water drowning occurs at water temperatures of less than 20C. Some references include very-cold-water drowning, which refers to submersion in water at temperatures of 5C or less. Additional classification may include the type of water in which the submersion occurred, such as freshwater and salt-water submersion injury. However, the distinction between freshwater and salt-water submersion injury is primarily academic because initial treatment is not affected by water type.

Pathophysiology
Submersion injury occurs when a person is submerged in water, attempts to breathe, and either aspirates water (wet drowning) or has laryngospasm without aspiration (dry drowning). Although most patients with submersion injury have aspirated a small amount of water or gastric contents into their lungs, approximately 10-15% of patients have become asphyxiated without evidence of aspiration. The most important contributory factors to morbidity and mortality from near drowning are hypoxemia and a decrease in oxygen delivery to vital tissues. The pathophysiology of near drowning is intimately related to the multiorgan effects of hypoxemia. CNS damage may occur because of hypoxemia sustained during the drowning episode (primary injury) or may result from ongoing pulmonary injury, reperfusion injury, or multiorgan dysfunction (secondary injury), particularly with prolonged tissue hypoxia. Although differences observed between freshwater and salt-water aspirations in electrolyte and fluid imbalances are frequently discussed, they are rarely of any clinical significance for people who have experienced near drowning. Most patients have fluid aspiration of less than 4 mL/kg. Fluid aspiration of at least 11 mL/kg is required for alterations in blood volume to occur, and aspiration of more than 22 mL/kg is required before significant electrolyte changes develop. Ingestion, rather than aspiration, is more likely to cause clinically significant electrolyte imbalances, including hyponatremia from ingestion of large volumes of fresh water (especially in children).
CNS effects

CNS injury remains the major determinant of subsequent survival and long-term morbidity in cases of near drowning. Primary CNS injury is initially associated with tissue hypoxia and ischemia. If the period of hypoxia and ischemia is brief or if the person is a very young child

who rapidly develops core hypothermia, primary injury may be limited, and the patient may recover with minimal neurologic sequelae. However, submersion injuries that are associated with prolonged hypoxia or ischemia are likely to lead to both significant primary injury and secondary injury from reperfusion, sustained acidosis, cerebral edema, hyperglycemia, release of excitatory neurotransmitters, seizures, hypotension, and impaired cerebral autoregulation, especially in older patients who cannot rapidly achieve core hypothermia. Although cerebral edema is a common consequence of prolonged submersion (or submersion followed by prolonged circulatory insufficiency), retrospective reviews and animal studies have not demonstrated any benefit from the use of intracranial pressure monitoring with diffuse axonal injury. However, as submersion injuries may be associated with trauma (especially to the head, neck, and trunk), focal or persistent neurologic deficit may indicate mass lesions or other injury amenable to surgical intervention. Autonomic instability (diencephalic/hypothalamic storm) is common following severe traumatic, hypoxic, or ischemic brain injury, often presenting with signs and symptoms of hyperstimulation of the sympathetic nervous system (including tachycardia, hypertension, tachypnea, diaphoresis, agitation, muscle rigidity). CNS infection, an uncommon but serious complication of near drowning, may result from unusual soil and waterborne bacteria and fungi, including Pseudallescheria boydii and Scedosporium apiospermum. These infections are usually insidious in onset, typically occurring more than 30 days after the initial submersion injury.
Pulmonary effects

Fluid aspiration of as little as 1-3 mL/kg can result in significantly impaired gas exchange, primarily secondary to altered surfactant function. Freshwater is considerably hypotonic relative to plasma and causes disruption of alveolar surfactant. Salt water, which is hyperosmolar, increases the osmotic gradient and therefore draws fluid into the alveoli, diluting surfactant (surfactant washout). Altered surfactant volume, function, or both result in atelectasis and pronounced injury to the alveoli-capillary unit, resulting in lower functional residual capacity and pulmonary edema. Acute respiratory distress syndrome (ARDS) from altered surfactant function and neurogenic pulmonary edema is a common complication in survivors of submersion injury. Increased airway resistance secondary to plugging of the patient's airway with debris, as well as release of inflammatory mediators that result in vasoconstriction, may impair gas exchange. Ventilator-associated lung injury (VALI) can further compromise noncompliant, edematous lung tissue. Newer modes of ventilation, including high-frequency oscillatory ventilation and airway pressure release ventilation, or an open-lung approach that limits tidal volumes to 6-8 cc/kg while using positive end-expiratory pressure (PEEP) to support optimal respiratory compliance, can help support oxygenation and ventilation with less risk of VALI than is associated with older methods of ventilation.

Pneumonia is a rare consequence of submersion injury and is more common with submersion in stagnant, warm, and fresh water. As with CNS infections, uncommon pathogens, including Aeromonas, Burkholderia, and Pseudallescheria, cause a disproportionate percentage of cases of pneumonia. Because pneumonia is uncommon early in the course of treatment of submersion injuries, the use of prophylactic antimicrobial therapy has not proven to be of any benefit.
Cardiovascular effects

Hypovolemia is primarily due to fluid losses from increased capillary permeability. Profound hypotension may occur during and after the initial resuscitation period, especially when rewarming is accompanied by vasodilatation. Myocardial dysfunction may result from ventricular dysrhythmias, pulseless electrical activity (PEA), and asystole due to hypoxemia, hypothermia, acidosis, or electrolyte abnormalities (less common). In addition, hypoxemia may directly damage the myocardium, decreasing cardiac output. Pulmonary hypertension may result from the release of pulmonary inflammatory mediators, increasing right ventricular afterload and thus decreasing both pulmonary perfusion and left ventricular preload. However, although cardiovascular effects may be severe, they are usually transient, unlike severe CNS injury.
Other effects

The clinical course may be complicated by multiorgan system failure resulting from prolonged hypoxia, acidosis, rhabdomyolysis, acute tubular necrosis, or infection or from the treatment modalities. Disseminated intravascular coagulation (DIC), hepatic and renal insufficiency, metabolic acidosis, and GI injuries must be considered and appropriately managed.

Epidemiology
Frequency United States

According to data from the 1997 National Center for Health Statistics, drowning is the second leading cause of injury-related deaths in children aged 1-14 years.[1] In California, Arizona, and Florida, it is the number one cause of injury-related death. The US Consumer Product Safety Commission reports that a swimming pool is 14 times more likely than a motor vehicle to be involved in the death of a child younger than 5 years. The overall drowning and submersion injury death rate was 1.93 per 100,000 people for all age groups in 1995. Peak incidence of 3.22 per 100,000 injury deaths occurred in children younger than 4 years.
Mortality/Morbidity

More than 1500 children die in the United States each year from submersion injuries. For every drowning death in this country, an estimated 4 additional hospitalizations and 14 emergency department (ED) visits are due to submersion injuries. Approximately 1 in 8 males and 1 in 23 females experience some form of water-associated event but never seek medical attention.

Boating and related water sports, combined with alcohol consumption, increase both the likelihood and severity of submersion injuries. Risk-taking behaviors, especially in males, are similarly associated with increased morbidity and mortality. As early resuscitation is associated with improved outcomes, many studies have attempted to determine clinical, laboratory, or other variables to identify which patients would benefit from resuscitative efforts. Although no individual characteristics have been found to predict survivability, the Orlowski score has been found to identify the likelihood of neurologically intact survival. In using the Orlowski score, 1 point is given for each item; scores of 2 or less are associated with a 90% likelihood of complete recovery, and submersion-injury patients with scores of 3 or more have only a 5% chance of survival. The items in the Orlowski score are as follows:
1. 2. 3. 4. 5. Age 3 years or older Submersion time of more than 5 minutes No resuscitative efforts for more than 10 minutes after rescue Comatose on admission to the emergency department Arterial pH of less than 7.10

Anecdotal reports of survival are noted in children with moderate hypothermic submersion (core temperature < 32C), but most persons experiencing cold-water submersion do not develop hypothermia rapidly enough to decrease cerebral metabolism before severe, irreversible hypoxia and ischemia occur.
Sex

Males are approximately 4 times more likely than females to have submersion injuries. This rate is consistent with increased risk-taking behavior in boys, especially in adolescence. Males are also 12 times more likely than females to be involved in a boat-related drowning; alcohol use is frequently a contributing factor.
Age

A bimodal age distribution is noted in persons with a submersion injury. Children younger than 4 years and adolescents aged 15-19 years are at highest risk. This bimodal distribution is predominantly observed in males, who have a much higher incidence of submersion injuries during adolescence than females do. Most toddlers drown in swimming pools and bathtubs, whereas most adolescents drown in natural bodies of water.

History
All aspects leading to the near-drowning episode should be determined. Rarely does a patient present with the classic "Hollywood scenario" of a novice swimmer stranded in water, frantically struggling and flapping his or her arms in desperation. Experienced snorkelers, for example, may

experience syncope secondary to hypoxia after hyperventilating to drive off carbon dioxide, and deep-water divers may succumb to "shallow-water blackout" as they ascend. Most persons are found after having been submerged in water for an unobserved period. Witnessed events may include experienced swimmers not resurfacing after a dive. Relevant factors include submersion time, associated trauma, drug or alcohol ingestion, type of water, amount of water contamination, water temperature, and attempted rescue maneuvers. Medical history must be obtained to look for a secondary cause or causes of drowning, including one or more of the following:

Trauma (unintentional and intentional) Seizures Cardiac disease, dysrhythmias, and syncope Exhaustion and hypothermia Hypoglycemia Alcohol and drug use

Physical
The clinical presentations of people who experience submersion injuries widely vary.

Asymptomatic, especially if brief, witnessed submersions with immediate resuscitation Symptomatic o Cough o Dyspnea o Wheezing o Hypothermia o Bradycardia or tachycardia o Vomiting, diarrhea, or both o Anxiety o Altered mental status Cardiopulmonary arrest o Cardiac arrhythmias (ventricular tachycardia, ventricular fibrillation, bradycardia) o Apnea Death

Causes
Drowning and near-drowning events must be thought of as primary or secondary events. Secondary causes of drowning include seizures, head or spine trauma, cardiac arrhythmias, hypothermia, alcohol and drug ingestion, syncope, apnea, hyperventilation, suicide, and hypoglycemia. Causes grouped by age of persons follows:

In infants younger than 1 year

Bathtubs and buckets of water are the most common means of drowning. Child abuse should be considered in all such cases. In children aged 1-5 years: Residential swimming pools are the most common venue. In young adults aged 15-19 years o Submersion injuries occur in ponds, lakes, rivers, oceans, and other natural bodies of water. o Injuries are frequently associated with boating, alcohol, or both.
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Differential diagnosis Child Abuse & Neglect: Physical Abuse Child Abuse & Neglect: Sexual Abuse Munchausen Syndrome by Proxy

Laboratory Studies
The following studies are indicated in near drowning:

Blood gas analysis with co-oximetry to detect methemoglobinemia and carboxyhemoglobinemia CBC count, prothrombin time with international normalized ratio (INR), partial thromboplastin time, fibrinogen, D-dimer, fibrin split products Serum electrolytes (with glucose) Liver enzymes, especially aspartate aminotransferase and alanine aminotransferase Renal function tests (BUN, creatinine) Drug screen and ethanol level (consider) Continuous pulse oximetry and cardiorespiratory monitoring (may be needed) Cardiac troponin I testing (may be useful as a marker to predict children who have an elevated risk of not surviving to hospital discharge)

Consider electrocardiography if the patient has arrhythmias. Monitor the patient if rewarming is necessary, because dysrhythmias are common when rewarming patients who suffer cold-water immersion injuries. Swan-Ganz catheter for monitoring cardiac output and related hemodynamic parameters may be useful in patients with unstable cardiovascular status or in those who require multiple inotropic and vasoactive medication requirements.

Procedures

Endotracheal intubation with mechanical ventilation for respiratory failure, persistent hypotension, or impaired airway protective reflexes. Nasogastric tube placement for removal of swallowed water and debris (Use orogastric route if head or facial trauma is suggested.) Urinary catheter placement for assessment of urine output Central venous catheter placement for use in measurement of central venous pressure, infusions, and blood sampling Arterial catheter for arterial blood pressure and blood gas analysis Extracorporeal membrane oxygenation (ECMO) - May be considered in the following circumstances: o Respiratory compromise resulting from lack of response to conventional mechanical ventilation or high-frequency ventilation o A reasonable probability of the patient recovering neurologic function o Persistent hypothermia from cold-water drowning Bronchoscopy if needed for removal of foreign bodies, such as aspirated debris or vomitus Intracranial pressure monitoring in patients with traumatic brain injury or mass lesions (eg, hematomas)

Medical Care

Prehospital care in patients who experienced near drowning o Success or failure of initial basic life support provided at the scene of the event is the most important determinant of outcome. o As in any rescue initiative, initial treatment should be geared toward ensuring adequacy of the airway, breathing, and circulation, with attention given to cervical spine stabilization if the scenario suggests spinal trauma or if the event is unwitnessed. o The patient should be removed from water as soon as possible. o Initiate rescue breathing immediately, even while the patient is still in the water, if necessary and feasible. o Chest compressions are not effective in the water and waste valuable time. o The Heimlich maneuver has not been shown to be effective in removing aspirated water. o Debris visible in the oropharynx should be removed with a finger-sweep maneuver. o Higher pressures may be required for ventilation because of the poor compliance resulting from pulmonary edema. o Supplemental oxygen, 100%, should be administered as soon as available. The degree of hypoxemia may be difficult to determine on clinical observation. ED care o Associated injuries must be considered, as in any other form of injury. Consider potential spinal injuries, especially if diving is part of the history. o The need for hospitalization is determined on clinical evaluation.

Noninvasive continuous pulse oximetry is valuable. Patients with completely normal findings on examination and trivial history may be discharged after a 6-hour observation period. o Admit any patient with respiratory symptoms, altered oxygenation by pulse oximetry or blood gas analysis, or altered mental status or any patient in whom child abuse is suggested. o The most critical role in management is prompt correction of hypoxemia and acidosis. o Ventricular dysrhythmias (typically, ventricular tachycardia or ventricular fibrillation), bradycardia, and asystole may occur as a result of acidosis and hypoxemia rather than electrolyte imbalance. o Consider intubation and mechanical ventilation in any patient with poor respiratory effort, altered sensorium, severe hypoxemia, severe acidosis, or significant respiratory distress. o Intravascular volume depletion is common, secondary to pulmonary edema and intracompartmental fluid shifts, regardless of the type of fluid aspirated. o Rapid volume expansion may be indicated using isotonic crystalloid (20 mL/kg) or colloid. o Inotropic support may be required using dopamine and/or dobutamine. o Most acidosis is restored after correction of volume depletion and oxygenation. o Hypothermia may also be present and exacerbate bradycardia, acidosis, and hypoxemia. o Ascertaining whether the drowning occurred in warm or cold water is essential. This depends on the temperature of the water, not of the patient. Guidelines for treating cold-water drowning o Patients with severe hypothermia may appear dead because of profound bradycardia and vasoconstriction. o Resuscitation should continue while aggressive attempts are made to restore normal body temperature. Guidelines for treating warm-water drowning: Patients arriving at the emergency department in cardiopulmonary arrest after a warm-water submersion have a dismal prognosis. The benefits of resuscitative efforts should be continuously reassessed in such situations. The Conn classification system: For other patients, the Conn classification system may be used as a guideline to quantify the extent of cerebral hypoxia. o Category A - Alert o Category B - Blunted consciousness; admit and observe for pulmonary compromise, which may result in hypoxemia and worsen CNS injury o Category C - Comatose (C1 - decorticate, C2 - decerebrate, and C3 - flaccid [worse prognosis than C1])
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Consultations

Consider neurology consultation for seizures or persistent neurologic deficit. Consider neurosurgery consultation if associated head or spine trauma, hematoma, aneurysm, or CNS abscess is present. Consider cardiology consultation for dysrhythmias or myocardial dysfunction. Physical therapy, occupational therapy, rehabilitation therapy consultation is needed to help prevent disuse injury and provide early rehabilitation. Consider pulmonology consultation for severe or persistent respiratory compromise. Consider infectious disease consultation for pneumonia or CNS infection.

Medication Summary

Corticosteroids have been shown to be of no benefit in the management of submersion injuries. Routine antibiotic prophylaxis is not indicated unless the patient was submerged in grossly contaminated water or sewage.