Drowning

Jana Stockwell, MD

Statistics
1995 data:
>1000 kids <14 years old drown
60% <4 years old

2000 CDC data:

3,281 unintentional drownings in USA (adults &

kids)
averaging 9 people/day - not including boatingrelated incidents

2003 CDC data:

For every child who drowns, 3 need ED care for

non-fatal submersion injuries
>40% of these children require hospitalization

2002 World Congress on

Drowning
Drowning = process resulting in primary

respiratory impairment from

submersion/immersion in a liquid medium
Regardless of survival
Drowning without aspiration does not occur
Terms which are out
Dry, wet, active, silent, secondary, neardrowning

1989-1998 CDC data

>75%ile of National avg

50-75%ile of National avg
25-50%ile of National avg
<25%ile of National avg

Groups at Risk (2001 data)

Males: 78% of drownings in the United

States
Children: 859 children ages 0-14 years
died from drowning
Drowning rates have slowly declined
2nd-leading cause of injury-related death for kids ages 114 years

African Americans: age-adjusted drowning

(CDC 2003)
rate
for African Americans was 1.4 X higher

Morbidity & Mortality

15% of children admitted for drowning die
in the hospital
As many as 20% of drowning survivors
suffer severe, permanent neurological
disability

Drowning modalities
Infants (age <1) -

bathtubs, buckets &

toilets
Children ages 1-4 years
- swimming pools, hot
tubs & spas
Children ages 5-14
years - swimming pools
& open water sites
(Brenner 2001)

Bucket drownings
~300 children in the US

since 1984
7-15 months of age
24 to 31 inches tall
Bucket may contain water
or nasty cleaning fluid

Tub drownings
Approximately 10% of childhood

drownings
Typically lacking adult supervision
Do tub seats help?

Bathtub seats - ? or ?
Not intended or marketed as safety devices
Bathtub drowning deaths of infants aged 6-10

mo from 1994-1998
40 infant drowning deaths associated with bath
seats
78 deaths not associated with bath seats
~45% of infants in this age group use bath seats
Data suggests seats either have no effect or they
may provide some slight protection against
unintentional bathtub drowning risks
Odds ratio 0.6 [95% CI 0.4-0.9]
Data: US Consumer Product Safety Commission & National Center for Health Statistics for US resident infants
(1994-1998)

Tub seat use

Baby swim classes

Done to teach babies to float
No reported drownings in class
Several reports of hyponatremic

seizures following class (How was school

today?)

False sense of security?

Pool/Spa drownings
Most residential pool drownings are in kids <4 yo
3,000 pool drownings require hospital ED
treatment each year

last seen inside the home

missing from sight <5 minutes
in the care of one or both parents at the time of the
drowning

>50% occur in the child's home pool

1/3 occur at homes of friends, neighbors or family
Since 1980, ~230 kids <4 yrs in spas & hot tubs
(Present 1987, Brenner 2001)

Cochran Review Pool

fencing

Meta analysis of casecontrol studies

evaluating pool fencing
Results:

Pool fencing significantly reduces the risk of drowning

Odds ratio (OR) for the risk of drowning or near drowning in a fenced
pool compared to an unfenced pool is 0.27 (95% CI 0.16 0.47)

Isolation fencing (enclosing pool only) is superior to perimeter

fencing (enclosing property and pool)

OR for the risk of drowning in a pool with isolation fencing compared

to a pool with three sided fencing is 0.17 (95% CI 0.07 0.44).

In-ground swimming pools without

complete 4-sided isolation fencing are 60%

more likely to be involved in drownings
than those with 4-sided isolation fencing

Boat-related drownings
2002 Coast Guard data, all ages:
5,705 boating incidents: 4,062 injured, 750
killed
70% of fatalities due to drowning
30% of fatalities due to trauma, hypothermia,
CO poisoning, or other causes
Alcohol was involved in 39% of fatalities
Open motor boats - 41%
Personal watercraft 28%

Alcohol
Involved in 25-50% of teen and adult

deaths associated with water recreation

(Howland 1995; Howland & Hingson 1988)

Alcohol influences balance, coordination,

and judgment, and its effects are

heightened by sun exposure and heat (Smith
and Kraus 1988)

Relative risk of drowning was 31.8 in

persons with a markedly elevated alcohol

level (>21.7 mmol/L) and 4.6 for levels
<21.6 mmol/L (Cummmings JAMA 281:2198, 1999)

The event, part 1

Voluntary breath-holding
Aspiration of small amounts into
larynx
Involuntary laryngospasm
Swallow large amounts
Laryngospasm abates (due to
hypoxia)
Aspiration into lungs

The event, part 2

Decrease in sats
Decrease in cardiac output
Intense peripheral

vasoconstriction
Hypothermia
Bradycardia
Circulatory arrest, while VF rare
Extravascular fluid shifts,
diuresis

Diving reflex
Bradycardia, apnea, vasoconstriction
Relatively quite weak in humans
better in kids

Occurs when the face is submerged in

very cold water (<20C)

Extent of neurologic protection in humans
due to diving reflex is likely very minimal

Pathogenesis 1
Asphyxia, hypoxemia, hypercarbia, &

metabolic acidosis
Fresh water vs salt water - little difference
(except for drowning in water with very
high mineral content, like the Dead Sea)
Hypoxemia

Occlusion of airways with water & particulate debris

Changes in surfactant activity
Bronchospasm
Right-to-left shunting increased
Physiologic dead space increased

Pathogenesis 2
Cardiac arrhythmias
Hypoxic encephalopathy
Renal insufficiency
Global brain anoxia & potential diffuse
cerebral edema

Findings at autopsy
Wet, heavy lungs
Varying amounts of hemorrhage and edema
Disruption of alveolar walls
~70% of victims had aspirated vomitus,
sand, mud, and aquatic vegetation
Cerebral edema and diffuse neuronal injury
Acute tubular necrosis

Signs & symptoms

75% of kids who develop sxs do so within 7
hours of event
Coma to agitated alertness
Cyanosis, coughing, and the production of
frothy pink sputum
Tachypnea, tachycardia
Low-grade fever
Rales, rhonchi & less often wheezes
Signs of associated trauma to the head
and neck should be sought

Prevalence of concomitant
traumatic injuries
143 drowned & near

drowned kids
Median age 3.8 years (1 mo
18.7 yrs)
30% with pre-existing
disease
CHD, sz, MR/CP, DD

5% with traumatic injuries

All boys
Older, mean age 13.5 years
6 of 7 had C-spine injury from
diving
(H Shofer, Ann Emerg Med 2004)

Labs & tests

Very mild electrolyte

changes
Moderate leukocytosis
Hct and Hgb usually normal
initally
Fresh water aspiration, the Hct
may fall slightly in the first 24
hrs due to hemolysis
Increase in free Hgb without a
change in Hct is common

DIC occasionally
ABG metabolic acidosis &
hypoxemia

EKG

Sinus tachycardia &

nonspecific ST-segment
and T-wave changes
Reverts to normal within
hours
Ominous - ventricular
arrhythmias, complete
heart block

CXR

May be normal initially

despite severe respiratory
disturbances
Patchy infiltrates
Pulmonary edema

Therapy for the lungs

CPAP or PEEP
Aerosolized -agonists for bronchospasm
Bronchoscopy
Prophylactic antibiotics have not been
shown to be beneficial
Steroids:

No controlled human studies to support use

Animal models and retrospective studies in
humans have failed to demonstrate benefit

Surfactant
Beneficial
Porcine surfactant
(Curosurf) 0.5 ml/kg
(40 mg/kg) IT for
ARDS 8h after
freshwater neardrowning in a 12yo
(Acta Anaesthesiol Scand
2004)

Not beneficial
Submerged rabbits
(A Anker, Acad Emerg Med 1995)

Kids
(F Perez-Benavides, Ped Emerg Care
1995)

Brain therapy
ICP monitoring - not indicated, typically irreversible

hypoxic cellular injury

Brain CT not indicated, unless TBI suspected
Mild hyperventilation?
Osmotherapy not indicated
Corticosteroids (dexamethasone) - no proven benefit
Seizures - treat aggressively
Shivering or random, purposeless movements can
increase ICP
Hypothermia and barbiturate coma - highly
controversial & unlikely to benefit the patient (31
comatose kids, J Modell, NEJM 1993)

Bad prognostic indicators

Submerged >10

min
Time till BLS >10
min
CPR >25 min
Initial GCS <5

Age <3 years

CPR in ER
Initial ABG pH <7.1
Initial core temp
<33o

Will the child die?

Neurologic prognosis
Absence of spontaneous respiration is an

ominous sign associated with severe

neurologic sequelae
Permanent neurologic sequelae persist in
~20% of victims who present comatose
Minimal brain dysfunction, spastic
quadriplegia, extrapyramidal syndromes, optic
and cerebral atrophy, and peripheral
neuromuscular damage

Cold vs icy water immersion

Usually hypothermia is an unfavorable
sign
Several case reports of dramatic
neurologic recovery after prolonged
(10-150 min) icy water submersions

Freezing-temperature water (<5C)

Core body temperature less than 28-30C, or
much lower

For hypothermia to be protective, core

body temperature must fall rapidly,
decreasing cellular metabolic rate,
before significant hypoxemia begins

Hypothermia easier in kids

High BSA/mass ratio and subcutaneous
fat insulation
Moderate hypothermia (core 32-35C)
VO2 due to shivering thermogenesis &
increased sympathetic tone
Severe hypothermia (core <32C)
shivering stops & the cellular metabolic
rate (~7%/C)

Hypothermia & brain

protection
Effective in protecting the brain and other

organs from anoxia for 75-110 min in

controlled circumstances where core body
temperature is cooled first to 18C and
then the heart is stopped
Deep hypothermic circulatory arrest (DHCA)

Once cell death from hypoxemia occurs

(~5-6 min), no protective hypothermic
effect or improve recovery

Hypothermia surface
cooling
Surface cooling alone is cannot core temp fast enough
to yield protection

Cooling rate in drowning victims is difficult to estimate as

patient may also be swallowing or breathing in cold water

Cardiac anesthesia literature:

Surface cooling of anesthetized naked infants with ice packs and ice cold
water decreases rectal temperature by ~2.5 C in the first 10 minutes
Another 32 minutes for the temperature to fall to 24-26C
During surface cooling in flowing water at 1C the nasopharyngeal
temperature of a naked infant (4 kg) falls 1C every 5 minutes

Hypothermic protection involving surface cooling only

would seem to require submersion in icy (not cold) water

Does aspiration of icy water

will accelerate the cooling
process?
80-90% of animals & human submersion victims
in warm or cold water drownings aspirate very
little (<2.2 ml/kg)
Theoretically, a very large quantity of icy water
would have to be aspirated or swallowed
Immersion in icy water results in involuntary
reflex hyperventilation and a decreased breath
holding ability to <10 sec, increasing the
likelihood of aspiration and rebreathing of icy
water in some victims

Ice water submersion - dogs

Rapid & violent hyperventilation lasts ~70 sec
Control animals submerged (ice water, head out
of the water) carotid artery temp fell 0.8C in 2
min
Completely submerged dogs temp fell ~8.0C
during the first 2 min in both ice-water (4C)
Rectal temp lagged behind in carotid temp
Victims of ice-water submersions more likely to
have involuntary breathing & aspiration
Brain may be cooled to a protective level
(~<30C) provided the water aspirated was icy
& cardiac output lasts long enough for sufficient
heat exchange to occur

Cold water submersion humans

Few cold water victims have significant brain

protection
Hypothermia is more commonly an unfavorable
prognostic sign
King County, WA (water is cold, but rarely icy)

Hypothermic protection has not been observed

92% of good survivors had initial core temp of >34C
61% of those who died or had severe neurologic injury had
core temp <34C

Finnish study:

Median water temp 16C

Submersion duration <10 minutes had greatest sensitivity
in predicting good outcome, even in kids

Re-warming
Re-warm 1-2oC per hour to range 33-36oC
Mild (32-35o) passive rewarming
Moderate (28-32o)
Shivering fails
J wave
Active internal/external rewarming (not extremities)

Severe (<28o)

Appears dead, pupils dilated/NR

VFib, extreme brady, pulseless
Deep rectal or esophageal temps
Maintain CPR until core temp >32o

Warm water data - site

274 patients
Age 6 months-15 years (mean 32 mos,
median 24 mos)
63% males
Submersion witnessed in 12% cases
Submersion site data (126 patients)

80% backyard pool or spa

11% in a bathtub
5% in a lake or pond
3% in other sites

Warm water data - response

Bystander resuscitation 80% patients

Average EMS respose time - 6.8 minutes
Upon EMS arrival
76 (28%) children were in cardiac arrest
13 (5%) with PEA

Paramedic CPR - 87/89 children

18 (20% of those w/ CPR) no longer needed CPR in
ED
Paramedics intubated 19 children

Epinephrine in 30 patients

Warm water outcomes

Cardiac

71 (80% of those in arrest @ scene) arrived to ED

in cardiac arrest
13 PEA
5 deteriorated & required CPR
All 89 received Epi - (average duration 8.9
minutes, range 2 to 105 minutes)
41 (46% of codes) survived (8 intact, 33 vegetative)
Longest CPR duration in an intact survivor was 47
minutes

Respiratory

125 (46%) patients were intubated

7 were apneic, 26 were breathing but comatose

Warm water outcomes

CNS
Persistent deficits in 15 of the 185 functionally intact
survivors
Initial ED GCS 3 in 100 kids
14 survived intact
165 patients having GCS 4 upon arrival in the ED
2 survived in PVS
all others survived intact

51 patients who subsequently died

Withdrawal 22
Brain death 23
All intact survivors demonstrated functional recovery within 48
hours

Warm water survival in kids

6 studies reported functional recovery 17% (overall

average) of victims who required CPR in the ED

Withholding or withdrawal of therapy from kids who have
low probability of functional survival after warm water
submersion injury has been suggested

Failure to respond to advanced life support within 25 minutes

Lack of purposeful movements or normal brain stem function @ 24
hrs
Anecdotal experience with spectacular recoveries & the small
numbers of severely injured patients in most studies raises
uncertainty about their predictive accuracy

Graf et al. suggested that outcome for pediatric

submersion victims can be predicted with 4 measures:

coma, absence of pupillary light reflex, admission blood
glucose concentration (high) and sex

Recommendations
Pre-hospital resuscitation, including early

intubation, ventilation, vascular access, and

administration of advanced life support
medications
Continued resuscitation and stabilization in the
ED
Full supportive care in the ICU for a minimum
of 48 hrs
Consider withdrawal of support if no neurologic
improvement is detected after 48 hours
Ancillary testing such as brainstem evoked
responses, EEG, and MRI (not CT) may prove helpful
to corroborate the neurologic examination
Pediatrics, 1997 Christenson, Jansen, Perkins

You cant make this stuff up

67 year old with pulmonary fibrosis
S/P lung resection
On ward, with O2
POD#2 developed distress, to ICU,
intubated, ARDS
Finally extubates
(CHEST 2001; 120:1021-1022)

Part deaux a better history

Day after extubation, RN noticed patient's friend

attempting to submerge the patient's face in a

water-filled basin
On questioning, patient indicated that he was
aspirating water to clean sinuses and lungs,
explaining that this was a daily routine for cleaning
airways in his family
He noted that on POD 1, while performing this ritual,
he had a severe coughing and choking spell while
his face was submerged
This "technique" was witnessed by the housestaff,
but not reported until directly questioned