3. Definition
2002 World congress on drowning defined drowning
as
“a process resulting in primary respiratory
impairment from submersion in a liquid medium”
Near drowning refers to survival (even if temporary)
beyond 24 hours after a submersion episode.
Shepard, Suzanne et al. Drowning. Emedicine.medscape.com/article/772753-overview. Updated 6/9/2009 .
4. Fatal Drowning Statistics
In 2005, 3,582 fatal unintentional drownings in U.S.
1 in 4 drownings were children < 14 years old
Drowning is the second-leading cause of unintentional
injury-related death for children ages 1 to 14 years
India has a drowning mortality rate of 8.5/100000
population.
Water Injuries-Fact Sheet. www .cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet Accessed
25 Sept 2009.
5. Location of Drowning
Brenner et al. looked at death certificates from
victims of unintentional drownings in 1995
Infant drownings: 55% in bathtubs
Age 1-4 years, 56% in artificial pools and 26% in other
bodies of freshwater
Children 63% of drownings were in natural bodies of
freshwater
Brenner RA, Trumble AC, Smith GS, Kessler EP, Overpeck MD. Where children drown,
United States, 1995. Pediatrics 2001;108(1):85 ﾐ
6. Features which differentiate between accidental, non-accidental, and homicidal
submersion injuries to children
Accidental submersion:
Typically a baby momentarily left alone or with a sibling in the bath
Majority of children 8-15 months of age
Child the youngest in the family
No features suggesting child abuse
Epilepsy related:
Child with history of epilepsy
Bathing alone
A child older than 24 months
Non-accidental submersion:
Atypical submersion description, with inconsistent details
Late referral to hospital
Associated history of child abuse
Child outside 8-24 month age span
Child left with unsuitable carer
Homicidal drowning:
Maternal history of mental illness
Child outside the 8-24 month age range
Previous history of child abuse
Kemp, Alison et al. Accidents and child abuse in bathtub submersions. Archives of Disease in Childhood 1994; 70: 435-438.
7. 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
8. “Hypoxic March of Drowning”
A pathophysiology summary
1. Involuntary submersion
Voluntary apnea, tachycardia, hypoxia, hypercarbia
1. Involuntary inspiration
Triggered by hypercarbia and hypoxia
arterial hypoxemia, tissue hypoxia, tissue acidosis, and
tachycardia
1. Water enters lungs
Increased peripheral airway resistance, pulmonary
vessel vasoconstriction/hypertension with shunting of
blood, decreased lung compliance, decreased
surfactant
Pearn, John. The management of near drowning. BMJ 1995. (291) 1447-1452
9. “Hypoxic March of Drowning”
continued
4. Decompensation
-gasping with further inhalation
-swallowing with emesis
-loss of consciousness
4. Neuronal dysfunction
-blood brain barrier breaks down
4. Cardiac dysfunction
-bradycardia, arrhythmias, asystole
7. Brain Death
8. Somatic Death
10. Diving Reflex
Infants and young children
Sudden contact with water less than 20 degrees
Celsius
Causes:
Bradycardia
vasoconstriction of nonessential vascular beds
shunting of blood to the coronary and cerebral
circulation
Shepard, Suzanne et al. Drowning. Emedicine.medscape.com/article/772753-overview. Updated 6/9/2009 .
11. Dry Drowning
10-20% of patients experience a laryngospasm
that prevents aspiration of fluid into the lungs
Tight spasm often persists until cardiac arrest
Lungs remain dry
Large volumes of fluid ingested into stomach
Major cause for electrolyte abnormalities in
children (hyponatremia from fresh water,
hypernatremia from salt water)
12. Wet Drowning
1-3 mL/kg water aspirated hinders gas exchange
When fluid is in the lungs, vagus nerve stimulates
vasoconstriction pulmonary vessels and
pulmonary hypertension
Freshwater diffuses rapidly across alveolar-
capillary membrane and saltwater damages the
membrane
Surfactant is denatured by freshwater and washed
away by salt water
In both salt water and freshwater aspiration,
compliance is decreased
14. Mechanism of Hypoxic-Ischemic Encephalopathy
Excitatory amino acids, glutamate and aspartate, are
released in response to hypoxia/ischemia
Activation receptors, NMDA, AMPA, Kainate
Ion channels open
Influx of calcium into cells
Cell death
Lipid peroxidation of cell membranes
Destruction of Na+/K+ ATPase
Cerebral edema, neuron death
Increased rate of apoptosis
Related to influx of calcium into cell and nucleus
18. Differentials
Child Abuse & Neglect: Physical Abuse
Child Abuse & Neglect: Sexual Abuse
Munchausen Syndrome by Proxy
19. WORKUP-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
20. Serum electrolytes (with glucose)
Liver enzymes, especially aspartate aminotransferase
and alanine aminotransferase
Renal function tests (BUN, creatinine)
21. 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)
22. Imaging Studies
Chest radiography
Head CT and cervical spine imaging if trauma
suspected
Extremity, abdominal, pelvic imaging if clinically
indicated
Echocardiography if myocardial dysfunction present
23. Other Tests
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.
24. 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.
25. Labs & testschanges
Very mild electrolyte
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
26. 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
27. Management: necessary
Bystander resuscitation CPR
30% pediatric cardiac arrest patients receive bystander
CPR
PUSH HARD, PUSH FAST
Minimize interruptions
Some bystander CPR, better than none
Heimlich maneuver contraindicated because it can
cause emesis, aspiration
Rescue breaths at rates > 20 breaths/min
contraindicated because venous return can be
obstructed
28. Arrival to the hospital
• General Assessment:
• Appearance
• Work of Breathing
• Circulation
• Primary Assessment:
• Airway
• Breathing
• Circulation
• Disability
• Exposure
Pediatric Advanced Life Support Provider Manual
29. Management
ET intubation:
Cannot maintain PaO2 > 80 mm Hg on 100% O2 by face
mask
Inability to protect airway or handle secretions
Respiratory failure - PaCO2 >45 mm Hg
Worsening ABG results
Peep:
shifts interstitial pulmonary water into the capillaries
increases lung volume by preventing of alveolar collapse
provides better alveolar ventilation and decreases
capillary blood flow
30. Management
ECMO
If despite intubation, cannot oxygenate
Broncoscopy
Removal of vomit, debris in lungs
Albuterol
For bronchospasm
Aspiration Pneumonia
Clindamycin for bacterial pneumonia is drug of choice
Manage electrolyte abnormalities
hypoglycemia
31. Management of Hypothermia
Two types:
1. Rapid immersion in cold water, rapid onset of
hypothermia, core temperature < 86 degrees F
Neuroprotective, preferential shunting of blood to heart, brain
2. Gradual onset of hypothermia
Rapidly re-warm patients with gradual onset of
hypothermia
patients at risk for ventricular fibrillation and neuronal
injury
32. Guidelines for treating cold-water
drowning
Patients with severe hypothermia may appear dead
because of profound bradycardia and
vasoconstriction.
Resuscitation should continue while aggressive
attempts are made to restore normal body
temperature.
33. Management
Do not stop resuscitation of a patient until their core
temperature is at least 30 degrees Celsius!
34. 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
35. Connpatients, the Conn classification system may be
For other
classification system:
used as a guideline to quantify the extent of cerebral
hypoxia.
Category A – Alert
Category B - Blunted consciousness; admit and observe for
pulmonary compromise, which may result in hypoxemia
and worsen CNS injury
Category C - Comatose (C1 - decorticate, C2 - decerebrate,
and C3 - flaccid [worse prognosis than C1])
36. Prognosis
Related to duration of submersion
Time greater than 25 min, prognosis is poor
Indicators of poor outcome:
Fixed, dilated pupils
Low GCS
coma
Survivors of resuscitation have good neurological
outcomes if they show purposeful movement
within 24 hours
37. Prevention
Designate a responsible adult to supervise
water related activities
Adults should not be doing other tasks at the same
time as supervision, no alcohol while supervising
Swim with a buddy
No alcohol before, during swimming
Learn to swim
AAP does not recommend swimming lessons as a
primary prevention method for children under 4
years old
Learn CPR
Water Injuries-Fact Sheet. www .cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet Accessed 25
Sept 2009
38. Prevention
Fence swimming pools on 4 sides, at least 4 feet
tall
Do not use air or foam filled water toys in place of
life-jackets
