Drowning and (Near)

Drowning

Matthew M. Eschelbach, DO, FACEP

Medical Director, Emergency Department
St Charles Medical Center, Redmond OR
Drowning Deaths in Oregon
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 boating-
related 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, near-drowning
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 1-14
years
• African Americans: age-adjusted drowning rate
for African Americans was 1.4 X higher
(CDC 2003)
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)
Baby swim classes

• Done to “teach” babies to float

• No reported drownings in class
• Several reports of hyponatremic seizures
following class
• 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 case–control 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
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 (<20°C)
• 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
Signs & symptoms
• 75% of kids who develop symptoms 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
Pre-Hospital Treatment
• Rapid and cautious retrieval from the
water Safety first (hypothermic)
• Immediately establish the airway with
C-spine precautions
• Breathing:
– Mouth-Mouth
– Bag-valve-mask
– Intubation
• Supplemental oxygen on all patients
Pre-Hospital Treatment
• Abdominal thrust:
– Remains controversial
– No change vs. gravitational drainage vs. no
treatment at all
– Delays ventilation and transport
– Can lead to regurgitation and pulmonary
aspiration
• CPR
• Transport ASAP
Pre-hospital Treatment
• Any patient with a significant episode,
including those asymptomatic at the
scene, should be transported to the
hospital for evaluation
• In-water CPR is generally ineffective
and dangerous
• Human near-drowning victims aspirate
small quantities of water; Postural
drainage or the abdominal thrust
(Heimlich maneuver) is of unproven
efficacy
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)

Therapy for the lungs

• CPAP or PEEP
• Aerosolized β-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
Bad prognostic indicators
• Submerged >10 min • Age <3 years
• Time till BLS >10 min • CPR in ER
• CPR >25 min • Initial ABG pH <7.1
• Initial GCS <5 • 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 (<5°C)
– Core body temperature less than 28-30°C, 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 32-35°C) VO2
due to shivering thermogenesis & increased
sympathetic tone
• Severe hypothermia (core <32°C) 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 18°C 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

• Hypothermic protection involving surface cooling only

would seem to require submersion in icy (not cold) water
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 >34°C
– 61% of those who died or had severe neurologic injury
had core temp <34°C
• Finnish study:
– Median water temp 16°C
– 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
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 Pediatrics,
examination1997 Christenson, Jansen, Perkins
The Ice Family
• Sunriver, OR - Fire R escue called to
the scene of a cold w ater im m ersion.
Apparently, the fam ily dog ran 30
feet from shore onto the ice behind
the Sunriver Resort’s Nature Center.
The dog fell through the ice and
could not get out.
• The Husband w alked out onto the ice
to rescue the dog. He too fell through
the ice. And could not get out.
• After seeing her husband and dog
unable to get out of the ice, the w ife
of the first victim w ent out onto the
ice in an attem pt to rescue both her
husband and dog. She left her
handicapped daughter and her w heel
chair on the shore. She also fell
through the ice in the sam e location.
• The daughter, in the w heel chair,
scream ed loud enough to alert a near
by visitor w ho called 911 .
The Ice Family
• Sunriver Fire The Ice
arrived on scene to
find 3 patients Family
im m erged 30 feet
from shore. The
crew used throw
bags to reach the
w ife and pull her to
shore, the husband
w as also reached in
this m anner and he
held onto the dog
as both w ere
pulled to safety.
• Both Husband and
W ife w ere
transported to St
The Ice Family
Charles M edical
Center
• Husband Core
Tem perature 89.4
F
• W ife Core
Tem perature
• 91.4
• Dog Unknow n
The Ice Family
• CLUES:
• Average Dog w eighs 60 pounds,
• Average husband w eight 190 pounds.
• I f the surface of the ice can not
tolerate the w eight of a dog or
husband w hat is the likelihood that
the ice w ill be able to tolerate the
w eight of an average fem ale (135
pounds)?