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Drowning

Submersion Immersion Fatal

Drowning is technically defined as the physical filling of the lungs with massive amounts of liquid like water. Statistics have shown that it is possible for people to drown in as little as 2 inches of water. Infants may drown in a bathtub while pre-school children are likely to drown in a swimming pool.


Presentation

Drowning victims may conveniently be classified under one of the four classifications, these are: the asymptomatic victims, the symptomatic victims, victims in arrest, and dead victims. Asymptomatic victims does not exhibit any signs and symptoms when brought to the emergency room. They are the class that underwent a very brief immersion episode or those who are immediately resuscitated at the site of the accident.

The symptomatic subgroup will present clinically with anxiety, altered vital signs, altered state of consciousness [7], dyspnea, coughing with wheezing, and vomiting. Victims in cardiopulmonary arrest will present with apnea, asystole, fibrillation, and immersion syndrome. However, victims who are obviously dead are usually wheeled in the emergency room with long standing apnea, asystole with nomothermia, dependent lividity, rigor mortis, and no central nervous system reflexes.

Hypothermia
  • Victims of drowning may develop primary or secondary hypothermia.[web.archive.org]
  • On arrival to our ED, hypothermia and hypoxemia overcame him. Endotracheal intubation and warm intravenous fluid were applied at once owing to drowsy consciousness, respiratory distress, and hypothermia.[ncbi.nlm.nih.gov]
  • Despite the protective effects of hypothermia and gradual improvement of symptoms over time, some of the deficits were permanent.[ncbi.nlm.nih.gov]
  • INTERVENTIONS: Therapeutic hypothermia versus therapeutic normothermia. MEASUREMENTS AND MAIN RESULTS: An exploratory study of pediatric drowning from the Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital trial was conducted.[ncbi.nlm.nih.gov]
Cough
  • More significant symptoms would be persistent cough, foam at the mouth or nose, confusion, or abnormal behavior, all of which warrant attention.[journals.lww.com]
  • […] autism and attention deficit disorder, was wearing flotation devices on his arms and was being monitored by his mother during his time in the pool, he did inhale some water while swimming; his mother described him as “taking a little bit of water in and coughing[snopes.com]
  • They include coughing, chest pain, difficulty breathing and feeling extremely tired. Children might also have a change in personality,and energy levels due to the brain not getting enough oxygen.[thesun.co.uk]
  • […] stories about the tragic deaths of children using incorrect terms, such as “dry drowning,” “delayed drowning,” or “secondary drowning,” have prompted the nation’s emergency physicians to reassure parents who might be alarmed if their child develops a cough[web.archive.org]
Tachypnea
  • Tachypnea —Rapid breathing. Trachea —Windpipe. Wet drowning —Water entering the lungs due to relaxation of the larynx. near-drowning can cause a substantial increase or decrease in the volume of circulating blood.[encyclopedia.com]
  • These patients often present with signs and symptoms of hyperstimulation of the sympathetic nervous system, including the following: Tachycardia Hypertension Tachypnea Diaphoresis Agitation Muscle rigidity Autonomic instability has also been found to[web.archive.org]
  • Symptomatic patients can present with symptoms such as respiratory distress, tachypnea, hypoxia, coughing, or foaming from the mouth or nose. Auscultation of the lungs may reveal rhonchi or rales. Vomiting is also common. Hypothermia may be present.[cdemcurriculum.com]
Painful Cough
  • Other symptoms include: cold or bluish skin abdominal swelling chest pain cough shortness or lack of breath vomiting Near-drowning most often occurs when no lifeguard or medical professional is present.[healthline.com]
Bronchospasm and Wheezing
  • Nebulized β 2 -agonists may help reduce bronchospasm and wheezing. Surfactant administration may be helpful in critically ill patients with significant lung compliance issues after drowning, although no clinical trials have addressed this.[merckmanuals.com]
Gagging
  • They might also start being sick as a result of inflammation and sometimes a lack of oxygen due to persistent coughing and gagging. In cases of dry drowning, symptoms are similar but more immediate. Dr Mark R.[thesun.co.uk]
Chest Pain
  • After 24 h, electrocardiogram changes and a typical echocardiographic pattern of apical ballooning with a mild increase of serum troponin level induced the suspicion of tako-tsubo cardiomyopathy despite the absence of chest pain.[ncbi.nlm.nih.gov]
  • Warning signs can include trouble breathing, coughing, chest pain, and in Delgado's case, vomiting. According to CNN, doctors believe that his vomiting and diarrhea were early signs of the condition.[refinery29.com]
  • Symptoms Drowning complications can include: Coughing Chest pain Trouble breathing Feeling extremely tired Your child may also have changes in behavior such as such as irritability or a drop in energy levels, which could mean the brain isn't getting enough[webmd.com]
  • Other symptoms include: cold or bluish skin abdominal swelling chest pain cough shortness or lack of breath vomiting Near-drowning most often occurs when no lifeguard or medical professional is present.[healthline.com]
  • They include coughing, chest pain, difficulty breathing and feeling extremely tired. Children might also have a change in personality,and energy levels due to the brain not getting enough oxygen.[thesun.co.uk]
Cyanosis
  • Bluish skin ( cyanosis ), coughing, and frothy pink sputum (material expelled from the respiratory tract by coughing) are often observed.[encyclopedia.com]
  • Cyanosis : Cyanosis can be an indicator of hypoxemia (an important marker for degree of asphyxia and therefore outcome). Cold water may also produce the appearance of cyanosis.[doi.org]
  • Patients may have respiratory failure with tachypnea, intercostal retractions, or cyanosis. Respiratory symptoms are sometimes delayed for up to 6 hours after submersion.[merckmanuals.com]
  • The skin may appear blue ( cyanosis ) indicating insufficient oxygen in the blood. In some cases, respiratory problems may not become evident for several hours after submersion.[merckmanuals.com]
Muscle Cramp
  • The myth involves the possibility of suffering severe muscle cramping and drowning from swimming on a full stomach.[medicinenet.com]
  • Practiced to excess, it causes decreased cerebral blood flow, dizziness and muscle cramping in the arms and legs. But moderate degrees of hyperventilation can cause a state of euphoria and well-being.[web.archive.org]
Altered Mental Status
  • Patients with hypoxia and altered mental status will require endotracheal intubation. The treatment of pulmonary injury due to drowning is similar to the treatment of ARDS and applicable protocols should be utilized.[cdemcurriculum.com]
Spastic Quadriplegia
  • Eleven children with chronic, spastic quadriplegia due to drowning-induced ABI were investigated. All were comatose immediately after the injury and gradually regained consciousness, but with varying ability to communicate their cognitive state.[ncbi.nlm.nih.gov]

Workup

The management of drowning victim is largely centered on the state of hypoxemia. Patients who are grossly asymptomatic are attached to pulse oximeter for close monitoring while arterial blood gases are taken to determine the extent of hypoxemia and metabolic acidosis. Blood tests like complete blood count, glucose levels, cardiac enzymes, and liver enzymes are taken to determine organ impairment after drowning.

Renal function test through serum creatinine determination establishes the extent of renal damage during metabolic acidosis states. Chest radiography demonstrates water aspiration, atelectasis, and pulmonary edema in patients after drowning. Electrocardiography (ECG) is routinely performed to spot arrhythmias and bradycardias after a drowning incident [8].

Staphylococcus Aureus
  • Edwardsiella tarda and methicillin-sensitive Staphylococcus aureus were isolated in both tracheal aspirate cultures and blood cultures.[ncbi.nlm.nih.gov]
  • Tracheal aspiration revealed the presence of polymorphous pharyngeal flora (59%) or one predominant bacteria species (41%) including Enterobacter aerogenes , Enterobacter cloacae , Staphylococcus aureus , Pseudomonas aeruginosa , Aeromonas hydrophilia[ncbi.nlm.nih.gov]
Francisella Tularensis
  • We highlight the challenges associated with laboratory identification of F. novicida and differences in the epidemiology of F. novicida and Francisella tularensis infections.[ncbi.nlm.nih.gov]
  • We report the first case of Francisella tularensis subsp. holarctica bacteremia after water contamination in France. A 75-year-old man developed septic pneumonic tularemia after a near-drowning accident.[ncbi.nlm.nih.gov]

Treatment

Best prognostic outcomes in post drowning patients are directly influenced by the conduct of pre- hospital care by the bystanders [9]. Patient must immediately be referred to an emergency service facility to conduct patients to the nearest tertiary hospital. Drowning victims are immediately removed from the water and initial cardiopulmonary resuscitation must be initiated. Patients who are hypoxemic (PO2 below 70) are intubated in the emergency room to increase blood oxygenation. Volume depletion brought about by the pulmonary edema is treated with an intravenous isotonic crystalloid solution.

A nasogastric tube is sometimes attached to drain fluids from the stomach. Patients with respiratory failure due to drowning are given surfactant therapy to improve ventilation and blood oxygenation [10]. It is imperative to treat physiologic imbalances like electrolyte imbalance, hypoglycemia, seizures, and bronchospasms as soon as they are detected in the hospital setting.

Prognosis

Drowned patients who are coherent, alert, or mildly obtunded when brought to the emergency room department have a better prognosis. Patients who are grossly comatose and unresponsive with delayed attempts for cardiopulmonary resuscitation carry a very poor prognosis. Studies have shown that 35% to 65% of these cases die in the emergency room. Although those who survive has a very high likelihood of sustaining neurologic sequelae in the future in up to 60% of cases. In general, 35% of water immersion injury in children are fatal.

Etiology

Accidents are the leading cause of drowning among toddlers between the ages 1 to 4 years old. Patients with organic diseases like seizure disorders, stroke, coronary conditions, and hypoglycemia are more prone to drowning. Adults who have taken in too much alcohol and sedatives are likely to drown while swimming in a body of water. Swimmers may also drown when a sudden cardiac arrhythmia strikes during the activity. Secondary drowning can occur if the lungs produce excessive liquids as a reaction to a gas or liquid irritants impairing the gas exchange.

Epidemiology

According to the World Health Organization (WHO), drowning represents the third leading cause of accidental death worldwide. There are approximately 372,000 drowning deaths occurring worldwide annually. Male children with access to water facilities are more prone to drowning than their female counterparts. On the average, there are 10 deaths per day due to drowning in the United States [3].

There is a bimodal distribution in the drowning victim incidence, the first peak is observed on the toddler years and the second peak is seen among adolescents below 14 years of age. Drowning usually occurs on weekends during summer time because of the increased water-related activities for children. British statistics elaborate that 10% of the drowning incidences occur domestically in bathtubs, water buckets, and garden ponds [4].

Sex distribution
Age distribution

Pathophysiology

The pathophysiology of drowning revolves in the propagation of tissue hypoxemia and metabolic acidosis that happens during the event. Primary damage of the cerebral tissues stems out from the initial hypoxemia during the event, although secondary cerebral hypoxemia may also occur in drowning especially when complications like cardiac arrhythmia and pulmonary edema sets in. The initial phase of drowning is characterized by severe laryngospasm due to the initial water irritation of the oropharyngeal area. The hypoxemia ensues when the air is no longer passing through the neck area causing carbon dioxide retention to the blood. The progressive carbon dioxide retention causes the laryngospasm to relax that makes the patient automatically gasp and hyperventilate.

This motion underwater causes more water fluids to rush in the lung air spaces aggravating the hypoxemic states. Water in the lungs must actively be ventilated in because victims that are already dead could not accumulate water in the pulmonary spaces even when thrown in the water post-mortem [5]. The active aspiration of water reaching a level of approximately 22 ml per kilogram body weight can already alter electrolyte balance and cause significant hyponatremia especially in drowning children. In 10 to 20% of cases, cardiac arrest ensues just a few minutes after severe laryngospasm, causing deaths referred to clinically as “dry drowning”. Patients who survive drowning may develop infections of the air spaces like the nasal sinuses, the lungs, and the central nervous system with unusual bacteria like Naegleria sp., Pseudallescheria boydii, Balamuthia, and Aeromonas spp. [6].

Prevention

Accidental drowning can actively be prevented by installing barriers to water hazards in the domestic setting. Teaching children how to swim greatly reduces the risk for drowning among school age children. Effective policies on safe boating, ferrying, and shipping prevents untoward maritime accidents that may lead to massive drowning.

Summary

Drowning is clinically defined as death due to asphyxia after submersion to a large amount of liquid within a period of 24 hours [1]. Drowning is considered as a serious public concern for it represents a major cause of disability and death especially among children [2]. Patients who survive drowning sustain permanent neurologic deficits in one-third of cases. The immediate threats associated with drowning are the untoward effects it has on the cardiovascular and nervous system. Community education is the best way to prevent unnecessary morbidity and mortality linked with drowning.

Patient Information

  • Definition: Drowning is clinically defined as death due to asphyxia by fluid accumulation in the lung spaces after submersion to a large amount of liquid within a period of 24 hours.
  • Cause: Accidental drowning abounds victims in the preschool age groups. Patients with hypoglycemia, seizure disorders, stroke paralysis and cardiovascular disorders are likely to be at risk of drowning.
  • Symptoms: Mild cases of drowning are grossly asymptomatic. Some symptomatic victims present with dyspnea, hypothermia, altered state of consciousness, and hypotension. Patients in arrest may present with apnea and asystole in the emergency room while dead patients will present with rigor mortis, lividity, and negative neurologic responses. 
  • Diagnosis: Hypoxemia in drowning is subsequently monitored by pulse oximetry and arterial blood gases. Blood test will determine renal function tests, electrolyte imbalance, and extent of liver injury. Chest radiograph elucidates pulmonary edema and atelectasis. ECG diagnoses cardiac dysrhythmias
  • Treatment and follow-up: An initial pre-hospital resuscitation is paramount to the good prognostic outlook of the patient. Fluid resuscitation is needed to address volume depletion. Correction of metabolic acidosis, hypoglycemia and electrolyte imbalance are imperative steps in the management of drowning patients. 

References

Article

  1. Papa L, Hoelle R, Idris A. Systematic review of definitions for drowning incidents. Resuscitation. Jun 2005; 65(3):255-64.
  2. Health, United States 1996-97 and Injury Chartbook. DHHS Publication No (PHS) 96-1232. US Department of Health and Human Services. Hyattsville, Md: National Center for Health Statistics. 1997.
  3. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Wisqars Details of Leading Causes of Death. National Center for Health Statistics (NCHS), National Vital Statistics System. 
  4. National Water Safety Forum, UK. Water-related fatalities, 2005. 
  5. Lunetta P, Modell JH, Sajantila A. What is the incidence and significance of "dry-lungs" in bodies found in water? Am J Forensic Med Pathol. Dec 2004; 25(4):291-301.
  6. Cortez KJ, Roilides E, Quiroz-Telles F, Meletiadis J, Antachopoulos C, Knudsen T, et al. Infections caused by Scedosporium spp. Clin Microbiol Rev. Jan 2008;21(1):157-97.
  7. Layon AJ, Modell JH. Drowning: Update 2009. Anesthesiology. Jun 2009; 110(6):1390-401.
  8. Choi G, Kopplin LJ, Tester DJ, Will ML, Haglund CM, Ackerman MJ. Spectrum and frequency of cardiac channel defects in swimming-triggered arrhythmia syndromes. Circulation. Oct 12 2004; 110(15):2119-24.
  9. Kyriacou DN, Arcinue EL, Peek C, Kraus JF. Effect of immediate resuscitation on children with submersion injury. Pediatrics. Aug 1994; 94(2 Pt 1):137-42.
  10. Cubattoli L, Franchi F, Coratti G. Surfactant therapy for acute respiratory failure after drowning: two children victim of cardiac arrest. Resuscitation. Sep 2009; 80(9):1088-9.

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Last updated: 2019-07-11 22:46