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com

Authors:
Kurt Weber, MD, Associate Management of the Drowned Patient
Professor, Department of
Emergency Medicine; Assistant “Critical alert. Be advised we are en route with a 23-month-old child found sub-
Director, Department of Research merged in a swimming pool. Unknown down time. Patient obtunded, assisting respi-
Operations, Orlando Regional rations. ETA 3 minutes.” This is a typical prehospital call for a drowned patient, and
Medical Center, Orlando, FL. it results in the entire staff gearing up for the incoming patient. Respiratory thera-
pists check and double-check their intubation equipment. The nurses prime their
Clifford Denney, MD, heated IV pumps and assemble warmed blankets anticipating a hypothermic patient.
Department of Emergency The radiology team waits at the bedside with a portable X-ray machine. Social work-
Medicine, Orlando Regional ers are alerted and wonder aloud how parents could allow a 23-month-old child to
Medical Center, Orlando, FL. become submerged in a pool.
Philip Giordano, MD, Associate The emergency physician (EP) is, of course, thinking about all these things and
Professor and Vice Chairman, more. During the initial stabilization, the EP must consider the precipitating events.
Department of Emergency Was there a seizure before the event? Could there have been trauma leading to the
Medicine, Orlando Regional drowning? What is the chance of a cervical spine injury? The EP must then antici-
Medical Center, Orlando, FL. pate the next steps in care. The patient above will be intubated and admitted to the
intensive care unit (ICU); this decision is easy. However, a drowned patient who
arrives asymptomatic or displaying only mild symptoms makes a more difficult dispo-
Peer Reviewer: sition. The EP must consider the ultimate prognosis and be able to relay this informa-
Andrew D. Perron, MD, FACEP, tion to concerned parents.
FACSM, Professor and Residency The drowned patient represents a unique and difficult challenge. A wide range of
Program Director, Department of physiologic insults may occur, making each management decision critical. This review
Emergency Medicine, Maine describes the epidemiology, pathophysiology, critical actions, and prognostic factors the
Medical Center, Portland, ME. emergency physician must know to provide the best care for the drowned patient.
—Sandra M. Schneider, MD, Editor

Definitions
The spectrum of submersion injuries ranges from death in the field to minor
sequelae from the event. Accordingly, multiple terms have been used, leading to
some confusion. In the past, drowning usually implied death from an initial sub-
mersion event. The often-used term near-drowning implied multiple situations
ranging from definite survival to survival of the initial submersion event regardless
of ultimate outcome.1 Some definitions have incorporated pathophysiology, i.e.,
Statement of Financial Disclosure wet vs. dry drowning while others used outcomes, i.e. hospitalization vs. no hos-
To reveal any potential bias in this publication, and in pitalization.1,2 In all, a review of the literature between 1960 and 2002 found 20
accordance with Accreditation Council for Continuing
Medical Education guidelines, we disclose that Dr. definitions for drowning and 13 for near-drowning.2
Schneider (editor) serves on the editorial board for Logical Realizing the need for standardization, a multidisciplinary consensus group
Images. Dr. Farel (CME question reviewer) owns stock in
Johnson & Johnson. Dr. Stapczynski (editor), Dr. Weber announced a formal definition at the 2002 World Congress of Drowning. Their
(author), Dr. Denney (author), Dr. Giordano (author), Dr. recommendation reads: “Drowning is a process resulting in primary respiratory
Perron (peer reviewer), Mr. Underwood (associate pub-
lisher), and Ms. Mark (specialty editor) report no relation- impairment from submersion/immersion in a liquid medium.”1 The group dis-
ships with companies related to the field of study covered couraged the use of misleading historical terms such as active/passive, wet/dry,
by this CME activity.
primary/secondary, and near drowning. This definition serves as the basis for
guidelines for uniform reporting of data in drowning victims1 and has gained the
support of both the World Health Organization and the Centers for Disease
Control and Prevention (CDC).3,4 A standard approach should promote cohesive
research; however, many historical terms persist in the literature. These inconsis-
 Executive Summary
● Previous literature differentiated between wet and dry ● Patients who are asymptomatic after a submersion incident
drowning. Clinically, “dry drowning” is rare and is not can be watched in the ED for 4-6 hours. If they remain
different from “wet.” In addition, there is no difference asymptomatic, they can be discharged home.
between salt- and fresh-water drowning. RBC lysis and
electrolyte shifts are not common. ● Resuscitation follows ACLS guidelines. Cervical spine
injuries occur but are rare.
● Drowning is most common in the pediatric age group,
particularly the very young. Fencing around swimming
pools is the best preventive measure.

tencies are a result of the complex engage in riskier swimming behav- more dangerous situations in the
pathophysiology of the drowning ior.6,9 Finally, the CDC reports that water, such as swimming far from land
process and the wide range of clinical African American children have a rate or performing difficult maneuvers
presentations in the drowned patient. of drowning approximately 3.2 times while in the pool.12
higher than Caucasians between the Existing neurologic conditions also
Epidemiology and Risk ages of 5 and 14.6 increase risk of submersion injuries.
Factors Location of drowning in pediatric Studies investigating epilepsy show
Drowning contributes significantly patients varies with age. About half of that this disease increases risk of
to accidental deaths. In 2005, the drownings among infants younger drowning by 15-19 times.13 A signifi-
CDC reported that 3,582 uninten- than 1 year occur in the bathtub. cant number of these drowning
tional drowning deaths occurred in Approximately 50% of drowning deaths occurred during bathing. For
the United States (more than 10 per deaths in children from 1 to 4 years of this reason, many experts on epilepsy
day).5,6 This ranked second overall in age occur in swimming pools. In recommend showering over bathing
mortality due to unintentional injury older children and young adults, nat- in patients with seizures disorders.13
in those younger than 45 years old. ural bodies of water provide the set- Research also suggests that psychiatric
More than triple this number visited ting of drowning about 65% of the disorders and developmental delay in
emergency departments for submer- time.9 conditions such as autism also are
sion events, with 1-4 hospitalizations Experts often cite alcohol abuse as a linked with a higher incidence of sub-
occurring for every drowning death.5,6 major contributor to submersion mersion injuries.14
Population data showed states such as injuries. Studies estimate that those Finally, cardiac abnormalities
Florida, California, and Arizona, who ingest alcohol while engaging in heighten the risk of drowning.
where swimming pools and natural activities where drowning can occur Population-based studies report
bodies of water are most prevalent, increase their risk of death due to sub- approximately 20% of drowning vic-
saw the highest number of drowning mersion by about 5 to 30 times, tims over a 15-year period had a his-
incidents.7 depending on their blood-alcohol tory of cardiovascular disease.15 Case
Younger ages are significantly asso- level.10 Half of those involved in reports link long QT syndrome with
ciated with downing. Overall, drown- drowning related to boating accidents drowning risk.16,17 Educating patients
ing is proportionally the highest- consume alcohol.11 Enforcing more who have a history of these medical
ranking cause of accidental death in stringent alcohol laws may decrease problems is essential, as it may
those younger than 24 years of age.7 deaths by drowning by up to 80%.10 decrease the risk of drowning for
In fact, drowning caused nearly 30% Swimming ability may not provide these individuals.
of deaths in those between 1 and 4 protection against drowning.
years old in 2005.6 Furthermore, in Population-based studies have demon- Pathophysiology
2006, as shown in Figure 1, this age strated conflicting results. Depending During normal submersion (i.e.,
group accounted for nearly half of all on the study, 20-70% of drowning swimming), the body undergoes
pediatric drownings. Not surprisingly, victims possess the ability to swim. primitive life-sustaining physiologic
seasonal variance exists as well. The Mortality data reported by the alterations, the “diving reflex,” illus-
National Safe Kids Campaign found Canadian government in 1998 trated in the top half of Figure 2.
that two-thirds of drownings in chil- reported that only 31% of drowning Bradycardia develops, decreasing the
dren 14 years old or younger patients either lacked the ability to oxygen demand of the heart. Cardiac
occurred between May and August.8 swim or were considered weak swim- output is maintained through periph-
Males account for approximately 75% mers.12 This makes logical sense when eral vasoconstriction. This vasocon-
of drowning deaths in those older one considers that stronger swimmers striction shunts blood to vital organs
than 12 months, as they tend to more often expose themselves to and away from the periphery of the

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Figure 1: Pediatric Deaths in which the cessation of laryn- to neuronal death. These hypoxic
from Drowning (n = 1052) gospasm fails to occur, leading to changes may be seen early on by
asphyxiation in the absence of signifi- MRI.26 Drowning in icy water may
cant liquid aspiration.2 Earlier offer some protection from this
researchers believed that this latter process, lessening the degree of neu-
sequence of events made up 10-15 rologic injury. Experts believe that
percent of drowning events.22 More colder water decreases the cerebral
recently, however, experts doubt that oxygen demand of the brain as the
this mechanism plays a significant role body temperature drops.21,27,28 In
in submersion injuries.22,23 Studies that addition, colder body temperature
evaluate lungs on autopsy after may protect against free radical forma-
drowning show an absence of signifi- tion from reperfusion.29 These factors
cant water aspiration less than 4% of appear to lessen the deleterious effects
the time.22 In addition, damage of drowning on brain injury.
occurs to the lungs when the victim In the past, it was thought that
aspirates as little as 1-3 mL/kg of metabolic changes other than those
Rate per 100,000 in white fluid.20 caused by hypoxemia alone occurred
Since only a small volume of fluid in submersion injury. Research in ani-
Data source: CDC/NCIPC Vital
results in injury, deleterious pul- mals in the 1930s showed that salt
Statistics monary changes occur early in the water submersion resulted in signifi-
process. Capillary permeability greatly cant increases in certain serum elec-
body in an attempt to conserve body increases, leading to pulmonary trolytes, while fresh water submersion
temperature.18 Furthermore, research edema. Aspirated water damages and caused dilutional effects. In addition,
measuring cerebral blood flow during washes away surfactants, leading to a it was believed that fluid shifts led to
an evoked dive reflex shows that cere- progression of atelectasis and ventila- red blood cell (RBC) lysis, causing
bral blood flow increases.19 Although tion/perfusion mismatches. The vic- anemia and hyperkalemia.30 Later
measurable changes occur during tim remains hypoxic even after research in humans, however, showed
harmless submersion, the implications removal from the water when signifi- these metabolic derangements fail to
of these physiological changes remain cant lung injury has occurred.20,21 play a clinically significant role. One
largely unknown in drowning. Adverse hemodynamic effects occur study that evaluated submersion vic-
The physiology of drowning differs as a result of the hypoxemia to the tims over a 17-year period showed
from routine water submersion. The myocardium. Cardiac output drops, that electrolyte and hemoglobin
sequence of events, shown in the bot- contributing to poor perfusion of abnormalities were rare.30 The fact
tom half of Figure 2, begins when the end-organs. Pulmonary hypertension that the average human aspirates
victim remains submersed in a liquid occurs as a consequence of the lung approximately 2-4 mL/kg during
medium long enough to hinder nor- injury.20 Case reports describe con- submersion injury as opposed to 10
mal respiration.1 Panic then ensues duction abnormalities as well, mL/kg used in the early animal mod-
while the victim struggles to keep his described in the past by the term els may explain this finding. Only a
or her head above water. Unsuccessful immersion syndrome.24 Contact with small number of patients show signifi-
attempts at this eventually lead to water colder than body temperature cant anemia when presenting after a
breath-holding. A period of laryn- may precipitate cardiac dysrhythmias. submersion event, and many of these
gospasm then occurs, which results in Catastrophic cardiac rhythm distur- probably suffered from an underlying
a cessation of gas exchange. bances such as ventricular tachycardia anemia prior to underwater injury.30
Eventually, laryngospasm ends, and and asystole due to prolongation of
the patient aspirates a large volume of the Q-T interval have been de-
Clinical Presentation and
fluid.1,20,21 As seen in Table 1, a com- scribed.16,17 As illustrated in Figure 3, Differential Diagnosis
plex physiologic cascade adversely patients with known QT abnormali- Considerations
affecting multiple organ systems then ties are at particular risk because the There is a large spectrum of patient
ensues. normal physiologic changes occurring presentations after drowning. Some of
Earlier work regarding drowning during submersion can unmask and the signs and symptoms result from
attempted to divide the physiological potentiate the underlying cardiac the event itself; however, strong con-
events that followed submersion into anomalies.16,25 sideration of precipitating causes is
two categories: wet-drowning and Submersion can result in neurologi- essential when evaluating these
dry-drowning. The above-mentioned cal sequelae ranging from brief loss of patients. Obtaining a succinct but
process of aspiration that leads to lung consciousness to devastating coma thorough initial history plays an
injury and hypoxemia describes wet- and brain death. Multiple biochemical important role in patient management.
drowning. In contrast, some processes in the brain occur secondary Questions addressing the location
described dry-drowning as a process to anoxic injury, which eventually lead of the event, temperature of the

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Figure 2: Drowning Process breathing pattern are always a top pri-
ority in any critical emergency depart-
ment patient. Assessing vital signs
Submersion early is essential. Monitoring should
be started early to detect a cardiac
dysrhythmia that requires immediate
attention. Body temperature allows
estimation of duration of submersion
Vasoconstriction Bradycardia
and water temperature. Finally, respi-
ration rate and oxygen saturations
serve as early clues to the severity of
lung injury.
A full head-to-toe physical examina-
Blood shunted from periphery tion is crucial when assessing these
• Increases cerebral blood flow

Physiologic
patients. Scalp lacerations, hema-
• Decreases total oxygen demand tomas, or contusions signal head
• Conserves body temperature trauma. Pupillary size and response
may indicate brain herniation if fixed
and dilated or suggest substance
ingestion such as narcotics if pinpoint.
Consideration must be given to cervi-

Pathologic
cal spine injuries, especially in sus-
Breath-holding failure pected trauma. A careful cervical-
Panic spine examination provides useful
information if the person remains fully
awake and alert without distracting
injury, but cannot be relied upon in
other cases.31 A population-based
study performed over a 22-year
Laryngospasm period showed less than 1% of all
• Hypoxia patients involved in a submersion
• Unconsciousness event suffered an injury to the cervical
spine.32 Nevertheless, proper cervical
Wet drowning spine precautions should be main-
tained until the physician can reliably
rule out that an injury is present.
An abnormal pulmonary examina-
Laryngospasm failure tion provides evidence of lung injury.
• Large volume aspiration The detection of subtle wheezing,
• Further hypoxia rales, or rhonchi suggests a mild
degree of insult. On the other hand,
severe respiratory distress including
tachypnea, hypoxia, and accessory
muscle use during breathing suggests
Multi-organ dysfunction extensive pulmonary injury. Cyanosis
is an ominous finding that usually
requires endotracheal intubation. In
water, and submersion time prove injuries. Past medical history, includ- situations of mild symptoms, the
important when considering manage- ing medications, may indicate the pre- dynamic state of the respiratory status
ment. Witnesses can provide details cipitating cause of the submersion or requires close observation for any
surrounding the event, such as a provide an idea of possible complica- worsening. A study involving adult
seizure or trauma preceding submer- tions to anticipate regarding that patients who presented to the emer-
sion. Loss of consciousness or patient in particular. (An example gency department after suffering a
bystander CPR may lead the emer- would be an acute myocardial infarc- submersion event showed 95% of
gency physician to suspect a more tion precipitated by the stress of these patients exhibited some degree
serious submersion injury. The local- drowning.) of hypoxemia, while roughly 40%
ization of pain or external signs of Drowning victims mandate early developed adult respiratory distress
trauma provide clues of concomitant evaluation. Airway patency and syndrome (ARDS).33

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 Table 1: Multi-System Dysfunction the likelihood of trauma related to the
System Impairment event. In children, physical examina-
tion findings such as bruising at dif-
Pulmonary Edema, V/Q mismatch, ferent stages, spiral fractures, and
hypoxemia, ARDS retinal hemorrhages suggest child
abuse, which occurs infrequently. In
Neurologic Anoxic encephalopathy, traumatic one study, about 13% of all child
brain/cord lesions homicides were due to drowning.35

Management
Acid/base Metabolic acidosis Ideally, aggressive management of
the drowning patient begins at the
Cardiac Decreased cardiac output, scene and follows through to the
dysrhythmia, infarction emergency department, as demon-
strated in Figure 4. The victim should
Renal Azotemia be removed from the water as quickly
as possible. The American Heart
Figure 3: Dysrhythmia from Submersion Association (AHA) supports early initi-
ation of rescue breathing in apneic
patients in its 2005 recommendations
on Advanced Cardiac Life Support
(ACLS). This may be initiated in shal-
low water as long as the rescuer can
safely do so. In cases in which the vic-
tim remains in the water and the res-
cuer cannot easily open the airway, the
committee recommends mouth-to-
nose ventilation.36 The Heimlich
maneuver to remove water or aspirated
material from the airway does not have
a role in prehospital care of the drown-
ing patients.37 Aspirated particulate
matter provides no airway obstruction
requiring dislodgment. In addition,
repeating the Heimlich maneuver in
the drowning patient delays hospital
arrival and poses a risk to anyone with
a cervical spine injury.37
Seen starting at the 8th beat, underwater submersion results in Patients experiencing cardiac arrest
after drowning should be treated simi-
bradycardia (“diving reflex”). This bradycardia accentuates the QT
larly to cardiac arrest in other situa-
interval and allows generation of PVCs. At the 13th beat, during a
tions, i.e., early CPR, minimizing
deep dive, a PVC results in a long compensatory pause. The next interruptions in chest compressions,
beat, a sinus complex, is followed quickly by a PVC that degenerates and early defibrillation. Concern exists
into a polymorphic ventricular tachycardia, torsades des pointes. The regarding the safety of defibrillation in
patient is then defibrillated successfully (bottom strip). a wet environment. Currently, the
Figure used with permission from: Batra AS, Silka MJ. Mechanism of AHA does not recommend any modi-
sudden cardiac arrest while swimming in a child with the prolonged fication of ACLS in the drowning
QT syndrome. J Pediatrics 2002;141: . patient.36 Experiments show that
although the rescuer may notice
Several causes of dysrhythmias exist ties and worsens as body temperature minor sensation when performing
during a submersion event. decreases.34 defibrillation in a pool of salt water,
Preexisting conduction abnormalities The physician should consider other defibrillation may be performed safely
predispose patients to drowning.16,17 possible precipitants of drowning, in wet environments.38 If rescuers take
Also, hypoxemia experienced as a including substance abuse, seizures, care to dry and step away from the
result of submersion may precipitate a hypoglycemia, syncope, and acute patient, no significant electric current
cardiac dysrhythmia. Hypothermia cerebrovascular accident. A thor- reaches them.
causes cardiac conduction abnormali- ough physical examination assesses Upon arrival to the emergency

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 Figure 4: Drowning Management

Prehospital Emergency Department

Move patient to safe area Initial stabilization
Provide spinal immobilization • ABCs, IV, monitor
Initiate ACLS resuscitation Chest x-ray
+/- CBC/electrolytes/ABG
+/- Head CT
Antibiotics for contaminated submersion

Asymptomatic
Disposition
4-6 h ED observation

Severe respiratory or
neurologic impairment
Asymptomatic
In
me terva Mild symptoms
nt l
of deve Low O2 requirement
sym lo
pto p-
ms

Home Floor observation ICU admit

department, patients should be placed Pediatric patients presenting to emer- in management. The majority of
on a cardiac monitor with a continu- gency departments often present more patients will exhibit abnormal chest
ous pulse oximeter. A serum glucose critically ill than adults, requiring intu- roentograms, as shown in Figure 5.
reading, often done in the prehospital bation about half of the time.39 The EP must keep in mind that early
setting, evaluates for hypoglycemia Although no definitive criteria for imaging may underestimate the extent
that could have precipitated or intubation universally apply, factors of damage, which may develop over a
resulted from the preceding events. A such as hypoxemia after supplemental few hours.41 Patients who present
primary survey, assessing airway oxygen, poor ventilation manifested by after a moderate to severe drowning
patency, breathing adequacy, circula- increased PaCO2 levels, and decreased episode should have laboratory tests
tory status, and cervical spine protec- level of consciousness resulting in fail- performed. An arterial blood gas also
tion, offers a starting point for patient ure to protect the airway indicate that can help provide accurate values on
assessment. If not already present, two intubation and mechanical ventilation oxygenation, ventilation, and pH.
large-bore peripheral IVs should be may be necessary. Although large fluid and electrolyte
placed by nursing staff. ACLS or Pediatric Advanced Life shifts do not typically occur as a result
Early airway management plays a Support (PALS) protocols should be of drowning,30,42,43 routine testing of
crucial role in caring for these patients. followed for hemodynamically unsta- serum electrolytes and renal function
The degree of pulmonary injury ble patients. Gentle fluid resuscitation should be obtained in patients who
resulting in hypoxemia varies. As men- may aid in supporting blood pressure, experience prolonged submersion.
tioned above, a spectrum of pul- but consider that overzealous fluid One study showed that about 50% of
monary injury frequently is seen after administration could worsen pul- patients admitted to the hospital suf-
drowning. A study in adults per- monary edema. An ECG screens for fered from some degree of acute renal
formed over an eight-year period any conduction abnormalities, such as failure, and a few from rhabdomyoly-
showed that although fewer than 10% QT prolongation.16,17,25 Also, drown- sis.44,45 While most of these patients’
of patients who presented after a sub- ing may precipitate acute myocardial renal function recovered, 7% required
mersion event required intubation, infarction, which also may be detected hemodialysis.44,45 A coagulation evalu-
about 80% showed some degree of by ECG.40 ation is important in patients taking
pulmonary edema on chest X-ray.33 Further diagnostic testing may aid drugs such as warfarin or heparin or if

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 Figure 5: Pulmonary Infiltrates after Submersion zopus, and zygomycosis.48-51 In fact,
60% of those who develop pneumonia
after a submersion episode will die.48
Specifically, reports show that
Aeromonas pneumonia often develops
within 24 hours of submersion and
results in high mortality.48,49 Even in
light of the such severe clinical conse-
quences, prophylactic antibiotics
rarely play a role in management of
drowning patients.48 Studies fail to
support improved outcomes with the
administration of prophylactic antibi-
otics.52,53 Drowning in contaminated
water, fever, or pulmonary deteriora-
tion a few days after the initial event
prompt the consideration for antibi-
otics. Antibiotic choice includes
extended-spectrum penicillin plus a ß-
lactamase inhibitor and gentamicin or
clindamycin and a fluoroquinolone.48

Prognosis
Clinical outcomes in drowning cases
range from quick return to physio-
logic baseline to severe neurologic
deficits. A large body of research
exists attempting to identify variables
that predict the clinical course and
severity following a submersion event.
(See Table 2.) Factors such as age of
the patient, submersion time, temper-
ature of water, and patient presenta-
tion all influence outcome.
In the past, many experts in sub-
mersion injury hypothesized that
the physician suspects disseminated patients following a ventricular fibril- pediatric patients had a favorable
intravascular coagulation. lation arrest.29 Inducing and/or main- prognosis when compared to adults.54
Emergency physicians should con- taining hypothermia for comatose Pediatric patients experience more
sider the possibility of concomitant drowning patients may offer improved rapid cooling due to their small body-
traumatic injuries. A large study in outcomes in drowning patients as surface-areas.55 In addition, adults
drowning patients showed that only well. Multiple case reports exist show- more often suffer from other comor-
patients with a mechanism of signifi- ing that adult drowning patients who bidities that may contribute to a
cant trauma or an abnormal physical present in coma may benefit from worse outcome. More recent studies
examination showed evidence of cer- therapeutic hypothermia, even after suggest that there may not be a sur-
vical spine injury.32 The American prolonged periods of submersion.46,47 vival advantage in younger patients. A
Heart Associations’ 2005 guidelines Further evidence must be obtained, study over a 12-year period compar-
on ACLS recommend placing a cervi- however, before this becomes the ing survival and neurologic outcome
cal collar only on patients who fit this standard of care. in patients admitted to the intensive
description.36 Head CT should be Pneumonia, although a rare compli- care unit showed no difference in out-
obtained in patients who have suf- cation of drowning, causes significant comes in pediatric patients vs.
fered significant head trauma or show morbidity. Submersion in contami- adults.54
focal neurological deficits on physical nated water such as sewage water Longer submersion time correlates
examination. Extremity radiographs increases risk.48 Case reports describe with a worse prognosis. Studies involv-
help evaluate those with abnormal pneumonia from multiple bacterial ing pediatric patients estimate submer-
musculoskeletal examinations. pathogens including Aeromonas, sion times longer than 5-10 minutes
Therapeutic hypothermia improves Klebsiella, and Legionella species, and correlate with worse outcomes.56,57
neurological outcomes in comatose fungal causes such as aspergillus, rhi- Studies involving adults echo this

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finding. Patients who survived with role in prognosis for submersion vic- Table 2: Factors Associated
full neurologic recovery remained tims. Bystander initiation of basic life with Favorable Prognosis
submersed for an average of 5 min- supports is the first important step in after Drowning
utes, while those who suffered some minimizing brain damage. An eight-
neurological insult and those who year study involving pediatric patients Demographic
died had median submersion times of showed a much better outcome when • Younger age
10 and 16 minutes, respectively.54 bystanders initiated resuscitation ver- • Female sex
Submersion time does not provide sus those in which bystanders waited
infallible prognostic value since it for paramedics to initiate resuscita-
Prehospital
often is incorrectly estimated by tion. The best outcomes occurred in
bystanders.54 In addition, case reports those who received mouth-to-mouth • Shorter submersion time
exist describing survival after submer- breathing plus chest compression, • Bystander initiated CPR
sion times greater than 1 hour.58 For while an improvement in clinical • Cold water temperature
these reasons, the emergency physi- course also was observed in those
cian should initiate aggressive resusci- receiving only chest compressions.61 Emergency Department
tation early. Rapid arrival by emergency medical • Reactive pupils
Hypothermia due to colder water services is a factor in survival. • GCS > 13
temperatures may improve clinical Approximately 10% of drowning vic- • Low PRISM score
course in drowning. This typically tims who suffer from pulseless arrest
occurs after submersion in icy water; show a shockable rhythm, and evi- Emergency Department
however, case reports exist reporting dence supports worse outcome with
this effect even in locations such as longer ambulance response times.62
Disposition
Florida.58 Hypothermia decreases Comparisons between prehospital car- Unfortunately, there are no well-
cerebral metabolism and oxygen diac arrest due to drowning versus established guidelines to assist the
demands.59 A study performed over a cardiac disease showed an improve- emergency physician with disposition.
10-year period of approximately 300 ment in survival in the drowning Patients presenting after submersion
children showed that those submersed group. One possible explanation is injury typically will fall into three
in water temperatures less than 15 that these patients tended to be groups. The first group has severely
degrees Celsius experienced a reduc- younger with fewer comorbidities.62 compromised respiratory or neuro-
tion in poor outcome defined as death Finally, patient survival was found to logic function that necessitates aggres-
or severe neurological sequelae by be extremely low in those who did sive management in the ICU setting.
greater than 30 times compared to not respond to advanced cardiac life The second group has mild lethargy
those submersed in warmer water.60 support for greater than 25 minutes.63 or thoracic symptoms of pain or dysp-
Studies in adult patients yield mixed Clinical presentation provides an nea. In these patients, an overnight
results that make it difficult to defi- idea of expected clinical course. stay in an observation unit is war-
nitely conclude that submersion in Patients requiring CPR face a worse ranted. The final group, those patients
cold water provides an advantage in outcome.56 Patients who arrive with- who are asymptomatic, presents a
them.54,56 out any neurological impairment greater challenge to the practicing EP.
A few reasons may explain this dis- almost always remain as such. In Reports in the past cited episodes in
crepancy in findings. First, not only addition, the vast majority of which the respiratory status of
does cerebral metabolism slow with patients who present obtunded but patients deteriorated clinically after
hypothermia, but cerebral perfusion arousable survive without any neuro- initially appearing to have no pul-
decreases as well. Hypothermia affects logical sequelae.41,56,64 Initial blood monary injury, termed secondary
cardiac output, resulting in decreased sugar above 400 proves to be a poor drowning.67-69 The possibility of dete-
blood flow to the brain.59 In addition, prognostic factor in children.64 rioration has led some EPs to admit
much of the literature reviewed Finally, complicated clinical criteria, all drowning victims regardless of
reports outcomes based on hypother- such as the Pediatric Risk of severity. However, a recent adult
mia rather than measurements of the Mortality Score (PRISM), take into study, in which age greater than 60
temperature of the bodies of water. In account factors such as vital signs, years old made up 79% of the patients
this setting, two causes of hypother- GCS, electrolyte readings, and coag- in the study, showed pulmonary
mia exist. The decreased body tem- ulation profile that offer preliminary improvement as opposed of worsen-
perature may result from potentially prognostic information. However, ing, after ED presentation.33 Similarly,
protective hypothermia due to cold drawbacks of this scoring system a study of 61 pediatric patients
water submersion, or hypothermia as include the complexity of calculating showed all of the children who pres-
a result of the patient decompensa- the score and findings that the inter- ent with an initially normal pul-
tion. The latter would be expected to mediate scores fail to provide reli- monary examination, GCS above 13,
be associated with poor outcomes. able prognostic information.65,66 and required supplemental oxygen for
Prehospital care plays an important no longer than 8 hours suffered no

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 Sheet. Available at
decompensation during their hospital recommends that fences stand at least http://www.cdc.gov/ncipc/factsheets/dro
course.68 Given the small but real 48 inches high and be built narrow wn.htm. Accessed February 1, 2009.
chance for delayed pulmonary compli- enough so that children cannot put 6. National Center for Injury Prevention and
cations, it is reasonable that the their feet through the fence. Gates Control, Centers for Disease Control and
asymptomatic submerged victim should be self-closing and self-latch- Prevention: Web-based injury statistics
query and reporting system [Database].
should be observed for a short period, ing and should open outward, away http://webappa.cdc.gov/sasweb/ncipc/m
4-6 hours, in the emergency depart- from the pool, so that if a child ortrate10_sy.html. Accessed February 1,
ment. If the patient remains without pushes against the gate, it will close 2009.
signs of respiratory compromise, he or instead of open.72 7. National Center for Injury Prevention and
Control. WISQARS Leading Causes of
she can be discharged home safely. Death Reports, 2005. http://www.cdc.
Summary gov/injury/wisqars/index.html. Accessed
Prevention Drowning is a process of respira- February 6, 2009.
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another common scenario of drown- severity of injury in the drowned Swimming lessons, swimming ability and
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floatation devices such as life jackets ED observation. For patients with
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 strategies for drowning prevention. World comes. drowning deaths than males.
Congress on Drowning: Prevention, Rescue C. The patient likely will suffer large fluid D. Drownings are more likely to occur dur-
and Treatment. Available at: and electrolyte shifts as a consequence of ing the winter months.
http://www.cslsa.org/events/ArchiveAttac drowning.
hments/Spr03Minutes/AttachmentG2.pdf. D. Antibiotics will prevent the development 20. A 57-year-old man is brought to the ED
Accessed February 19, 2009. of pneumonia. after a prolonged submersion and resuscita-
73. US Consumer Product Safety Commission. tion time. He is intubated without sedation
Safety Barrier Guidelines forHome Pools. 16. A 15-month-old boy is brought to the ED for respiratory support. He has an abnormal
CPSC Publ. No. 362. Available at: after a brief (< 1 min) submersion injury in pupillary response and shows no sponta-
http://www.cpsc.gov/CPSCPUB/PUBS/ a bathtub. Upon removal, the patient neous movements. Regarding the patho-
Pool.pdf. Accessed June 19, 2009. coughed briefly but did not require rescue physiology of the disease process in this
breathing. In the ED, the patient appears patient:
Physician CME Questions comfortable with normal vitals and physical A. Aspiration of large amount of water must
examination. The appropriate disposition for occur to produce lung damage.
this patient is: B. Dilutional anemia and electrolyte abnor-
11. According to published data, in the United
States, which of the following characteristics A. immediate discharge from the ED if chest malities are likely.
is associated with higher incidence of x-ray is normal C. Traumatic brain injury, not anoxic insult,
drowning? B. inpatient admission regardless of ED causes the majority of neurologic mani-
course festations of drowning.
A. adult age group C. discharge to home if asymptomatic after D. Concomitant cardiac disease heightens
B. female sex a 4- to 6-hour observation period in the the risk of dying from drowning.
C. swimming in a supervised pool ED
D. history of epilepsy D. ICU admission and oxygen by nasal
canula
12. A 5-year-old patient is brought to the ED
pulseless and apneic after a prolonged sub- 17. Primary prevention plays an important role
mersion. During the drowning process, in limiting the number of deaths from
which of the physiologic responses likely drowning. Which of the following provides
occurred? the best protection against drowning inci-
A. tachycardia upon initial submersion in dents?
water A. fencing around swimming pool
B. vasodilitation to preserve blood flow to B. swimming ability
peripheral muscles C. supervision of young child by siblings
C. direct damage to lung tissue from aspi- D. drinking in moderation when operating a
rated water resulting in hypoxemia personal watercraft
D. persistent laryngospam resulting in “dry
drowning”
18. A 27-year-old man is ejected from a boat
during a collision with a pier. Regarding the
13. A 17-year-old girl is brought to a shallow pre-hospital management of this victim:
area of a pool. She is pulseless and found to
be in ventricular fibrillation. Important con- A. The Heimlich maneuver is necessary to
siderations for her resuscitation include: remove aspirated material.
B. Bystander-initiated CPR has not been
A. Defibrillation is contraindicated in a wet shown to improve clinical outcomes.
environment. C. ACLS resuscitation should begin as soon
B. Spine immobilization should be used. as the rescuer can safely do so.
C. Airway, breathing, and circulation D. Cervical spine injuries are very common
remain the initial priorities of resuscita- in drowning incidents. CME Answer Key
tion.
D. Witness accounts of the event are of lit- 11. D; 12. C; 13. C; 14. D; 15. B; 16. C; 17. A;
tle importance in drowning episodes. 19. A 3-year-old girl is brought to an ED after 18. C; 19. B; 20. D
a drowning episode. From an epidemiologic
perspective:
14. A 7-year-old boy is brought to the ED after
a prolonged submersion in a pool. He is A. The drowning most likely occurred in a
obtunded and in respiratory distress. His bathtub. In Future Issues
temperature is 95.7; pulse 115; blood pres- B. Drowning accounts for 30% of the unin-
sure 115/75; respiratory rate 42; O2 satura- tentional deaths in this age group. Alcohol Withdrawal
tion 90% on a non-rebreather mask. Lungs C. Females are more likely to be involved in
sounds demonstrate diffuse crackles. Chest
x-ray shows bilateral infiltrates. Regarding
management of this patient, the EP should
consider:
Emergency Medicine Reports
A. immediate administration of antibiotics CME Objectives
B. initiating large-volume fluid resuscitation To help physicians:
C. aggressive re-warming measures
D. placing a definitive airway for respiratory • quickly recognize or increase index of suspicion for specific conditions;
support • understand the epidemiology, etiology, pathophysiology, and clinical features
of the entity discussed;
15. After successfully resuscitating a 9-year-old • apply state-of-the-art diagnostic and therapeutic techniques (including the
girl from a drowning event, the EP should
consider the following when discussing implications of pharmaceutical therapy discussed) to patients with the partic-
prognosis to the family: ular medical problems discussed;
A. Mild hypothermia from cold water • understand the differential diagnosis of the entity discussed;
drowning will worsen the clinical course. • understand both likely and rare complications that may occur.
B. Submersion time of greater than 5-10
minutes is associated with worse out-

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 Editors Michael L. Coates, MD, MS
Professor and Chair
Charles V. Pollack, MA, MD, FACEP
Chairman, Department of Emergency
Charles E. Stewart, MD, FACEP
Associate Professor of Emergency
Sandra M. Schneider, MD
Professor Department of Family and Community Medicine, Pennsylvania Hospital Medicine, Director of Research
Department of Emergency Medicine Medicine Associate Professor of Emergency Department of Emergency Medicine
University of Rochester School Wake Forest University School Medicine University of Oklahoma, Tulsa
of Medicine of Medicine University of Pennsylvania School of
Gregory A. Volturo, MD, FACEP
Rochester, New York Winston-Salem, North Carolina Medicine
Chairman, Department of Emergency
Philadelphia, Pennsylvania
J. Stephan Stapczynski, MD Alasdair K.T. Conn, MD Medicine
Chair Chief of Emergency Services Robert Powers, MD, MPH Professor of Emergency Medicine and
Emergency Medicine Department Massachusetts General Hospital Professor of Medicine and Emergency Medicine
Maricopa Medical Center Boston, Massachusetts Medicine University of Massachusetts Medical
Phoenix, Arizona University of Virginia School
Charles L. Emerman, MD
School of Medicine Worcester, Massachusetts
Chairman
Charlottesville, Virginia
Editorial Board Department of Emergency Medicine Albert C. Weihl, MD
MetroHealth Medical Center David J. Robinson, MD, MS, FACEP Retired Faculty
Paul S. Auerbach, MD, MS, FACEP Cleveland Clinic Foundation Vice-Chairman and Research Director Yale University School of Medicine
Professor of Surgery Cleveland, Ohio Associate Professor of Emergency Section of Emergency Medicine
Division of Emergency Medicine Medicine New Haven, Connecticut
Department of Surgery Kurt Kleinschmidt, MD, FACEP,
Department of Emergency Medicine
Stanford University School of FACMT Steven M. Winograd, MD, FACEP
The University of Texas - Health
Medicine Professor of Surgery/Emergency Attending, Emergency Department
Science Center at Houston
Stanford, California Medicine Horton Hill Hospital, Arden Hill
Houston, Texas
Director, Section of Toxicology Hospital
Brooks F. Bock, MD, FACEP The University of Texas Southwestern Barry H. Rumack, MD Orange County, New York
Professor Medical Center and Parkland Hospital Director, Emeritus
Department of Emergency Medicine Allan B. Wolfson, MD, FACEP, FACP
Dallas, Texas Rocky Mountain Poison and Drug
Detroit Receiving Hospital Program Director,
Center
Wayne State University David A. Kramer, MD, FACEP, FAAEM Affiliated Residency in Emergency
Clinical Professor of Pediatrics
Detroit, Michigan Program Director, Medicine
University of Colorado Health Sciences
Emergency Medicine Residency Professor of Emergency Medicine
William J. Brady, MD, FACEP, FAAEM Center
Vice Chair University of Pittsburgh
Professor and Vice Chair of Emergency Denver, Colorado
Department of Emergency Medicine Pittsburgh, Pennsylvania
Medicine, Department of Emergency York Hospital Richard Salluzzo, MD, FACEP CME Question Reviewer
Medicine, York, Pennsylvania Chief Executive Officer
University of Virginia School of CME Question Reviewer
Wellmont Health System
Medicine Larry B. Mellick, MD, MS, FAAP, Roger Farel, MD
Kingsport, Tennessee
Charlottesville, Virginia FACEP Retired
Professor, Department of Emergency John A. Schriver, MD Newport Beach, CA
Kenneth H. Butler, DO FACEP, FAAEM Medicine and Pediatrics Chief, Department of Emergency
Associate Professor, Associate Medical College of Georgia Services © 2009 AHC Media LLC. All rights
Residency Director Augusta, Georgia Rochester General Hospital reserved.
University of Maryland Emergency Rochester, New York
Paul E. Pepe, MD, MPH, FACEP,
Medicine Residency Program FCCM, MACP David Sklar, MD, FACEP
University of Maryland School Professor of Medicine, Surgery, Professor of Emergency Medicine
of Medicine Pediatrics, Public Health and Chair, Associate Dean, Graduate Medical
Baltimore, Maryland Emergency Medicine Education
The University of Texas Southwestern University of New Mexico School of
Medical Center and Parkland Hospital Medicine
Dallas, Texas Albuquerque, New Mexico

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