Pediatric Drowning
Pediatric Drowning
Authors:
Sheri Knepel, MD, FACEP, Assistant Professor, Department of Emergency Medicine, The Ohio State University, Columbus.
Amanda Aemisegger, MD, Resident, Department of Emergency Medicine, The Ohio State University, Columbus.
Peer Reviewer:
Christopher J. Haines, DO, FAAP, FACEP, St. Christopher's Hospital for Children, Director, Department of Emergency Medicine, Medical Director, Critical Care Transport Team, Philadelphia, PA.
Drowning is a major global public health problem. In 2000, the World Health Organization reported drowning as the second leading cause of unintentional death worldwide.1 In the United States, drowning remains a leading cause of death in children. The U.S. Product Safety Commission has stated that death in children younger than age 5 in the United States is 14 times more likely to be related to swimming pools than caused by motor vehicle collisions.2 Additionally, drowning survivors are at high risk for significant morbidity and neurologic sequelae.
Early aggressive resuscitation of the pediatric drowning victim is of the utmost importance. Current management strategies emphasize the rapid reversal of hypoxia to minimize the initial injury, and aggressive supportive care to prevent a second insult. Researchers continue to explore novel therapies to increase survival and improve neurologic outcomes in pediatric drowning victims.
In addition, drowning is a preventable problem. The emergency department encounter is a good time to provide drowning prevention education to patients and caregivers.
This article reviews the definition, complex pathophysiology, and current management of drowning for the pediatric emergency department patient. We also review outcome predictors and preventive strategies for this major public health problem.
The Editor
Definition
More than 20 definitions of drowning have previously appeared in the literature.3 Unfortunately, these variations in terminology have made it difficult to study drowning, to draw conclusions from studies on drowning, and to form policies for prevention.
In 2002, the World Congress on Drowning issued a new consensus definition for drowning to decrease confusion and allow for easier drowning surveillance worldwide. The goal was to develop a simple, inclusive, specific, and internationally accepted definition. The outcome was the following definition: "Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid." It excludes submersion or immersion incidents in which no respiratory impairment is evident.
Drowning outcomes should be classified as death, morbidity, and no morbidity.4 Morbidity can be further broken down into moderately disabled, severely disabled, vegetative state/coma, and brain death. The terms wet, dry, active, passive, secondary, and silent are now outdated and should no longer be used.
Over time, this definition should lead to more reliable and comprehensive data to address this preventable health problem.
Epidemiology
Drowning is a major cause of death and disability in all age groups worldwide, particularly in the pediatric population.
According to the World Health Organization, an estimated 409,272 drownings occurred worldwide in 2000, making it the second leading cause of unintentional death globally after road traffic injuries.1 In 2004, drowning resulted in more than 175,000 deaths in children ages 0-19 years worldwide, making drowning the third leading cause of unintentional death in the pediatric population.5 Additionally, an estimated 2-3 million children aged 0-14 survived a drowning incident.5
According to the 2007 National Center for Health Statistics Report, drowning is the second leading cause of death in children in the United States.6 One in five fatal drownings occurs in children younger than age 14, and for every child who dies from drowning, four more receive emergency department care for nonfatal submersion injuries.6
Etiology
In the United States, the greatest risk factors for pediatric drowning are sex, age, and minority status.
Males have a 3.7 times greater risk of drowning than females.7 This is possibly attributed to greater male predisposition toward risk-taking and toward activities that put them at greater risk, such as surfing, fishing, and diving.
Age is a bimodal risk factor, with children younger than 4 years and adolescents 15 to 19 years being at highest risk.8 In children younger than 1 year of age, bathtubs, buckets, and abuse are the most likely causes of drowning. In children ages 1 to 5, swimming pools become more likely sources of drowning. In all children in this age group, inattention for less than 5 minutes can lead to drowning. In the teen years, the most likely causes of drowning become natural bodies of water and sport-related injuries.8
The rate of drowning deaths is significantly higher in minority populations as compared to whites.9,10 Between 2000 and 2007, African-American children had a 1.2 times higher risk of drowning than white children, and Native American and Alaskan Natives had a rate of drowning 1.7 times higher than whites.9 Children with parents from rural areas, depressed socioeconomic areas, or with lower education levels are also at increased risk of drowning, regardless of race.11
Drowning also has a clear temporal association. Time of year is an important predictor of drowning. Two-thirds of pediatric deaths from drowning occur between May and August, and most of these occur on the weekends between noon and 8 p.m.12
Additional risk factors for drowning include overestimation of swimming ability, underestimation of environmental factors, lack of available safety equipment, unsafe water transport, and vacationing in unfamiliar settings.
In addition, medical emergencies may contribute to drowning in pediatric patients. These include, but are not limited to, seizures, arrhythmias, syncope, and hypoglycemia. Traumatic injuries to the head or spine may play a role in drowning as well. Unfortunately, drowning may occur as the result of child abuse. In the teen years, psychiatric illness and risk-taking behaviors, such as drug and alcohol use, are associated with drowning.
Pathophysiology
Drowning is a complex process. Upon submersion, voluntary or involuntary breath-holding begins. Involuntary breath-holding is stimulated by the presence of liquid in the oropharynx. Breath-holding is followed by laryngospasm. Halted ventilation leads to the development of hypoxia and hypercarbia, which eventually stimulate laryngospasm release and trigger an involuntary gasp. The liquid medium is subsequently ingested.
In current practice, it is no longer necessary to distinguish between fresh- and salt-water drowning.13,14 Aspirated liquid washes away or damages surfactant, resulting in atelectasis, bronchospasm, noncardiogenic pulmonary edema, shunting, and ventilation-perfusion mismatches. It is the volume, and not the composition, of the aspirated liquid that correlates with the degree of pulmonary dysfunction.
Impaired pulmonary gas exchange results in profound hypoxia and severe acidosis, leading to altered mental status, neurocardiac dysfunction, and, finally, death.15 In the past, it was theorized that 10-15% of drowning victims maintained laryngospasm until death ensued. Death by this manner was termed "dry drowning," as patients died without aspirating water. Experts now believe that death in these cases is likely due to causes other than simple submersion.16 The currently accepted mechanism for drowning is summarized in Figure 1.
Figure 1. Pathophysiology of Drowning
Ingestion of liquid
Involuntary gasp
Impaired gas exchange
Breath-holding
Laryngospasm
Hypoxia
Hypercarbia
Neurocardiac dysfunction
Persistent laryngospasm
Cardiac arrest
Human responses to cold-water submersion are variable and only partially understood. A protective process, similar to the diving reflex exhibited by mammals such as seals, has been described in young children. Exposure to cold water or fear of immersion causes apnea and bradycardia, which are followed by the vasoconstriction of non-essential vascular beds, with shunting to essential coronary and cerebral beds. This allows a longer duration of asphyxia before the patient suffers irreversible cardiac or neurologic injury.15,17 There is question as to whether this phenomenon actually exists in humans.14
Another unique pathophysiologic process is that of the immersion syndrome. The immersion syndrome (also known as the immediate disappearance syndrome) is a dangerous response to cold-water submersion exhibited in some humans. Immersion syndrome is defined as syncope provoked by bradycardia, tachycardia, or arrhythmia precipitated by sudden contact with water at a temperature of at least 5° Celsius less than body temperature.13 The syncope causes loss of consciousness and loss of airway protective mechanisms. This causes earlier aspiration and an accelerated drowning process. The mechanism of this phenomenon has been hypothesized to be that extreme cold exposure causes vagal stimulation and massive release of endogenous catecholamines, which leads to sudden asystole or ventricular fibrillation.18 Interestingly, patients with genetic channelopathies, such as long QT syndrome, are prone to arrhythmias after sudden exposure to cold water.19,20 Fortunately, although some patients may be genetically predisposed, wetting the face and head prior to water entry has been shown to reduce the risk of immersion syndrome.13
As described above, drowning-induced pulmonary injury results in hypoxemia and a combined metabolic/respiratory acidosis. This causes impairment of multiple organ systems, leading to significant morbidity and mortality.
The acute pulmonary injury can be severe. Some patients may even develop acute respiratory distress syndrome (ARDS) due to pulmonary injury. It is important to remember, however, that the clinical manifestations of the initial pulmonary insult may be delayed for several days in some drowning victims. Of note, the aspiration of contaminated water or gastric contents can cause a delayed pneumonia, adding to the initial pulmonary injury.15,21
Neurologic injury is primarily caused by hypoxia and ischemia, and it is secondarily caused by reperfusion injury. Acidosis, edema, and hypotension can lead to impaired cerebral auto-regulation and seizures. Spinal injuries and stroke may also occur.15 Neurologic sequelae are seen in 33% of pediatric drowning survivors, and about 10% have severe sequelae.1
Hypoxemia, acidosis, electrolyte abnormalities, and hypothermia all contribute to cardiovascular dysfunction in drowning. Bradycardia, pulseless electrical activity (PEA), and asystole are common in severely injured patients, while ventricular fibrillation is rare.22 Acute coronary syndrome may also occur.15 Of note, hypotension in drowning victims is usually multifactorial. Hypovolemia may result from blood loss in trauma patients, and patients with hypothermia can become profoundly dehydrated as peripheral vasoconstriction shunts blood centrally, mimicking increased blood volume, which triggers a brisk diuresis.23 Decreased cardiac output from myocardial depression and/or arrhythmias is also possible. In the 24 to 72 hours after injury, Takotsubo stress-induced cardiomyopathy can develop.24
Musculoskeletal injury secondary to trauma or hypoxia may lead to rhabdomyolysis. Acute tubular necrosis and renal impairment may follow up to several days later.15 Disseminated intravascular coagulation (DIC) is another serious complication of near death from drowning.15
Gastrointestinal injuries occur primarily from the ingestion of large amounts of water or secondarily due to ischemia and metabolic abnormalities. Vomiting is a common occurrence.15
In general, electrolyte changes are secondary to gastrointestinal absorption rather than aspiration. The differences between fresh-water and salt-water ingestions are frequently discussed in the literature, but rarely affect clinical practice, as drowning victims have been shown to aspirate a relatively small volume. Autopsies show that most drowning victims inhale less than 4 mL/kg body weight.25 If more than 11 mL/kg is inhaled, blood volume can be increased, and at 22 mL/kg (or approximately 1.5 L in an average adult), changes in electrolytes can be seen, but this is rare.25 A hospital-based case series of 91 drowning victims revealed no patients who required emergent electrolyte interventions.26 In subsequent studies, Modell reported that clinically important electrolyte disturbances were found in less than 15% of human drownings.27,28 The most common electrolyte derangement is metabolic acidosis.23 Hyponatremia may be encountered in children who swallow large volumes of fresh water, and a case of hypercalcemia has been reported in a patient after submersion in drilling fluid and oily sea water.29
Infections may result if pathogens inhaled during drowning increase the risk of some unusual infections. Sinus, pulmonary, and central nervous system (CNS) are the most common sites, and typical organisms include Pseudallescheria boydii-complex, Burkholdina, and Aeromonas.30-32
Hypothermia is a common complicating factor in submersion injuries. Of note, thermal temperature in water is 30 times that of air, and heat loss increases with physical exertion, such as efforts not to drown. Hypothermia develops if the temperature is less than 25°C (77°F). Upon immersion in ice water, hypothermia occurs in as little as 30 minutes, and lift-threatening hypothermia can occur within 60 minutes. Children submerged in cold water develop hypothermia more quickly and to a greater degree than adults due to their higher body surface area to mass ratio.15 Hypothermia may convey a neuroprotective effect, but, overall, is a poor prognostic factor for drowning victims.15
Trauma may also complicate drowning, and it is important to consider the mechanism of injury, such as diving into shallow water, being ejected from a water craft, or being lacerated by debris. In children, a fall from a low height typically results in extremity fractures. Medium heights are associated with both extremity fractures and head and neck injuries, and high falls are associated with multiple trauma.24
Clinical Features
Patients with submersion complaints can run the spectrum from asymptomatic to cardiac arrest.
Chief Complaint. The typical movie portrayal of drowning with dramatic flailing and a prolonged course to submersion is, in reality, quite rare. Drowning victims typically are unable to call for help and actually may appear to be playing, making it difficult for nearby individuals to recognize the earliest signs of distress. Children can only struggle for 10 to 20 seconds before succumbing to submersion.33 Classic presentations of drowning include the unattended toddler, the person floating, or the diver who does not resurface.
Table 1. Important Information to Obtain When Taking Submersion History
|
Components of the Submersion History |
|
|
Environmental |
Water temperature Water composition Water contamination |
|
Drowning event |
Was the event witnessed? Is there a concern for trauma? How long was the patient submerged? |
|
Resuscitation |
Describe the resuscitative efforts. Was CPR required? If so, how long? How much time elapsed between the drowning event and the initiation of resuscitative efforts? How long did the patient require resuscitation prior to arrival in the ED? Was hypoglycemia or hypothermia noted at the scene? |
|
Symptoms |
Does the patient report any symptoms? Does the patient have any respiratory complaints? |
History. History may be obtained from the patient, from EMS, or from bystanders. Key aspects of the submersion history include environmental factors, details of the drowning event, the resuscitation course, and the presenting symptomatology. (See Table 1.) Hypoglycemia and/or hypothermia noted at the scene by EMS are relevant to care in the emergency department. Accurate historical data are difficult to obtain in drowning situations, but it is important for both patient management and to assist in predicting neurologic outcome.
Additional pertinent history information includes known trauma or injury and any use of drugs or alcohol. Also, obtain a past medical history, as underlying medical problems may have contributed to drowning and may influence the management plan.
Examination. A thorough physical examination should be done as part of the evaluation and should include a search for evidence of trauma and the associated injuries. Physical presentation of drowning victims varies widely; patients range from asymptomatic to rigor mortis on arrival to the ED.
Evaluate airway, breathing, and circulation first. Note general appearance, respiratory effort, and Glasgow Coma Scale (GCS). Complete the primary survey with a thorough evaluation of disability and full head-to-toe exposure. The secondary survey should follow.
Vital-sign abnormalities on physical exam may include hypothermia, bradycardia or tachycardia, tachypnea, and hypoxia. Patients may appear anxious or have an altered mental status. The cardiac exam may elicit an arrhythmia, while the respiratory exam may range from clear to poor effort to wheezing and coughing. The gastrointestinal exam is usually unremarkable unless the patient is actively experiencing nausea, vomiting, or diarrhea. The musculoskeletal exam should focus on evaluation for injuries. A thorough neurologic exam should be completed and re-assessed frequently.
Of note, death can only be established if the patient is normothermic with asystole and apnea, if there are signs of prolonged arrest such as rigor mortis or dependent lividity, or if there is no CNS function based on brain death criteria.
Diagnostic Studies
Given the spectrum of clinical presentation in drowning victims, a wide range of diagnostic studies may be appropriate. First, obtain a complete set of vital signs, including an accurate core body temperature with a low-reading thermometer in ill-appearing patients.15 Continuous pulse oximetry is recommended.
Emergently analyze an arterial blood gas (ABG) to accurately assess hypoxemia, as even asymptomatic patients may be surprisingly hypoxic. Obtain an electrocardiogram and institute continuous cardiac monitoring to identify the presence of an arrhythmia, prolonged QT, or evidence of electrolyte abnormalities.
Check rapid bedside blood glucose. Order further laboratory tests, including serum creatinine, electrolytes, and complete blood count. Consider coagulation profile, DIC panel, lactate, liver function tests, urinalysis, and troponin in critically ill patients. Consider toxicologic screening if warranted by history.
Obtain a chest X-ray in all patients. Remember, most radiographs will be normal initially and can grossly underestimate the degree of pulmonary injury.15 If concern for head or neck trauma exists, consider computed tomography (CT) of the brain and cervical spine. Other imaging should be obtained as indicated by the trauma assessment. Abnormal neuroimaging in the first 24 hours, whether CT or MRI, is associated with poor outcome. Intracranial hemorrhage and unilateral findings support a traumatic mechanism and are not typical of hypoxic ischemic encephalopathy.34-36 A normal CT of the brain in the first 24 hours does not ensure good neurologic outcome. The prognostic value of neuroimaging is best 3 or 4 days after injury.34,36
Management
In general, the management of drowning victims should focus on reversing hypoxia to decrease mortality and preserve neurologic function.
Prehospital. In 2010, the U.S. Lifeguard Association reported 46,682 rescues. Children with good outcomes are more likely to have a history of immediate rescue and resuscitation, which highlights the need for good prehospital care.26 Consider scene safety prior to attempting a rescue. Water conditions and panicked drowning victims can be dangerous to rescuers. Approach a struggling victim with an intermediary object to avoid rescuer injury, which is counterproductive and potentially deadly.13,30
Pulmonary resuscitation should begin immediately upon reaching the victim. If deemed safe to perform by the rescuer, rescue breaths should be given prior to extrication from the water. Assessment of pulse can be delayed until the victim has been removed from the water, as buoyancy issues make chest compressions ineffective. Extricate victims as quickly as possible to a safe place where resuscitation may continue. Pay special attention to full spine immobilization when moving the victim. Do not perform the Heimlich maneuver or make other attempts to empty water from the victim's lungs, as these efforts have not been shown to provide benefit and may actually cause harm.13,37
Check for airway obstruction. Relieve upper-airway obstruction with a quick finger sweep or suctioning. Chest compressions may be delivered to relieve lower-airway obstruction. Abdominal thrusts, as in the Heimlich maneuver, should be avoided, as this may precipitate vomiting and aspiration of gastric contents.37 Maintain cervical spine immobilization throughout prehospital resuscitation.
Early resuscitative efforts to restore oxygen supply and circulation improve outcomes.23,38 Administer supplemental oxygen when available. In pulseless patients, continue basic life-saving measures with high-quality chest compressions and utilize an automated external defibrillator (AED) if available.39 Generally, an AED should not be used if the victim or rescuer is in a puddle of water.40 Use AEDs cautiously in hypothermic patients, as multiple defibrillation attempts can be harmful.
In hypothermic victims with a pulse, begin rewarming at the scene. Remove wet clothes and cover the patient with dry blankets or towels. In victims who have arrested and are resuscitated, there is ongoing debate regarding rewarming vs. cooling. Remember, advanced cardiac life support (ACLS) techniques should not delay transport to the ED.
Hospital. The management course for drowning victims in the ED is variable and depends mostly on the severity of injury. (See Figure 2.)
Figure 2. Disposition Algorithm
Absent or Normal
History of:
LOC
Apnea
Cyanosis
Need for pulmonary resuscitation
Abuse concerns
Vital signs
Physical exam
CXR
ABG
ED Observation (6 hours)
Recheck:
Respiratory symptoms
Mental status
Vital signs
Room air pulse-ox
Ambulatory pulse-ox
Present or Abnormal
Absent or Normal
Present or Abnormal
DISCHARGE
ADMIT
Indications for ICU Admission:
Post-arrest patients
Abnormal ABG
Abnormal CXR
Patients requiring ongoing aggressive resuscitation and/or mechanical ventilation
Provide education:
Drowning prevention
Delayed symptoms
Well-appearing patients with a trivial history and normal physical exam may only need parental reassurance.
Asymptomatic patients with a concerning history and mildly symptomatic patients will need observation and diagnostic studies in the ED. At a minimum, obtain a complete set of vital signs with continuous pulse oximetry and a chest X-ray.
Symptomatic patients with hypoxia or any abnormal diagnostic studies will require admission. Moderate-to-severely symptomatic patients requiring aggressive resuscitation likely will require intensive care unit (ICU) admission.
Despite the variations in presentation, the management for all drowning victims in the emergency department begins with the typical airway-breathing-circulation sequence of evaluation and interventions.
Oxygen therapy is the mainstay of treatment for drowning victims. Supplemental oxygen may be administered via nasal cannula or face mask. Some patients may require noninvasive positive pressure ventilation (NIPPV) such as CPAP or BiPAP for additional support. Patients with impaired ventilation and persistent hypoxia despite these noninvasive measures should be intubated and mechanically ventilated. Patients with altered mental status who have lost the ability to provide innate airway protection should be intubated as well. Initial ventilator settings should reflect limited tidal volumes (about 6-8 mL/kg of ideal body weight) and elevated PEEP (5 to 10 cm H2O or higher) to avoid ventilator-associated lung injury (VALI). Elevated PEEP also shifts interstitial water to capillaries, increases lung volume and alveolar ventilation, decreases capillary blood flow, and increases the diameter of small and large airways.
In difficult-to-ventilate patients, consider the following adjuncts. Place an NG or OG to decompress the stomach. Abdominal distension is common after swallowing large amounts of liquid and may contribute to impaired ventilation, especially in young children. Give nebulized albuterol to patients with bronchospasm. In patients with a history of reactive airway disease, corticosteroids may be given for refractory bronchospasm; however, steroids have not been shown to improve outcomes in drowning victims.13 It also may be useful to administer exogenous surfactant.41-44 Surfactant reduces pulmonary surface tension and allows for easier exchange of gas. Patients often require oxygen for 48-72 hours, which is the time it takes pulmonary surfactant to reconstitute. Artificial surfactant may improve hypoxia in drowning victims. Also consider emergency bronchoscopy for refractory hypoxia to evaluate for obstructive foreign material in the bronchi. Up to 60% of drowning victims aspirate foreign material, with common aspirates being mud, sand, and aquatic vegetation.45 Relieving obstruction may improve overall ventilatory status. If a patient suddenly deteriorates, consider pneumothorax, especially if the patient is requiring high levels of PEEP for adequate oxygenation.
If these measures fail and the patient remains persistently difficult to oxygenate, consider high frequency oscillation, prone positioning, or extracorporeal membrane oxygenation (ECMO). ECMO should be considered only if oscillation fails, there is reasonable probability of neurologic function, or if there is persistent hypothermia. In the literature, there are multiple case reports of successful, prolonged treatment.46 Cost and resources remain a consideration, and more research is needed.
Circulation may be a concern in drowning patients as well. ACLS guidelines should be followed in patients who are normothermic with ventricular fibrillation or ventricular tachycardia. If the patient is hypothermic and in ventricular fibrillation, one shock is given and CPR is continued until core temperature is corrected to 30°C, when it is safer to attempt defibrillation again.47 For most patients, arrest will be secondary to PEA from hypoxia, acidosis, and hypothermia. In these cases, correcting the underlying abnormality while continuing resuscitative efforts is paramount.
For hypotension, the initial therapy should be intravenous fluid administration because drowning victims are usually functionally hypovolemic. Begin with a 20 mL/kg bolus of isotonic fluid. Consider bolusing with warm fluids in the hypothermic patient. If pressors are required, dopamine and dobutamine are first-line choices. Patients also may require a central venous catheter for CVP monitoring. This can be helpful in differentiating the etiology of shock: cardiogenic vs. hypovolemic vs. neurogenic. An arterial line also may be useful in the unstable or difficult-to-monitor patient.
Neurologic disability is a major concern in drowning victims. A complete neurologic exam and frequent reassessment are important in the management of a drowning victim. Strive to shorten the duration of the initial insult with early resuscitation and to prevent a second injury with aggressive supportive care with a goal of maintaining adequate oxygen supply to the brain.
Unfortunately, over the last several decades, no new interventions have been found to improve neurologic outcome in children with hypoxic-ischemic injury.48,49 There are insufficient data to support pharmacologic therapy or invasive monitoring to prevent or reduce secondary cerebral edema in cerebral resuscitation.13,24,50 HYPERtherapy (hyperhydration, hyperventilation, hyperpyrexia, hyperexcitability, and hyper-rigidity) is no longer recommended.14,50 Further investigation is needed to improve cerebral resuscitation.
The cervical spine should be immobilized on arrival if not done so already in the prehospital setting. In patients with altered mental status, an unclear or concerning history, and/or signs of serious injury on physical exam, it is safest to maintain c-spine immobilization until imaging studies confirm the absence of injury. In awake and alert patients with a history that is not consistent with significant trauma (i.e., a high-impact event such as diving, fall from height, or boating accident), cervical spine imaging is probably unnecessary.24,51
Hypothermia is common in pediatric drowning victims. Obtain an accurate core temperature and allow sufficient time to assess vital signs, as at least one minute may be required to detect one breath or one heartbeat. Rewarming methods include removing wet clothing, wrapping in warm blankets, giving warm fluids, and using warmed oxygen. More aggressive rewarming methods, including gastric, bladder, mediastinal, or peritoneal lavage with warm fluids, may be needed in unstable patients. In patients who remain hypothermic (< 30°C) despite the above measures, consider cardio-pulmonary bypass or ECMO.52 In current practice, rewarming goals include a rapid correction to 30-32°C, followed by a slow return to normothermia and avoidance of hyperthermia.
There is ongoing debate about intentional hypothermia in post-arrest drowning victims. Literature in other post-arrest patients seems to support hypothermia for better neurologic outcomes.53-57 A few case reports and small studies indicate that this same neuroprotection may be conveyed to drowning victims, but more research is needed to reach any meaningful conclusions, especially in the pediatric population.58-60
Following the primary survey, complete a thorough secondary survey looking for traumatic injuries or clues of medical emergency. In critically ill patients, place a Foley catheter to monitor urine output. Consider antibiotics in a patient who has drowned in contaminated water or sewage. Otherwise, antibiotics are not indicated in the initial management of a drowning victim.21 Send appropriate cultures prior to the initiation of antibiotic therapy.
Consultations
Early consultation with the pulmonary critical care team or the admitting physician should occur in patients with respiratory compromise or neurologic dysfunction, especially if there is ongoing hypoxia. If considering ECMO or cardiopulmonary bypass, consult trauma surgery or cardiovascular surgery as appropriate in your institution. Consider neurosurgical, trauma, or orthopedic surgery consultation for significant head, spine, or other trauma.
Disposition
Symptomatic patients must be admitted to the hospital. Patients who have required CPR or ventilatory support or who have abnormal chest radiographs or blood gases in the emergency department should be admitted to the ICU or transferred to a facility with the appropriate level of care.13 (See Figure 2.)
Asymptomatic patients with a history of loss of consciousness, apnea, cyanosis, or need for pulmonary resuscitation should be admitted for observation. (See Figure 2.)
After 6 hours of observation, you may safely discharge asymptomatic patients with a trivial submersion history, normal physical examination, normal room air pulse oximetry, normal chest radiograph, and normal blood gas.15,61,62 Ambulatory pulse oximetry in older patients may be useful in borderline cases.
Admit patients when child abuse is a concern. See Figure 2 for a summary of disposition decision-making.
Discharge instructions must educate patients and caregivers on the signs and symptoms of delayed pulmonary or neurologic complications.15,61 It is important to educate parents about drowning prevention at the time of discharge.63 Ensure follow-up with the patient's primary care doctor in 1-3 days for a recheck.
Predicting Outcomes
The most important determinant of neurologic outcome is the duration and severity of the initial asphyxial insult.23 Fast rescue and early resuscitation have been shown to improve outcomes.13,22,23,38,50,64 In a study of out-of-hospital cardiac arrest due to drowning, authors found that being witnessed, a short duration of submersion, early resuscitation by EMS, and rapid transport to the hospital are important factors for survival after drowning.65 Several prognostic scoring systems have been developed to predict neurologic outcomes in drowning victims.
The Orlowski criteria, which was first published in 1979, is still used today.66 The criteria in the Orlowski score are as follows:
Age less than 3 years;
Submersion time of more than 5 minutes;
No resuscitative efforts for more than 10 minutes after rescue;
Comatose on admission to the emergency department;
Arterial pH of less than 7.10.
Each criterion is equal to one point. If the score is less than 3, a patient has a 90% likelihood of neuro-intact recovery. A score of 3 or more is associated with only a 5% chance of survival.66
The Pediatric Risk of Mortality (PRISM) score has also been used to predict prognosis in critically ill children.67 When applied to drowning victims, the PRISM score has been useful in determining those patients with a high risk of death or severe neurologic impairment and those with no risk, but an intermediate PRISM score does not allow a reliable prediction of prognosis.68
Despite these scoring systems, patients who arrive in the ED comatose with nonreactive pupils and a GCS of 3 after drowning have been shown to have full neurologic recovery.69 Accurate prediction of long-term outcomes in the ED is not possible at this time. Therefore, all victims should be treated initially unless rigor mortis is present.14,50 Discontinuing care is at the judgment of the treating physician.
Deterrence and Prevention
Risk of drowning is multifactorial. Several interventions have been shown to decrease the risk. Unfortunately, no one intervention will prevent all drowning deaths. Drowning prevention strategies should target both the environment and the individual, and the overall strategy for decreasing risk of drowning should be as multifactorial as the risks.
Parents should be educated that adult supervision is paramount. Inattention for less than 5 minutes can result in devastating drowning or near-drowning in the pediatric population. Supervision of young children in swimming pools and bathtubs should be touch close, and close supervision of older children should also occur. Despite known risks, a 2007 study showed that nearly half of parents failed to provide close supervision to children ages 5-9 at the beach.70
To augment adult supervision, environmental risks should be minimized when possible. Since the most likely source of drowning in children younger than age 1 is shallow water accumulations, unnecessary water in buckets and bathtubs should be drained. Additionally, wells should be covered with heavy grills. In children ages 1 to 4 years, most drownings occur in residential swimming pools. Pools should be fenced with fences at least 4 feet high with self-closing and self-latching doors, with the latch at least 54 inches from the bottom of the gate.11 Fifty percent to 90% of childhood drowning events could be prevented by four-sided isolation fences around pools.71-73 Of note, solar pool covers actually add to the danger of pools. Children may perceive that they can walk on these, become entangled, and drown.
Swimming proficiency is important as well. The American Academy of Pediatrics (AAP) recommends swimming lessons for children ages 4 years and older without physical or developmental disabilities. Additionally, since better outcomes are associated with immediate resuscitation, the AAP also recommends that parents and caregivers be trained in infant and child CPR.
The use of personal floatation devices (PFDs) when boating is also recommended.11 In 2008, the U.S. Coast Guard reported 709 boating-related deaths. In 90% of these, PFDs were not worn.39 Of note, inflatable swimming aids and toys should not be used in place of PFDs.11 Arm buoys should be avoided in children.
Alcohol is known to be a contributor in adolescent and teen drownings. Fifty percent of adolescent and adult drowning deaths are related to recreational water activities, and 1 in 5 boating fatalities involves alcohol.74,75 Children and parents should be counseled that no alcohol should be consumed while swimming, participating in water activities, or boating.
Additional counseling for swimming in natural bodies of water should include knowing the weather, heeding beach flags, and being aware of large waves and rip currents.
Other possible interventions, including restricting access to dangerous areas, physician counseling of water risks, and laws involving the blood alcohol level of swimmers, remain under study. Drowning prevention education provided by emergency physicians is well received by patients and caregivers.63 Specific advice to parents from the AAP regarding drowning prevention is included in Table 2. Incorporating this information into discharge instructions is a great, time-efficient way to provide drowning prevention education in the emergency department.
Table 2. Drowning Prevention Handout
Drowning Prevention
Advice from the American Academy of Pediatrics:
1. Never even for a moment leave small children alone or in the care of another young child while in bathtubs, pools, spas or wading pools, or near irrigation ditches or standing water. Bath seats cannot substitute for adult supervision. Empty water from buckets and other containers immediately after use. To prevent drowning in toilets, young children should not be left alone in the bathroom.
2. Closely supervise children in and around water. With infants, toddlers, and weak swimmers, an adult should be within an arm's length. With older children and better swimmers, an adult should be focused on the child and not distracted by other activities.
3. If children are in out-of-home child care, ask about exposure to water and the ratio of adults to children.
4. If you have a pool, install a four-sided fence that is at least 4 feet high to limit access to the pool. The fence should be hard to climb (not chain-link) and have a self-latching, self-closing gate. Families may consider pool alarms and rigid pool covers as additional layers of protection, but neither can take the place of a fence.
5. Children need to learn to swim. AAP supports swimming lessons for most children 4 years and older. Classes may reduce the risk of drowning in younger children as well, but because children develop at different rates, not all children will be ready to swim at the same age.
6. Parents, caregivers, and pool owners should learn CPR.
7. Do not use air-filled swimming aids (such as inflatable arm bands) in place of life jackets. They can deflate and are not designed to keep swimmers safe.
8. All children should wear a life jacket when riding in a boat. Small children and nonswimmers should also wear one at water's edge, such as on a river bank or pier.
9. Parents should know the depth of the water and any underwater hazards before allowing children to jump in. The first time you enter the water, jump feet first; don't dive.
10. When choosing an open body of water for children to swim in, select a site with lifeguards. Swimmers should know what to do in case of rip currents (swim parallel to the shore until out of the current, then swim back to the shore).
11. Counsel teenagers about the increased risk of drowning when alcohol is involved.
Summary
Drowning is a common, complex, often fatal event that can be especially devastating in the pediatric population. Prognosis is directly related to the duration and magnitude of hypoxia, and treatment should focus on early aggressive management to correct hypoxia and preserve neurologic function. Despite the frequency of drowning events worldwide, there are still many questions yet to be answered in the search for the best approach to prevention and treatment.
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Drowning is a major global public health problem. In 2000, the World Health Organization reported drowning as the second leading cause of unintentional death worldwide.Subscribe Now for Access
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