Pediatric Drowning
AUTHOR
Daniel Migliaccio, MD, Clinical Assistant Professor, Ultrasound Fellowship Director, Department of Emergency Medicine, University of North Carolina, Chapel Hill, Vice President, AAEM Young Physician Section
PEER REVIEWER
Aaron Leetch, MD, FACEP, Associate Professor, Director, Combined EM and Peds Residency, University of Arizona College of Medicine, Tucson
Pediatric drowning events are associated with consequences varying from transient pulmonary symptoms to devastating neurologic disability. All acute care providers need to be prepared to diagnose and effectively manage a child with this type of injury.
— Ann M. Dietrich, MD, Editor
Introduction
Drowning refers to the process of submersion/immersion into a liquid medium, which results in respiratory difficulty and/or arrest.1,2 Definitions of drowning are widely inconsistent and have led to confusion among medical professionals.3 To prevent the use of nonspecific and outdated terminology, consensus guidelines from the World Health Organization have put forth three specific classes of drowning: drowning death, drowning with morbidity, and drowning without morbidity.4,5,6 The terms “near drowning” and “dry drowning” are no longer recommended as diagnoses and should no longer be used in the description of a submersion injury. Although the vast majority of victims involved in submersion accidents survive, there is a wide range of morbidities, which may be associated with a drowning event, including minimal transient pulmonary symptoms to profound long-term neurological disability.7 Emergency providers frequently encounter victims of submersion injury, and knowledge of the pathophysiology, clinical presentation, and management are crucial.
Epidemiology
Each year there are more than 370,000 deaths associated with drowning worldwide.8 Alarmingly, it is estimated that there are potentially 40% to 50% more drowning deaths that are unaccounted for in this figure, since they are classified as “water transport incidents” and not drowning.9 Rates of drowning also are significantly higher in low- and middle-income countries, accounting for greater than 90% of all drowning deaths worldwide.10 Moreover, drowning is one of the 10 leading causes of death in every region of the world for people ages 1-24 years. In the United States, each year there are more than 500,000 drowning events and more than 1,100 deaths. Drowning is the leading cause of accidental death among children younger than 15 years of age.11
The highest incidence of drowning occurs in children younger than 5 years of age, with a second peak occurring in teenage children from 15 to 24 years of age.12,13 Approximately 25% of all drowning victims are children younger than the age of 14 years and more than 50% of all drowning deaths are among those younger than 25 years of age.14,15 The groups of children with the highest rates of drowning in the United States are African-Americans, children in southeastern states, children in areas of poverty, and among children from a low socioeconomic status.16,17,18 Males are at higher risk to drown and are two times as likely to drown than females regardless of age.19,20
With increasing participation in water sports, drowning is more frequent in the summer months and in locations closer to bodies of water, oceans, lakes, rivers, and ponds.21,22 Drowning is a leading cause of death in children younger than 5 years of age in locations where bodies of water are more accessible and with heavy engagement in water sports, such as Florida and California.23,24,25 Regardless of access to a coast, however, it appears most drowning happens inland in bathtubs, ponds, and pools. Drowning is thought to be the most preventable cause of accidental death and injury among children.26
Risk Factors
Multiple risk factors have been associated with an increased risk of drowning. In children younger than 5 years of age, the greatest risk factors include a lack of adult supervision, behavioral disorders, and undetected seizure or dysrhythmic disorders. For older children, a lack of water safety practices and misjudgment in swimming skill have been shown as risk factors associated with an increased risk of drowning. Children with behavioral disorders and children with a greater propensity to higher risk-taking behavior also are at a greater risk for drowning. Perhaps the most important risk factor for drowning worldwide is inappropriate use of alcohol and other illegal drugs, especially for adolescents and young adults.27
Pathophysiology
Drowning injuries initiate after a victim’s airways become submerged in a liquid substance. Initially, there is a stimulation of an innate protective parasympathetic nervous system activation, known as the diving reflex. This reflex leads to peripheral vasoconstriction, central shunting of blood flow, bradycardia, and hypopnea. This reflex was thought to provide some initial protection in patients experiencing submersion injury. However, the stimulation of the fight-or-flight response and activation of the sympathetic nervous system immediately overwhelms the diving reflex and dissipates its protective nature.28 Following the initial diving reflex, a drowning person begins to have a pattern of disorganized breathing, breath-holding, and eventually a reflex inspiratory effort leading to aspiration of liquid.
The liquid that is aspirated creates a dilution effect on surfactant, leading to an alteration in alveolar surface tension, alveolar collapse, and a decrease in lung compliance. This surfactant washout leads to a ventilation/perfusion mismatch with intrapulmonary shunting of blood flow (as these alveoli are not ventilated) and, ultimately, hypoxemia. In addition, fluid that is inhaled enters into the airways and alveoli, leading to the development of noncardiogenic pulmonary edema.
The distinction of the type of water aspirated leading to drowning is irrelevant.29,30 Previously, it was thought that aspirated salt water and its hypertonicity led to a shifting of water into the alveolar space and pulmonary interstitium, leading to pulmonary edema and hypertonic serum. Alternatively, aspirated fresh water or hypotonic solution aspiration was thought to lead to shifting of fluid into the intravascular compartment from the alveolar space, leading to volume overload and electrolyte dilution, such as hyponatremia. This distinction is only apparent in patients who were found dead on arrival, as opposed to nonfatal drowning victims, given that for a shift in electrolytes/blood volume to occur, the person would need to aspirate 11 mL/kg to 22 mL/kg of body weight.31,32,33 Typically, in nonfatal drowning victims, there is less than 3 mL/kg to 4 mL/kg of fluid aspirated, making the distinction between salt and fresh water clinically irrelevant.34,35
Another potential mechanism for the development of hypoxia after submersion injury involves reflexive laryngospasm. On aspiration of a liquid medium, a person may develop a reflex laryngospasm, which leads to hypoxemia. This is followed by aspiration of the liquid into the airways, which worsens this hypoxemia. The reflex laryngospasm was the mechanism previously thought to be involved in “dry” drowning death. This out-of-date term was coined secondary to the absence of fluid in the lungs on autopsy. However, the absence of aspirated fluid has been widely disproven, and all drowning deaths will have some degree of water in airways.36 The term “dry drowning” should be avoided.37
Regardless of the initial mechanism leading to fluid in the airways, there is an ensuing hypoxia, hypercapnia, and acidemia. End organ damage is a result of the lack of tissue oxygenation in patients with submersion injury. Ultimate morbidity, mortality, and outcome in submersion injury are related to the degree of hypoxic end organ damage and, most importantly, are related to the degree of ischemic insult to the central nervous system.38
Clinical Presentation
The end organ effects of submersion injuries or drowning with morbidity are secondary to the hypoxemia that ensues.39 The most commonly affected system is the respiratory system. The aspiration of fluid can lead to a clinical picture akin to any etiology of noncardiogenic pulmonary edema and, in some cases, a clinical picture of acute respiratory distress syndrome (ARDS).40 Respiratory failure can ensue, and pulmonary symptoms can develop immediately and/or can occur in a subacute manner. Patient symptoms include shortness of breath and cough. Physical exam findings can include hypoxia, increased work of breathing with tachypnea, accessory muscle use, rhonchi, rales, crackles, and/or wheezing.
Neurologically, hypoxemia can lead to neuronal hypoxia and cellular damage. This cellular damage can lead to cellular apoptosis, a degree of cerebral edema, and an increase in intracranial pressure. It is estimated that approximately 20% of nonfatal drowning victims sustain some degree of hypoxic-ischemic brain injury that leads to an increased risk of long-term morbidity.41,42 The hypoxemia from drowning and the potential hypothermia that ensues after a nonfatal submersion injury can lead to cardiac dysrhythmias. These arrhythmias can include atrial fibrillation, ventricular dysrhythmias, and sinus bradycardia.43
Another frequently encountered complication in patients with a significant submersion injury is renal injury. Renal injury in drowning victims typically occurs secondary to acute tubular necrosis from the hypoxemia and/or the cardiovascular compromise resultant from the shock that may occur secondary to the submersion event. As mentioned earlier, it is relatively infrequent that submersion injuries lead to life-threatening electrolyte disturbances regardless of water tonicity secondary to the quantity of water aspirated in nonfatal drowning victims. Rarely, electrolyte abnormalities may develop as a result of the renal injury from the submersion-related hypoxemia.44,45 Infrequently, drowning victims also may develop a consumptive coagulopathy or disseminated intravascular coagulation.
Diagnostic Studies
In patients who are symptomatic from a submersion injury, chest radiography, such as a plain film chest X-ray, along with laboratory studies should be performed to evaluate for complications of pulmonary aspiration and/or hypoxia-related end organ damage. It is unnecessary to obtain chest imaging and/or laboratory studies in patients who are asymptomatic since they are not predictive of morbidity or the need for hospitalization.46 In addition, initial chest imaging may be normal in patients with submersion injury.
Potential findings on chest imaging include patchy airspace opacities, an increase in perihilar markings, cephalization, and/or diffuse pulmonary edema. (See Figures 1 and 2.) Drowning victims typically do not develop pleural effusions and/or pneumothorax unless these pathologies complicate their hospital course. Neuroimaging also may be indicated in patients with significant submersion injury who develop significant alteration to their mental status to detect the amount of hypoxic-ischemic brain tissue damage. Of note, hypoxic-ischemic brain tissue injury may not be apparent on the initial computed tomography (CT) performed in the emergency department, and the patient may require delayed inpatient advanced neuroimaging such as magnetic resonance imaging (MRI).
Figure 1. Chest Radiograph Following Drowning Event |
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Image courtesy of Ann M. Dietrich, MD. |
Figure 2. Chest Radiograph with Atelectasis |
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Image courtesy of Ann M. Dietrich, MD. |
The use of point-of-care ultrasound (POCUS) also can be incorporated in the evaluation of drowning victims. POCUS is readily available, repeatable, and without ionizing radiation. It can be used to monitor a patient during the emergency department observation period, or while the patient is admitted to evaluate the progression of pulmonary injury. Specifically, the degree of pulmonary edema is evaluated by noting the quantity and patterns of B lines present. B lines on POCUS in drowning victims generally will be bilateral and seen in multiple lung zones. B lines result from reverberation artifact created by the presence of fluid in the alveolar space and they appear as a vertical beam extending from the proximal pleura (closest to the transducer) to the bottom of the ultrasound screen. (See Figure 3.) Normal lung, on the other hand, will typically demonstrate A lines. (See Figure 4.) A lines are also created by reverberation artifact, but they appear as multiple horizontal lines that are equidistant from the pleural line. Diffuse B lines in the clinical setting of drowning can be secondary to pulmonary edema and/or acute respiratory distress syndrome. Other nondrowning differential diagnoses for diffuse B lines include cardiogenic pulmonary edema and pulmonary fibrosis.47
Figure 3. Point-of-Care Ultrasound |
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Point-of-care ultrasound of the lung demonstrating multiple B lines (arrows) originating from pleural line (star) and extending to the bottom of the ultrasound monitor. Typically, a diffuse bilateral thorax B line pattern will be seen in patients with significant respiratory symptoms after drowning. |
Figure 4. Point-of-Care Ultrasound Demonstrating A Lines |
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Point-of-care ultrasound of the lung demonstrating multiple A lines (arrows) originating from pleural line (star). Note each A line is equidistant from the pleural line. |
Initial Management
Management of patients who survive submersion injuries initiates with prehospital care. Prehospital management focuses on immediate cardiopulmonary resuscitation as indicated. Standard guidelines for basic life support should be followed.
Although the overall rate of cervical spine injury in drowning victims is low,48 prehospital care may need to consider spinal motion restriction if there was a potential associated traumatic mechanism (such as diving, etc.), and/or evidence of intoxication. Concomitant dysrhythmias should be treated via pediatric advanced life support protocols.49
On arrival to the emergency department, drowning victims need to have immediate assessment of their airway. Symptomatic patients should have continuous oxygen saturation monitoring, cardiac telemetry, and end-tidal carbon dioxide monitoring. Submersion injury victims presenting with a Glasgow Coma Scale score of less than 13 and/or hypoxia should be provided supplemental oxygen and potentially ventilatory support.
In patients who are symptomatic but who do not require immediate intubation, supplemental oxygen should be given to maintain oxygen saturation above 94%. Options for oxygenation include noninvasive positive pressure ventilation (NIPPV) such as continuous positive airway pressure or bilevel positive airway pressure (CPAP/BiPAP). The positive end expiratory pressure (PEEP) achieved with NIPPV can improve oxygenation and decrease ventilation/perfusion mismatch in patients who have pulmonary edema from a submersion injury.28 Patients who cannot tolerate CPAP or BiPAP can receive a trial of high-flow nasal cannula (HFNC), although the PEEP that can be obtained via HFNC is limited compared to NIPPV.
Ultimately, drowning victims may require tracheal intubation. Endotracheal intubation should be considered if the patient is unable to achieve a partial pressure of oxygen of greater than 60 mmHg in adults and greater than 80 mmHg in children or if there is an inability to maintain an oxygen saturation above 90% despite NIPPV. Similarly, endotracheal intubation is indicated in victims who are obtunded, unable to protect their airway, and/or with significant neurological deterioration.
In addition to airway and breathing assessment and management, the drowning victim should have a trauma exam performed noting any potential traumatic injuries and follow advanced trauma life support guidelines as appropriate. However, it is infrequent that a drowning victim will have concomitant life-threatening trauma and/or spinal injury.
Pediatric drowning victims presenting to the emergency department in cardiopulmonary arrest should be resuscitated according to pediatric advanced life support guidelines. Victims with a shorter submersion duration (less than five minutes), immediate bystander CPR, and rapid presentation to the emergency department should undergo an aggressive cardiopulmonary resuscitation attempt since they have a greater likelihood for favorable neurological outcomes. Similarly, pediatric drowning victims presenting in cardiac arrest with concomitant hypothermia from drowning in cold water (icy water) should receive aggressive and potentially prolonged resuscitative efforts because of the possibility of favorable neurological outcome.50,51
Pediatric victims who are hypothermic (core temperature < 35°C) should be resuscitated while rewarming to a core temperature of 32°C to 35°C.52,53 However, pediatric drowning victims who have a prolonged submersion (greater than 15 minutes) and who are normothermic, aggressive emergency department resuscitation may be avoided as there is extremely poor prognosis for an intact neurological outcome in these circumstances.54,55 A good neurological outcome is more likely when spontaneous circulation returns within 30 minutes of advanced life support, especially when the drowning incident occurs in winter.56 In addition, hyperkalemia (> 10 mmol/L) in hypothermic drowning victims can be used as an indication to consider cessation of resuscitation.57,58 Immediate removal of wet clothing should be performed, in an effort to decrease the potential hypothermia.
Hypothermia Management
Hypothermic victims should be rewarmed via passive (immediate removal of wet clothing) and/or active rewarming techniques. (See Table 1.) Various levels of hypothermia typically will present with specific features. Drowning victims with mild (35-32°C) hypothermia usually have an intact mental status, are shivering, and are usually without organ dysfunction such as cardiac dysrhythmias. They should have passive and active external warming, such as forced warmed air, performed.59 Victims with moderate hypothermia (< 32-28°C) may have an altered mental status, shivering may not be present, and patients are predisposed to atrial dysrhythmias (fibrillation/flutter). Moderate hypothermia patients should be rewarmed via active internal techniques. Similarly, an electrocardiogram (ECG) obtained on patients with moderate hypothermia may demonstrate a J- (Osborn) wave, and the amplitude correlates with the degree of hypothermia. Victims presenting with severe hypothermia (< 28°C) typically are obtunded, have absent reflexes, and are susceptible to ventricular fibrillation and asystole.60,61 Of note, defibrillation and resuscitative drugs/antiarrhythmic agents may be ineffective at temperatures < 32°C.62,63
Table 1. Rewarming Techniques |
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Passive |
Active External |
Active Internal |
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Remove cold wet clothes |
Warm blankets |
Warm intravenous fluids |
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Give warm clothes |
Bair hugger |
Warm water lavage (gastric/bladder/rectal/thoracic/peritoneal) |
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Increase room temperature |
Forced warm air |
Warm humified oxygen via endotracheal tube |
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Extracorporeal rewarming |
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Active internal techniques of rewarming hypothermic patients in cardiopulmonary arrest can involve the use of warm intravenous (IV) fluids (38-42°C), warm water lavage (gastric/bladder/rectal/thoracic/peritoneal), and provision of warm humidified oxygen via the endotracheal tube.64 If it is available, extracorporeal rewarming and extracorporeal membrane oxygenation (ECMO) should be a consideration in pediatric drowning victims presenting in cardiac arrest with concomitant hypothermia. ECMO has the fastest rate of rewarming, at a rate of ~7°C/hour.65 A retrospective study demonstrated a 23.4% survival in drowning victims placed on extracorporeal life support during cardiac arrest from drowning.66
In addition, it is important to note the concept of core temperature afterdrop in the management of hypothermic patients. This phenomenon occurs from continued cooling after the patient is removed from the cold environment secondary to the return of cold blood from the periphery to the core. This continued drop in core temperature is frequently encountered during the initial resuscitation, but it typically is transient and should not alter rewarming management and resuscitation.
Pediatric patients presenting with drowning injury and hypothermia also may develop hypotension secondary to a phenomenon known as a “cold diuresis.” Diuresis occurs secondary to peripheral vasoconstriction leading to the central volume receptors sensing a hypervolemia. In turn, this leads to a decreased production of antidiuretic hormone and an inappropriate diuresis and potential hypotension. Intravenous fluid administration may be required to maintain volume status in these patients. However, another etiology of hypotension in drowning victims includes a hypoxia-induced cardiomyopathy, which can lead to a picture of decompensated cardiogenic shock. Fluid administration in this case can create a worse hemodynamic status and potentially cardiopulmonary collapse.
Post-Resuscitation Management
Management for symptomatic patients who are admitted to the hospital is mostly supportive. Pediatric patients who require cardiopulmonary resuscitation, as well as those who require prolonged positive pressure ventilation in the emergency department, should be admitted to an intensive care unit for continuous cardiopulmonary monitoring.67 Continued positive pressure ventilation may benefit in recruiting fluid-filled alveoli and improving oxygenation. It is important that these admitted patients be monitored for acute respiratory distress syndrome. Additionally, drowning victims who obtained a return of spontaneous circulation (ROSC) after cardiopulmonary arrest may require continuous pressor support with epinephrine.
The routine use of antibiotics has not been demonstrated to improve outcome and should only be reserved for evidence of pulmonary infection and/or submersion in grossly contaminated water. Coverage for species such as Pseudomonas and/or Aeromonas species should be considered in these circumstances.68 In cases of submersion in grossly contaminated water, antibiotic selection should include an antipseudomonal beta lactam.68 Systemic glucocorticoids often are given for patients with significant pulmonary involvement after a submersion event, but they have not been shown to improve outcomes.
Submersion injury can lead to hypoxic-ischemic brain injury and associated cerebral edema. Intensive care management may include attempts to manage the associated increase in intracranial pressure with hypertonic saline, mannitol, and/or loop diuretics. These attempts to decrease intracranial pressure should be considered but have failed to demonstrate significant benefit in long-term neurological disability in drowning victims.67 Similarly, pediatric victims of drowning who undergo aggressive post-resuscitation care, such as induced hypothermia, induced coma or paralysis, and invasive intracranial monitoring, have not been shown to have improved long-term neurological outcomes.45
Admission/Discharge Planning
Patients who present to the emergency department with an intact mental status and an oxygen saturation above 95% on room air are considered low risk for complications and should be monitored in the emergency department for approximately six to eight hours. If after this period of observation the patient remains asymptomatic or minimally symptomatic with a normal pulmonary examination (absence of rhonchi, rales or wheezing, increased work of breathing as well as an oxygen saturation above 95% on room air), they can be discharged home safely if the child has a safe social disposition and appropriate adult supervision.69,70 Strict return precautions should be discussed and include the occurrence of pulmonary symptoms such as cough, shortness of breath, development of fever, and/or any neurological symptoms. If after the period of observation the victim develops an oxygen requirement or abnormal pulmonary exam findings, such as rales, rhonchi, or increased work of breathing, the patient should be admitted to the hospital to a monitored setting until symptoms and/or hypoxia are resolved. Other indications for hospital admission are detailed in Table 2.
Table 2. Indications for Hospital Admission for Nonfatal Drowning |
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Prognosis
Data are limited regarding the survival rate post-drowning secondary to inadequacies in data reporting. In addition, the incidence of long-term morbidity from neurological complications has varied widely.71 However, the majority of patients involved in a submersion incident who are asymptomatic, with stable vital signs and normal neurological exam on presentation to the emergency department, will survive with minimal to no long-term disability. Similarly, drowning victims requiring hospital admission and/or who had a submersion injury that did not require first responder or emergency department cardiopulmonary resuscitation will typically recover within 48 hours. Infrequently, submersion victims will develop a delayed acute respiratory distress syndrome and will require prolonged hospitalization and can develop significant morbidity and risk for mortality.
On the contrary, drowning victims who require CPR at the scene or in the emergency department have a poor prognosis.55,72 In the same light, victims who arrived to the emergency department with an unstable cardiorespiratory status and/or poor mental status/stupor have been shown to have a higher likelihood of long-term morbidity and mortality from hypoxic-ischemic central nervous system (CNS) damage.73,74 There is an approximate 20% mortality rate among pediatric patients who require cardiopulmonary resuscitation at the scene of the incident. Of those who do survive, approximately 5% will have significant long-term CNS damage from hypoxic-ischemic neurological insult.73
Several other prognostic factors have been correlated with a worse prognosis in patients with submersion injuries. (See Table 3.) These include duration of submersion greater than five minutes, delayed time to basic life support, a prolonged resuscitative effort, a Glasgow Coma Scale score of less than 5 on emergency department presentation, severe acidosis with an arterial blood pH less than 7.1 on presentation, persistent and prolonged apnea, as well as the requirement of cardiopulmonary resuscitation in the emergency department.75 Worse outcomes also have been seen in patients with concomitant suspected drug and/or alcohol abuse.
Table 3. Prognostic Indicators for Worse Outcomes in Drowning Victims |
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There have been rare case reports of pediatric survival after cardiac arrest following an ice water submersion. This is thought to be secondary to the benefits of hypothermia.28,75 It is believed that cold water leads to CNS cooling prior to significant hypoxic tissue damage.26 However, available data have failed to demonstrate any favorable survival among victims with prolonged submersion greater than 15 minutes, whether in cold or warm liquid medium.76 Case reports also have failed to demonstrate any significant survival after a submersion of greater than 60 minutes.76 In addition, there has been no demonstrated difference in survival rates of pediatric victims as compared to adults with regard to water temperature.76,77,78
Prevention
Most cases of pediatric drowning are preventable. Prevention measures, such as secure fencing and appropriate enclosures/gating of swimming pools, can prevent children younger than 4 years of age from being exposed to the body of water and potentially decrease the incidence of drowning by 80%.23,79 Similarly, it is important that children have adequate adult supervision and use protective personal flotation devices. It is also crucial that parents are educated regarding the possibility of toddlers drowning in extremely shallow areas of water, including bathtubs, buckets, and toilets, if there is inadequate supervision. The American Academy of Pediatrics Subcommittee on Injury, Violence and Poison Prevention has made available technical support on drowning prevention to assist in instructing community programs.80,81 Similarly, the World Health Organization and the Centers for Disease Control and Prevention have published online materials to guide nonmedical personnel and parents to prevent drowning injuries.5,82
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Pediatric drowning events are associated with consequences varying from transient pulmonary symptoms to devastating neurologic disability. All acute care providers need to be prepared to diagnose and effectively manage a child with this type of injury.
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