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Drowning Episodes: Family Medicine Residency, Methodist Hospital, St OnLine ExCluSivE Sean C. Engel, MD University of Minnesota Drowning episodes: Family Medicine Residency, Methodist Hospital, St. Prevention and resuscitation tips Louis Park [email protected] CPR for drowning survivors differs from that commonly The author reported no potential conflict of interest used in cardiogenic cardiac arrest. Routine antibiotic relevant to this article. prophylaxis is not indicated. young mother in your practice wants her toddler to be- PraCtice gin swimming lessons because her family loves water recommenDation activities. How would you advise her? In fielding an › A Recommend swimming urgent call about a drowning incident, what priorities would lessons for all children you urge regarding resuscitation at the scene? For a stabilized ages 4 and older. C patient following a drowning episode, when might antibiotics › Consider antibiotics be indicated? This article covers these issues as well as follow- after a drowning event up matters such as assisted ventilation and tiered hypothermia only if the water is known intervention. to be contaminated or the victim has aspirated a large volume of water. C Drowning likely occurs more often › Monitor asymptomatic than is reported patients for at least 4 hours Worldwide, drowning accounts for more than 388,000 deaths after a drowning event. C annually and is the third leading cause of unintentional in- jury death. Low- and middle-income countries represent 96% Strength of recommendation (SOR) of the yearly total.1 As reported in the United States, nearly A Good-quality patient-oriented evidence 6000 individuals are hospitalized and nearly 4000 die from B Inconsistent or limited-quality drowning events annually.2 But these figures likely underes- patient-oriented evidence timate the true rate, as many drowning fatalities are officially C Consensus, usual practice, opinion, disease-oriented attributed to floods, boating accidents, or other associated evidence, case series events. Nonfatal drownings often go unreported. Children under the age of 5 years have the highest drown- ing mortality worldwide, and drowning is the leading cause of unintentional injury death for this age group in many coun- tries, including the United States.1,2 Men are nearly 4 times as likely to die from drowning than women.2 Predictably, in the United States most drowning happens on the weekend and dur- ing summer months. More than half of drownings in children younger than 4 years occur in swimming pools; with increasing age, drowning is more likely to occur in natural bodies of water.2 With adults in higher income countries, alcohol is a significant contributor to drowning events during recreational activities.3-5 conTinUed jfponline.com Vol 64, no 2 | FEBRUARY 2015 | The journAl of FamilY PracTice E1 Much effort has been made in recent and mortality from drowning episodes. Breath years to standardize the nomenclature and holding and immersion in cold water each can treatment of drowning episodes. The Inter- induce cardiac arrhythmias. When combined, national World Congress on Drowning met in these events may increase the risk of an arrhyth- the Netherlands in 2002, and established the mogenic state secondary to opposing chrono- definition of drowning as “the process of ex- tropic effects: the diving reflex (bradycardia periencing respiratory impairment from sub- via parasympathetic activation), and the cold mersion/immersion in liquid.”6 Submersion shock response (tachycardia via sympathetic refers to the complete submergence of the activation). This is thought to be an underre- victim under the water, while immersion im- ported cause of death in drowning, as arrhyth- plies that the victim’s airway remains above mias are undetectable during autopsy.8,11 the water. The Congress recommended that terms such as “wet-drowning,” “dry-drowning,” and Drowning prevention “near-drowning” be discontinued in favor The American Academy of Pediatrics (AAP) of the outcome classifications “death,” “no recommends swimming lessons for most morbidity,” and “morbidity.” The “morbid- children ages 4 years and older.12 Previously, ity” subgroup was further characterized as swimming lessons were not recommended “moderately disabled,” “severely disabled,” for children ages 1 to 4 because evidence of CPr should “vegetative state/coma,” and “brain death.” benefit was lacking, and there was some con- begin, if This meeting established guidelines on the cern that it might reduce children’s caution possible, the treatment of drowning victims in addition to around water and reduce parents’ perceived moment the outlining points for future research.6 level of need for supervision. Although data victim is out of are still conflicting, some reports have since the water. shown benefit in early swimming lessons for Physiologic chain of events toddlers.13,14 in drowning As of 2010, the AAP acknowledges that An unexpected immersion in water, particu- training may be beneficial for children in this larly cold water, causes a reflexive inspiratory age group, but cautions that not all children gasp, and some degree of aspiration occurs in will be ready for swimming by this age.12 In- most, if not all, cases of drowning. Aspiration fant water safety programs for children under further impairs victims’ ability to hold their the age of 1 are not recommended because breath or breathe normally.5,7,8 It decreases evidence of benefit is lacking.12 lung compliance due to surfactant washout Evidence is growing to support teaching or intrapulmonary shunting and thereby basic water survival skills in low- to middle- leads to hypoxia. Aspiration-induced severe income countries where water sources are laryngospasm can also lead to hypoxia. Pul- abundant, particularly in Southeast Asia. monary edema and acute respiratory distress Specifically, the SwimSafe survival swimming syndrome (ARDS) can follow. program has yielded impressive results in The cardiovascular effects of drowning Bangladesh.15 This program targets children mirror those seen in hypoxia. Initially, apnea starting at age 5, and involves 20 lessons teach- leads to decreased oxygen saturation and ing basic water survival and rescue skills. precipitates tachycardia and hypertension. Results have shown a 93% reduction Bradycardia and hypotension follow and in drowning rates for children enrolled in blood is shunted to vital organs, such as the the program, compared with those not en- brain, heart, and lungs.9 This phenomenon is rolled.15 Subsequent analyses have proposed accelerated in cold water and leads to “swim- that swimming lessons for children in these ming failure,” the impaired ability of the vic- parts of the world would be as cost effective tim to swim because of decreased perfusion as current attempts to prevent diarrheal and of the extremities.5,7,8,10 respiratory diseases in the same areas.16 “Autonomic conflict” has been proposed Additional preventive measures that are as an additional mechanism for morbidity effective in the United States include 4-sid- E2 The journAl of FamilY PracTice | FEBRUARY 2015 | Vol 64, no 2 DROWNING EPISODES ed pool fencing, use of personal flotation ries are more likely to result from falling or devices, and bystander cardiopulmonary diving into the water.24 resuscitation (CPR).2,5,17 z Administer oxygen supplementation when available to all spontaneously breath- ing individuals. Individuals who respond well on-scene evaluation and treatment to initial resuscitation and who don’t require Drowning victims can appear mottled and intubation tend to have a very good prognosis have minimal or no peripheral pulses despite overall.25 a heartbeat. Rescuers may assume the victim Total time of submersion and the tem- is dead when, in fact, there is cardiac func- perature of the water have bearing on the tion. Because initial assessment in this situa- likelihood of survival. Only in rare cases have tion is difficult, CPR should begin, if possible, victims survived submersion lasting longer the moment the victim is out of the water. than 30 minutes. Ten minutes generally is Successful on-scene resuscitation is the sur- considered the “point of no return.”9,26 This is est predictor of survival.9,18 In fact, delay of consistent with data suggesting 10 minutes of CPR until the arrival of emergency personnel hypoxic insult causes irreversible neurologic lessens the likelihood of survival.19 damage, with each additional minute rapidly z CPr applied to drowning. For car- leading to coma.20 However, to complicate diogenic cardiac arrest, chest compressions matters, unlike cardiac arrest victims, drown- alone may be better than compressions ing victims can lose cerebral blood flow slow- CPr for victims with rescue breathing. For victims of drown- ly after respiratory impairment, which makes of drowning ing, though, coordinated compressions and duration of submersion a potentially unreli- should always rescue breathing are recommended.20 The able predictor of neurologic outcome.20,26 involve rescue 2010 revision of the American Heart Associa- z Does hypothermia have a protective breathing in tion Guidelines for CPR and Emergency Car- effect? Hypothermia can occur in water 85°F addition to chest diovascular Care emphasize “compression (30°C) or cooler.10 It has been hypothesized compressions. first” for CPR in cases of cardiogenic cardiac that resuscitation can be achieved after longer arrest, but continue to support the traditional periods of submersion in cold water. Howev- Airway-Breathing-Chest Compressions se- er, the considerable debate on this topic has quence for drowning victims in its Special been based on little more than case reports. Situations section.21 For hypothermia to have a protective z Ventricular fibrillation (vF) is rare af- effect on neurologic function, cooling must ter submersion injury. An external defibril- take place rapidly and, ideally, before any lator should be used when available, but it hypoxic insult. The water would have to is unlikely to play a significant role in initial be exceptionally cold, likely less than 50°F resuscitation.9 (10°C).27 The greater surface-to-volume ratio z Don’t attempt to remove water from in children enables more rapid cooling and the victim’s mouth before resuscitation.
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