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Prevention and Treatment of Drowning TIMOTHY F Prevention and Treatment of Drowning TIMOTHY F. MOTT, MD, and KELLY M. LATIMER, MD, MPH, Naval Hospital Pensacola Family Medicine Residency, Pensacola, Florida Nearly 4,000 drowning deaths occur annually in the United States, with drowning representing the most common injury-related cause of death in children one to four years of age. Drowning is a process that runs the spectrum from brief entry of liquid into the airways with subsequent clearance and only minor temporary injury, to the prolonged presence of fluid in the lungs leading to lung dysfunction, hypoxia, neurologic and cardiac abnormalities, and death. The World Health Organization has defined drowning as “the process of experiencing respiratory impairment from submersion/immersion in liquid.” Terms such as near, wet, dry, passive, active, secondary, and silent drowning should no longer be used because they are confusing and hinder proper categorization and management. The American Heart Association’s Revised Utstein Drowning Form and treatment guidelines are important in guiding care, disposi- tion, and prognosis. Prompt resuscitation at the scene after a shorter duration of submersion is associated with better outcomes. Because cardiac arrhythmias due to drowning are almost exclusively caused by hypoxia, the resuscita- tion order prioritizes airway and breathing before compressions. Prevention remains the best treatment. Education, swimming and water safety lessons, and proper pool fencing are the interventions with the highest level of current evidence, especially in children two to four years of age. Alcohol use during water activities dramatically increases the risk of drowning; therefore, abstinence is recommended for all participants and supervisors. (Am Fam Physician. 2016;93(7):576-582. Copyright © 2016 American Academy of Family Physicians.) More online rowning kills nearly 4,000 per- same principles to clarify definitions, termi- at http://www. sons in the United States and nology, and data sets used in the epidemiol- aafp.org/afp. more than 300,000 persons ogy and treatment of drowning.5 Following CME This clinical content worldwide every year.1 For U.S. extensive discussion and debate, the World conforms to AAFP criteria Dchildren between one and four years of Health Organization agreed on the follow- for continuing medical education (CME). See age, drowning has surpassed motor vehicle ing definition: “Drowning is the process of CME Quiz Questions on crashes as the most common injury-related experiencing respiratory impairment from page 551. cause of death at 2.6 per 100,000 persons submersion/immersion in liquid.”3 Author disclosure: No rel- annually.2 Despite this significant health Terms such as near, wet, dry, passive, active, evant financial affiliations. burden, public health initiatives have lagged secondary, and silent drowning should not ▲ Patient information: because of lack of standardization in defini- be used because they can be confusing and A handout on this topic, tions and reporting. ultimately hinder classification or manage- written by the authors of ment.3 The Utstein approach simplified the this article, is available Definition at http://www.aafp.org/ classification of drowning outcomes to only afp/2016/0401/p576-s1. Before the first World Congress on Drown- three domains: death, morbidity, and no html. ing (WCOD) in 2002, public health surveil- morbidity.3 lance, research, and policy on drowning were impeded by a lack of clear terminology.3 Epidemiology Highlighting this problem, a systematic Despite declines in the death and hospital- review of the literature from 1966 to 2002 ization rates from drowning over the past found at least 33 different definitions for decade, it remains the top injury-related drowning incidents.4 The WCOD was orga- concern in children.2,6,7 Approximately 5,800 nized largely to remedy this issue. The persons are treated in U.S. emergency depart- WCOD developed consensus guidelines ments each year for submersion or drown- using the Utstein principles—a term coined ing injuries, with one-half of those patients from a series of meetings held at Utstein requiring hospital admission.6,8,9 Permanent Abbey in Stavanger, Norway, to clarify the neurologic sequelae, such as persistent veg- nomenclature associated with out-of-hospital etative state or spastic quadriplegia, occur in cardiac arrests.4 The guidelines applied the 5% to 10% of childhood drowning cases.10 576Downloaded American from the Family American Physician Family Physician website at www.aafp.org/afp.www.aafp.org/afp Copyright © 2016 American Academy of VolumeFamily Physicians. 93, Number For the 7 private,◆ April noncom 1, 2016- mercial use of one individual user of the website. All other rights reserved. Contact [email protected] for copyright questions and/or permission requests. Drowning The typical location of drowning varies depending on is associated with shorter duration of anoxia and a age. Children younger than four years are more likely higher rate of survival.19 Lack of adequate training, open- to drown in a swimming pool, whereas adults are more water conditions, distance to shore, water depth, equip- likely to drown in a natural body of water (Figure 1).6 ment availability (e.g., flotation devices), and a person’s A systematic review found drowning to be the most features (e.g., injury, obesity) may limit the feasibility of common cause of recreational aquatic activity death in-water resuscitation.19 in persons 15 years or older; 30% to 70% of drowning Cold water submersion was previously considered neu- fatality victims had alcohol in their bloodstream.11 Even roprotective because of decreased metabolic demands small amounts of alcohol increase the risk of drown- of hypothermia and the diving reflex. Case reports ing, and this risk increases with the amount of alcohol described young victims with prolonged submersion in consumed.10-13 very cold water who survived neurologically intact.20,21 However, it has been determined that water temperature Pathophysiology and Clinical Presentation has no correlation with overall outcome.18 Contrary to Understanding the drowning process bolsters accu- popular belief, fresh vs. saltwater aspiration makes no rate diagnosis, treatment, and prognosis. Initially, fluid difference in the degree of lung injury.15 enters the oropharynx and is cleared, if possible. If clear- Unless the victim has experienced a diving or boat- ing is not possible, conscious breath holding ensues. ing accident or has fallen from a height, cervical spine Eventually, the internal drive to inspire becomes insur- immobilization is unnecessary because only 0.5% of mountable, and fluid enters the airways, stimulating drowning victims have a cervical spine injury.22 cough or laryngospasm. If the drowning process con- tinues, a number of events may occur, such as fluid and PHYSICAL EXAMINATION AND INITIAL TREATMENT electrolyte shifts, alveolar dysfunction, and hypoxia.14,15 A drowning classification system has been established to These may trigger further deterioration with pulmo- classify victims at the rescue scene based on the clinical nary edema, decreased lung compliance, and broncho- parameters of respirations, pulse, pulmonary ausculta- spasm.14,15 Cardiac deterioration develops after seconds tion, and blood pressure14,17 (Figure 217). to minutes of hypoxia, typically progressing from tachycardia to bradycardia, pulseless 100 electrical activity, and asystole.15-17 Evaluation and Treatment 80 The Utstein approach to the evaluation of drowning victims not only standard- 60 izes reporting and data collection but also provides guidance for the history, physical examination, and appropriate management Percentage 40 (eFigure A). HISTORY 20 Details of the drowning event guide treat- ment and determine prognosis. Younger 0 patients tend to have better outcomes.18 Sub- 0-4 yrs 5-14 yrs ≥ 15 yrs 0-4 yrs 5-14 yrs ≥ 15 yrs mersion for six minutes or longer is associ- Fatal Nonfatal ated with a significantly poorer prognosis. Type of drowning When considering open water drowning All other and unspecified Unspecified pool Private pool victims with good outcomes (i.e., did not die Natural water, including boating Public pool Bathtub or experience severe neurologic sequelae), 88% were submerged less than six minutes Figure 1. Distribution of fatal and nonfatal drownings, by location and age group from the National Vital Statistics System and National vs. 7.4% of victims with six to 10 minutes of Electronic Injury Surveillance System—All Injury Program, United 18 submersion. In-water resuscitation, where States, 2005-2009. several rescue breaths are given by trained Adapted from Centers for Disease Control and Prevention. Drowning—United States, 2005- lifesaving personnel while still in the water, 2009. MMWR Morb Mortal Wkly Rep. 2012;61(19):346. April 1, 2016 ◆ Volume 93, Number 7 www.aafp.org/afp American Family Physician 577 Drowning Classification System of Drowning Grades to Guide Risk Stratification and Management Check for response to verbal and tactile stimuli Evaluation No answer Answer Open the airway and check for ventilation; if breathing, Perform pulmonary auscultation perform pulmonary auscultation; if not breathing, give five initial breaths and check carotid pulse Abnormal Normal Pulse absent Pulse present Rales in all pulmo- Rales in With cough Without nary fields (acute some pulmo- cough Submersion time Submersion time pulmonary edema) nary fields > 1 hour or ≤ 1 hour, no obvious physical obvious physical evidence
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