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Drowning: Epidemiology, Prevention, Pathophysiology, Resuscitation, and Hospital Treatment

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Drowning: Epidemiology, Prevention, Pathophysiology, Resuscitation, and Hospital Treatment Emergencias 2019;31:270-280 SPECIAL ARTICLE Drowning: epidemiology, prevention, pathophysiology, resuscitation, and hospital treatment Cristian Abelairas-Gómez1,2, Michael J. Tipton3, Violeta González-Salvado2,4, Joost J. L. M. Bierens5 This narrative review discusses the evidence relevant to key aspects of drowning, which is defined by the World Authors’ affiliation: Health Organization as the process of respiratory difficulty caused by submersion/immersion in liquid. The length of 1Research Group CLINURSID and Faculty of Education Sciences, time the victim is submerged is a key factor in survival and neurologic damage. Although respiratory distress and Universidade de Santiago de hypoxia are the main events, other complications affecting various systems and organs may develop. Drowning is one Compostela, Spain. 2 of the main causes of accidental death worldwide, yet deaths from drowning are underestimated and morbidity is Instituto de Investigación Sanitaria (IDIS) of Santiago de unknown. Prevention is essential for reducing both mortality and morbidity, but if prevention fails, the speed of Compostela, Spain. access to and the quality of prehospital and hospital care will determine the prognosis. It is therefore essential to 3Extreme Environments Laboratory, Department of Sport understand the factors and mechanisms involved in these emergencies. and Exercise Science, University Keywords: Risk factors. Mortality. Respiratory distress syndrome, adult. Cardiac arrest. Case management. of Portsmouth, Portsmouth, United Kingdom. Cardiopulmonary resuscitation. Prognosis. Survival. 4Cardiology Service, Complejo Hospitalario Universitario de Santiago, CIBERCV, Universidade El ahogamiento: epidemiología, prevención, fisiopatología, reanimación de la de Santiago de Compostela, víctima ahogada y tratamiento hospitalario Santiago de Compostela, Spain. 5Research Group Emergency and Disaster Medicine, Vrije El objetivo de esta revisión narrativa fue elaborar un documento que trate los aspectos clave del ahogamiento de Universiteit Brussel, Brussels, acuerdo con la evidencia científica disponible. El ahogamiento se define como el proceso de sufrir dificultades respira- Belgium. torias por sumersión/inmersión en un líquido. El tiempo de sumersión es un factor clave en la supervivencia y daño Corresponding author: neurológico. Aunque el distrés respiratorio e hipoxia es el cuadro predominante, pueden presentarse otras complica- Cristian Abelairas-Gómez ciones que afecten a distintos sistemas y aparatos. El ahogamiento es una de las principales causas de muerte acci- Facultad de Ciencias de la Educación, Universidade dental en el mundo. Sin embargo, la mortalidad por ahogamiento está infraestimada y la morbilidad desconocida. La de Santiago de Compostela prevención es el factor clave para la reducción de la mortalidad y morbilidad, pero si esta falla, la rapidez y calidad Av/Xoán XXIII, s/n. del tratamiento tanto prehospitalario como hospitalario determinarán el pronóstico. Por tanto, resulta fundamental 15782 Santiago de Compostela, A Coruña, Spain conocer los factores y mecanismos particulares implicados en esta emergencia. Palabras clave: Factores de riesgo. Mortalidad. Síndrome de dificultad respiratoria del adulto. Parada cardiaca. E-mail: [email protected] Manejo de atención al paciente. Reanimación cardiopulmonar. Pronóstico. Supervivencia. Article information: Received 29-01-2019 Accepted: 30-03-2019 Online: 1-7-2019 Editor in charge: Juan González del Castillo Every hour of every day, more than 40 people lose considered in the study of drowning according to cu- their lives by drowning.” The World Health rrent evidence: epidemiology, prevention, physiopatho- Organization’s (WHO) 2014 World Drowning Report logy and treatment of the drowned victim. begins by saying that drowning is among the top ten causes of death among children and young people in almost every region in the world1. Epidemiology Drowning is a cause of death that was associated with lower rates of financing and publications than esti- Drowning is one of the leading causes of uninten- mated on the basis of mortality2, which translates into a tional death in the world. About 372,000 deaths are pronounced discrepancy between the relevance of the reported each year, 90% of which occur in developing problem and the still scarce volume of information avai- countries according to WHO statistics based on the lable. Fortunately, the number of publications and ini- International Classification of Diseases (ICD) codes1. The tiatives aimed at increasing knowledge about and pre- change from the ninth to the tenth version of the ICD, venting this important cause of death is increasing, and its subsequent reviews and the inclusion of a fourth even the so-called Drowning Survival Chain3 has been character in the event location registry codes resulted created. This review of the literature aims to bring to- in a substantial increase in the accuracy of the drow- gether in a single document the main factors to be ning mortality registry. However, in a study that 270 Abelairas-Gómez C, et al. Emergencias 2019;31:270-280 Table 1. Number of deaths in Spain in 2016 and 2017 related to drowning and submersion 2016 2017 W M Total W M Total V90-V94 Water transport accident 0 10 10 3 21 24 V90 Boat accident causing drowning and submersion 0 7 7 3 16 19 V92 Drowning and submersion related to transport by water, no accident 0 3 3 0 5 5 to the vessel W65-74 Accidental drowning and submersion 95 344 439 88 387 475 W65 While in the bathtub 2 1 3 0 1 1 W67 While in a swimming pool 11 8 19 10 21 31 W68 Fall in a swimming pool 0 4 4 5 10 15 W69 While in natural waters 32 110 142 33 134 167 W70 After fall in natural waters 0 31 31 4 45 49 W73 Other specified drownings and submersions 0 12 12 4 23 27 W74 Unspecified drowning and submersion 50 178 228 32 153 185 X71 Intentionally self-inflicted injury by drowning and submersion 43 73 116 44 62 106 X92 Drowning and submersion aggression 0 0 0 0 1 1 Y21 Drowning and submersion, of unspecified intent 1 1 2 1 1 2 Total 139 428 567 136 472 608 M: men; W: women. analyzed 52 countries, only 23 used ICD-10 with the sex and location of the event. In this sense, men are fourth character4. In another study that analyzed 69 twice as likely to drown as women, more than half the countries, many drowning deaths were recorded with victims are under 25 years of age and mortality in codes referring to unspecified situations or locations, low-income countries is three times higher than in hi- calling into question the quality of the information re- gh-income countries1. However, since drowning is a ported in 1 out of 7 countries5. The WHO itself ack- multifactorial event, its epidemiology varies from coun- nowledges that drowning mortality is underestimated try to country. Thus, suicide was the cause of 36% of and can be 50% higher than that reported in develo- drownings between 1988 and 2012 in Ireland10; be- ped countries and five times higher in developing tween 2008 and 2012 in Canada, 65.6% of drownings countries1. related to boating accidents did not carry any flotation In Spain, the National Statistics Institute (INE) has material11; alcohol consumption was present in more reported a total of 5,848 deaths due to “accidental than 70% of unintentional drownings between 1970 drowning, submersion and suffocation” between 2016 and 2000 in Finland12; and people over 65 accounted and 2017, of which 1,175 were specifically related to for 17.3% of drownings in Australia between 2002 and submersion (Table 1). However, the number of deaths 201213. Epilepsy has even been shown to multiply the and the ICD classification system could be insufficient risk of drowning up to tenfold14. This heterogeneity in to know exactly the epidemiology due to scarce infor- epidemiological determinants highlights the need for mation in medical reports, insufficient training of the adequate recording systems that allow for greater preci- forensic services or lack of resources5. In addition, Spain sion. However, a study recording drownings in swim- is one of the countries with the worst quality of regis- ming pools in France showed that up to nine different tration regarding the fourth character of the ICD-104. services were responsible for recording the information, The reasons include the complexity of the procedures making it difficult to make a rigorous assessment of the through which information circulates, from the event to number and causes of drowning15. its final registration, and the time between the autopsy The consolidation of the registry and collaboration and the definitive results6. According to INE data, more tools of different local, national and international bodies than 25% of registered deaths occurred “in an unspeci- would greatly contribute to a greater precision on the fied place”, which added to events categorized as epidemiological knowledge of drowning. In an attempt “other unspecified drownings and submersions”, results to improve the quality of registration, the recommen- in a lack of relevant information in almost half the ca- dations for recording data on drowning resuscitation ses. Other epidemiological reports on drowning in (Utstein style) include in their latest update the inclu- Spain have considered only press reports7 or have not sion of cases of patients treated only by first responders taken into account all drowning events8. On the other and those in which hospital referral has not been hand, some studies have attempted to delve deeper necessary16. into the description of the drowned victim profile, such as a multicentre study of 21 Spanish hospital emergen- cy departments that identified children under 6 years of Drowning Prevention age as a risk subgroup among minors9. However, this type of study is not common. Most drowning deaths could be prevented with Based on international literature, three variables preventive measures1, regarded as key to fighting this seem to influence the number of drowning deaths: age, cause of death (Figure 1). The lack of education on pre- 271 Abelairas-Gómez C, et al.
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