1. Drowning
Myra Lalas Pitt
8/15/11

2. Definition
In 2002, the World Congress on Drowning published the following consensus definition for drowning:
"Drowning is a process resulting from primary respiratory impairment from submersion/immersion in a liquid medium."

3. Epidemiology
Drowning is the third most common cause of accidental death in the US.
Second leading cause of death from unintentional injuries in children aged from 1 to 14 years.
Leading cause of death in children aged from 1 to 4 years.
Males are more likely to drown than females in all age groups, with the highest rate in the 0 to 4 age group.

4. Pathophysiology

5. Management
Prehospital care
ER management
Inpatient care

6. Prehospital care
Ventilation is the most important initial treatment for victims of submersion injury.
Rescue breathing should begin as soon as the rescuer reaches shallow water or a stable surface.
Perform CPR as per BLS guidelines.
Victims are prone to arrythmias.

7. ER Management
In the symptomatic patient, indications for elective intubation include the following:
Signs of neurologic deterioration or inability to protect the airway
Inability to maintain a PaO2 above 60 mmHg or oxygen saturation (SpO2) above 90 percent despite high-flow supplemental oxygen
PaCO2 above 50 mmHg

8. If you intubate, insert an OGT/ NGT to prevent gastric distension.
Wet clothing should be removed.
For hypothermic patients, rewarming should be initiated.
Rewarming methods include:
passive techniques (use of blankets or other insulators to reduce heat loss)
active external rewarming (application of warm blankets, heating pads, radiant heat)
active internal rewarming (pleural and peritoneal irrigation with warm saline, hemodialysis, and cardiopulmonary bypass).

10. Inpatient Management Neurochecks
Watch out for signs of cerebral edema.
Monitor respiratory status.
Antibiotics should be used only in cases of clinical pulmonary infection or if the victim was submerged in grossly contaminated water. If pneumonia follows near-drowning, there should be a high suspicion for water-borne pathogens, such as Aeromonas, Pseudomonas, and Proteus.
Exogenous surfactant?

11. Prognosis
The following factors at presentation have been associated with a poor prognosis:
Duration of submersion >10 minutes
Time to effective basic life support >10 minutes
Resuscitation duration >25 minutes
Water temperature >10ºC (50ºF)
Age <3 years
Glasgow coma scale <5 (comatose)
Persistent apnea and requirement of cardiopulmonary resuscitation in the emergency department
Arterial blood pH <7.1 upon presentation

12. Prevention
For children 0-4 years, parents and caregivers should always supervise their kids while in or near bathtubs, pools, spas, or wading pools, or near irrigation ditches or other open bodies of water.
There is no substitute for at least a four-foot-high, nonclimbable, four-sided fence with a self-closing, self-latching gate for pools.
Swimming lessons should not be considered as a way to “drown-proof” your child.

13. References
Martino Julie, Mackey Mark, "Chapter 137. Drowning" (Chapter). Gary R. Strange, William R. Ahrens, Robert W. Schafermeyer, Robert A. Wiebe: Pediatric Emergency Medicine, 3e: