1. Drowning
NEJM Review
NEJM 2012;366:

2. Leading cause death boys 5-14yrs
0.7% all deaths worldwide
>500,000 deaths/year
Leading cause death boys 5-14yrs
Second leading cause of death due to injuries 1-4yrs
25% are > 14y/o
Males > Females (4:1)
Alcohol involved
Epilepsy
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. (2008) [cited 2008 March 23]. Available from: URL:
Third leading trauma cause of death in NZ, but 2nd worldwide in 2000
Death stats from third world underreported
Stats also don’t include cataclysmic events like tsunamis in Thailand or Japan
Key Risk Factors:
- Male
- age <14
- ETOH
- Low income
- Poor education
- Rural residency
- Aquatic exposure
- Risky behaviour
- Lack of supervision
Epilepsy - risk of drowning is times as high as the risk for those without Ep
For every person that dies from drowning, another 4 revcieve care in the ED for non-fatal drowning
Deaths occur mainly in adult NZ European Males swimming in rivers, per capita – on the west coast
Hospitalisations occur in infants and young children, male, NZ europeans
Orlowski JP, Szpilman D Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am Jun;48(3): Review.
Pediatr Clin North Am. 2001 Jun;48(3):
Drowning. Rescue, resuscitation, and reanimation.
Orlowski JP, Szpilman D.
Division of Pediatrics, Department of Pediatric Critical Care Medicine, University Community Hospital, Tampa, Florida, USA.
Several myths about drowning have developed over the years. This article has attempted to dispel some of these myths, as follows:
Drowning victims are unable to call or wave for help.
"Dry drownings" probably do not exist; if there is no water in the lungs at autopsy, the victim probably was not alive when he or she entered the water.
Do not use furosemide to treat the pulmonary edema of drowning; victims may need volume.
Seawater drowning does not cause hypovolemia, and freshwater drowning does not cause hypervolemia, hemolysis, or hyperkalemia.
Drowning victims swallow much more water than they inhale, resulting in a high risk for vomiting spontaneously or on resuscitation.
No discussion of drowning would be complete without mentioning the importance of prevention. Proper pool fencing and water safety training at a young age are instrumental in reducing the risk for drowning. Not leaving an infant or young child unattended in or near water can prevent many of these deaths, especially bathtub drownings. Also crucial is the use of personal flotation devices whenever boating. Proper training in water safety is crucial for participation in water recreation and sporting activities, including SCUBA diving. The incidence of pediatric drowning deaths in the United States has decreased steadily over the past decade, perhaps as a result of increased awareness and attention to drowning-prevention measures

3. How many people drowned in NZ in 2010?
87 people died of drowning in New Zealand during This is the lowest annual toll since Three regions (Waikato, Tasman and West Coast) had increased drowning tolls from 2009.
160 people were hospitalised due to immersion incidents in New Zealand during This is the highest annual toll since The five year average is 136 hospitalisations per year.
Deaths Auckland – 18 NZ - 87
Hospitalisations
Australian report estimated for every child who drowns, 4 are hospitalised and 16 receive ED level care.

4. Deaths *Watersafety NZ

5. Site of accident Hospitalised cases – does it really matter to us
Site of accident Hospitalised cases – does it really matter to us? *Watersafety NZ

6. Definitions
“Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid” WHO 2002
Respiratory impairment as airway goes below the surface (submersion) or water splashes over the face (immersion)
Rescue at any time, process of drowning interrupted  nonfatal drowning
Death as a result of drowning  fatal drowning
Water rescue: Any submersion or immersion incident w/o evidence of resp impairment

7. Terms to avoid Near drowning Dry or wet drowning Secondary drowning
Active and passive drowning
Delayed onset of respiratory distress

8. From Auerbach: Wilderness Medicine, 5th ed
From Auerbach: Wilderness Medicine, 5th ed. ( Submersion or near-drowning) Fig 68.4.
When a drowning person can no longer keep their airway clear, water entering the mouth is voluntarily spat out or swallowed
Next conscious response id to hold your breath 0 lasts for no more than ≈1min
After this, the inspiratory drive is too high to resist and some amount of water is aspirated into the lungs and coughing occurs as a reflex response
In some cases laryngospasm occurs, but it is rapidly terminated by onset of brain hypoxia
If not rescued, water aspiration continues, hypoxaemia quickly leads to LOC and apnoea
The sequence of cardia rhythm deterioration is usually tachy -> brady -> pea and finally asystole
Whole drwning process from submersion/immersion to cardiac arrest usually occurs in secs to few mins
But, in cases such as hypothermia or drownin in icewater, this process can last for an hour

9. Cold Water Drowning
Immersion syndrome (water temp >5o less than body temp)
Death shortly after cold water immersion 2o vagally induced VF arrest (?diving reflex)
Cold Water shock
On exposure to cold water, uncontrollable gasping for approx 1 min that will result in aspiration if head submerged
Catecholamine surge that may precipitate arrythmia
Cooling peripheries decrease nerve conduction and impair muscle co-ordination and impair self rescue
Immersion hypothermia
Diving reflex is meant to conserve brain function and O2 use by diverting blood away from splanchnic / skin and divery it to heart and brain and muscles of locomotion, there is an associated bradycardia

10. RESPIRATORY EFFECTS

11. Which of the following factors is most relevant in history?
Fresh Water/Salt Water/Polluted water How many mls/kg does the average submersion injury aspirate ? How many mls/kg aspirate of salt water causes alteration of blood volume? electrolytes? Orlowski et al instilled differing NaCl conc into dog ETT tubes
Average presentation to hospital aspirates 3-4ml/kg
To alter blood volume need to aspirate 11mls/kg
To alter electrolyte balance need >22mls/kg
Most cases of significant aspiration have been found in postmortem patients and the relevance to the patients we see is debatable
But!! Apparent higher mortality in salt water
Does not seem related to aspirated contents
Intubated dogs, -control, sterile water, 0.225%, 0.34%, 0.9, 2% & 3% NaCl +/- chlorine 20mls/kg
Into ETT, clamped 5 minutes before ventilating with 100% O2 & 10cm PEEP
Chlorine – no difference
0.225% least deleteriious effect on gas exchange (PaO2/FiO2 ratio)
Most damage from sterile water
The exception to this is the dead sea which has a 50% mortality rate, patient get arrythmias from electrolyte imbalances(Na, Cl, K, Ca, Mg)

12. Pulmonary Injury Effects of alveolar fluid
Effects of alveolar membrane damage
Effects of vascular endothelial damage
Inflammatory response
If the person is rescued alive, the clinical picture is determined predominately by the amount of water that has been aspirated and its effects
Water in the alveoli causes surfactant disruption and washout
- aspiration of salt and fresh water cause similar degrees of injury but with differences in osmotic gradient
In either sitution, the effect of the osmotic gradient on the alveolar-capillary membrane disrupts the integrity of the membrane, increases its permeability and exacerbates fluid, plasma and electrolyte shifts
Clinically this gives rise to massive, often blood stained, pulmonary oedema that decreases the exchange of O2 and CO2
The combined effects of pulmonary oedema, loss of surfactant and increased alveolar-capillary membrane permeability  decreased lung compliance, increased areas ofvery low or zero ventilation to perfusion in the lungs, atelectasis and bronchospasm
Fluid in the alveoli dilutes surfactant
Alters lung compliance
Alveolar instability and collapse
Ventilation/perfusion mismatch
Shunt = Hypoxia
Alveolar membrane damage (esp from hypertoniciity of salt water) reduces pulmonary edema clearance
Endothelial damage – vascular leakage of further protein rich fluid into alveolus
Generalised inflammatory response results in further drives pulmonary oedema

13. Nasty Water Pollutants Microorganisms Fungi
Hydrocarbons (Low viscosity /High Volatility)
Heavy Metals
Particulates
Microorganisms
Gram Negative
Pseudomonas, Aeromonas, Burkholderia, Legionella
Gram Positive
Streptococci and Staphylococci (from mouth)
Fungi
Pseudoallallescheria boydii
Prophylactic treatment not indicated (maybe if raw sewage)
Increases inflammatory component and increases risk of lung injury
Drilling rigs use Ca Salts which may cause hypercalcaemia in victims
May have particulate matter such as sand/mud - bronchoscopy

14. Pulmonary Aspiration (1-3mL/kg) can reduce gas exchange Bronchospasm
Chemical pneumonitis
Pulmonary vasoconstriction/hypertension (vagally mediated)
Surfactant destruction
 alveolar instability, atelectasis, and decreased compliance, with marked ventilation/perfusion (V/Q) mismatching
Acute respiratory distress syndrome (ARDS) 
Pneumonia 
Aeromonas, Burkholderia, and Pseudallescheria
Fibrosis, restrictive lung disease, and decreased diffusion capacity

15. Cardiovascular Effects
Hypotension
Shock, acidosis, hypovolemia (natriuresis), autonomic instability
Arrhythmias
Asystole (55%),
Ventricular tachycardia/fibrillation (29%)
Bradycardia (16%)
Brugada
Long-QT syndromes
The sequence of cardiac rhythm deterioration is usually tachy -> brady -> pea and finally asystole
Whole drowning process from submersion/immersion to cardiac arrest usually occurs in secs to few mins
But, in cases such as hypothermia or drowning in icewater, this process can last for an hour

16. Other systems Neurological Renal Electrolytes/Hem Neurologic asphyxia
Seizure, coma, death
Encephalopathy
Cardiocerebral protection?
(Remember head trauma/
c-spine)
Renal
Natriuresis
Acute renal failure
Rhabdomyolysis
Electrolytes/Hem
Normal aspiration of 3-4ml/kg
Changes in blood volume at 11ml/kg
Haemolysis at 22ml/kg (1.5L)
If CPR is required, the risk of neurologic damage is similar to that in other instances of cardiac arrest
However, hypothermia associated w/ drowning can provide a protective mechanism that allows patient to survive prolonged submersion episodes
Hyothermia can reduce O2 consumption in the brain, delaying cellular anoxia and ATP depletion
Hypothermia reduces the electrical and metabolic activity of the brain in a temp dependent fashion
The rate of cerebral O2 consumption is reduced by approximately 5% for each reduction of 1 deg C in temp within a range of deg C
RENAL – Acute tubular necrosis or tubular injury from hypoxia can occur
Electrolyte disturbance is rarely significant

18. Rescue and in-water resuscitation
Areas with lifeguards:
<6% require medical attention
0.5% require CPR
Untrained resuers need to avoid drowning themselves
Conscious: Take to land and initiate BLS
Unconscious: Ventilation alone.
C-spine injuries <0.5%
Many people who are drowning are able to help themselves or are rescued by bystanders
In areas with lifeguards, <6% of all rescued people require medical attention and just 0.5% require CPR
Important that untrained rescuers do not become victims themselves
Call for emergency services ASAP
Conscious  bring them to land and initiale BLS asap
Unconscous  inwater resuscitation may increase likelihood of a favourable outcome by a factor of >3, cf taking time to bring them to land.
In water resus only possible with a highly trained rescuer and consists of ventilation alone. Attempts at chest compression futile as long as you’re in deep water, so Ax pulse no purpose
Drowning personswith only respiatory arrest usually respond after a few rescue breaths.
If there is no response, should be assumed to be in cardiac arrest and taken to land asap to initiate CPR
C-spine injuries occur in <0.5% of drowning victims and immobilisation of c-spinein water is indicated only in cases in which head and neck injury strongly suspected – diving, water-skiing, surfing
Should try and maintain person in a vertical position while keepin airway open, helps to prevent vomitin and further aspiration of water and stomach contents

19. Initial Resuscitation on land
Rescue ventilation essential
Cardiac arrest due primarily to lack of oxygenation so CPR should follow ABC approach
5 initial rescue breaths
30:2
Most frequent complication is regurgitation of stomach contents. 65% rescue breathing alone and 85% who require CPR
Avoid abdominal thrusts or placement head down
Unconscious but breathing  recovery position
Not breathing  rescue ventilation is essential. Unlike primary cardiac arrest, drowning can produce a gasping pattern or apnoea while the heart is still beating and the person may require only vent
Cardiac arrest from drowning is du primarily to lack of O2, so CPR should follow the traditional ABC approach not CAB
5 rescue breaths, followed by 30 compressions and continue at a rte of 30:2 until signs of life, rescuer exhaustion or ALS becomes available
In cases of drowning, the European Resus Council recommend 5 initial rescue breaths instead of 2 as initial ventilation can be more difficult to achieve since water in the airways can interfere with effective lung expansion
Most frequent complication during a resuscitation is regurgitation of stomach contents, which occurs in 65% of patients who require rescue breathing alone and 85% of those requiring CPR
Presence of vomitus in the airway  further aspiration injury and oxygenation impairment
Efforts to expel water from the airway should be avoided as they delay initiation of ventilation and greatly increase the risk of vomiting, with significant increase in mortality

20. ADVANCED PREHOSPITAL CARE

21. Because of the wide variety of clinical presentations of drowning, a classification system of 6 grades, with higher numbers indicating more severe impairment, can help to stratify risk and guide interventions
A person with pulmonary damage may initially be able to maintain adequate oxygenation through tchypnoea and can be treated with FMO2 15L/min
Early intubation and ventilation are indicated when they show signs of deterioration/fatigue (GRADE ¾)
Once intubated, most pts can be oxygenated and ventilated effectively
Can get copious amounts of pulmonary fluid in ETT, suctioning needs to be balanced against the need to V+O as can disturb oxygenation
Aim arterial Sat 92-96%
If hypotension is not corrected by oxygenation, a rapid crystalloid infusion should be administered regardless of whether salt or fresh water has been inhaled
The presenting drowning rhythm in cases of cardiac arrest (GRADE 6) is usually asystole or PEA.
VF rarely reported – usually pts with hx cardiac disease, use of Adr/Norad (which may increase myocardial contractility) or presence of severe hypothermia

22. This table summarises the recommendations on when to begin CPR and how long it should be maintained in cases of drowning

23. Obvious death Submerged for >1 hour
Normothermia (>30°C) with asystole with CPR >30min
Rigor mortis
Dependent lividity
No apparent CNS function

24. CARE IN THE ED

25. Scoring Systems on Hospital Arrival
Modell & Conn 1984 – in ED within 1 hr of rescue (paeds)
The simple approach
Category
Description
GCS
Neurologically Intact (%) A
Awake – fully orientated
14-15
100 B
Blunted- rousable, purposeful to pain
8-13 C
Comatose- not rousable, abnormal response to pain
6-7
>90 C1
Flexor response to pain 5 C2
Extensor response to pain 4 C3
Flaccid 3
<20 C4
Arrested
Asymptomatic
Symptomatic
Critical
Obviously dead
C1 – Decerebrate
C2 – Decorticate
Expected likelihood of good neurological outcome (neurologically intact)

26. Asymptomatic patient No comorbidities If at 4 - 6 hours:
CXR, ABG normal
Normal vitals on air
Remain ASx = discharge with advice
If aspirated potential for delayed deterioration
Once airway secured, O2 improved, circulation stabilised and NG inserted, thermal insulation of the patient should be instituted
Followed by physical exam, CXR, ABG
Metabolic acidosis occurs in the majority of patients, and is usually corrected by the patient’s spontaneous effort to increase minute ventilation or by setting a higher minute ventilation (30-35 L/min) or a higher PIP (35cm water) on the ventilator
Routine use of Na bicarbonate is not recommended
History important – drowning sometimes ppt by an injury or medical condition (trauma, seizure or cardiac arrhythmia), and these will affect Rx decisions
Pts with good arterial oxygenation without adjuvant therapy and who have no other associated co-morbidity can be safely discharged home
Hospitalisation is recommended for all patients with a presentation of GRADE 2-6
For most patients with a grade 2 presentation (scattered creps on exam), non-invasive O2 administration results in normalisation of clinical status within 6-8hrs and hey can then be Dx

27. Symptomatic Patient
Consider foreign material in airway (approx. 50% of surf submersions)
Salbutamol / Ipratoprium nebs for bronchospasm
NG placement on free drainage may improve ventilatory distress
High risk for vomiting and gastric content aspiration
Suction +++
Most will require fluid resuscitation secondary to diuresis
Beware hypothermia and trauma
Patients whose clinical state deteriorates need to be admitted for period of prolonged observation.
Patients with GRADE 3-6 prrsentations, who usually need I+V are admitted to the ICU
If the person remains unresponsive without an obvious cause, toxicology and CT head and neck should be considered
Electrolyte, BUN, creat and Hct are rarely helpful and abnormalities are unusual. Correction of electrolyte imbalance is rarely needed

28. Hypothermia Common following drowning
Arrhythmias more common, can be refractory at temps < 30°C – limit defibrillation shocks to 3
Dose interval of resuscitation drugs is doubles at temps between 30 and 35°C
Continue resuscitation until core temp at least 32°C
Generally allow temp to rise by °C /hr to reduce haemodynamic instability
Vasodilation during rewarming  BP, large volumes of warmed IVF
Therapeutic hypothermia
Hypothermia is common following drowning and adversely affects symptomatic resuscitation attempts unless treated
Not only are arrhythmias more common but some, such as VF, may be refractory at temps <30 when defibrillation should be limited to 3 shocks and inotropic or antiarrhythmics should not be given
If unsuccessful, patient should be warmed to above 30 as quickly as possible when further defibrillation can be attempted
The dose interval for resuscitation drugs is doubled between 30 and 35deg
Resuscitation should be continued until the core temp is at least 32 or cannot be raised despite active measures
Most hypotermic patients are hypovolaemic, during rewarming, vasodilation occurs, resulting in BP, requiring large volumes of warmed IVF whilst trying to avoid overfilling and pulmonary oedema
Continuous haemodynamic monitoring is essential
Therapeutic hypothermia (32-34°C ) for at least 24hrs has been shown to improve neurological outcome

29. Treatment in the ICU Indications for Intubation:
Decreased GCS for airway protection
Unable to maintain PaO2 > 90 on high flow, non-rebreather mask
Unable to maintain PaCO2 < 45

30. Tend to recover much faster than pts with ARDS
Respiratory:
Tend to recover much faster than pts with ARDS
Late pulmonary sequelae uncommon
Wean ventilation after 24hrs
Guidelines for ventilation in ARDS should be followed
Since the pulmonary lesion is caused by a temporary and localinjury, patients with resp distress due to drowning tend to recover much faster than patients with ARDS
And late pulmonary sequelae in uncommon
Best not to wean ventilation before 24hrs as the local pulmonary injury may not have resolved sufficiently and pulmonary oedema may recur leading to re-intubation and prolonged hospitalisation and increased morbidity

31. Ventilation
Most text books will support a trial of NIV if blood pressure and GCS appropriate, however there are no literature to support its use
Start low and titrate up
volume support
Vt low – 6mls/kg
PEEP 5-10 cm H20 only if PaO2 < 60 on FiO2 <0.6
Ventilate for 24 hours to allow regeneration of surfactant

32. Pneumonia No prophylactic antibiotics No prophylactic steroids
If starting Abx, start broad
Often misdiagnosed initially because of the early radiographic appearance of water in the lungs
In a series of hospitilised cases, only 12% pts rescused from drowning had pneumonia and needed Rx with Abs
Phophylactically administered Abs tend to select more resistant and aggressive organisms
Best to monitor pts daily for definite fever, sustained leucocytosis, persistent or new pulmonary infiltrates, and leucocyte response in the tracheal aspirate, with c+s testing from daily TA
Early-onset pneumonia can be due to the aspiration of polluted water, endogenous flora or gastric contents.
Aspiration of swimming pool water rarely results in pneumonia
Risk increases with prolonged ventilation and can be detected by the 3rd/4th day of hospitilisation when pulmonary oedema has nearly resolved
Pneumonia often related to nosocomial pathogens
Once diagnosis is made, empirical therapy with broad spectrum Abs covering most predictable G-ve and +ve orgs – rationalising when C+S available
Consider fungal and anaerobic infections
ECMO

33. Rapid crystalloid infusion Normalisation of body temp
Circulatory:
Oxygenation
Rapid crystalloid infusion
Normalisation of body temp
Early cardiac dysfunction in Grade 4-6
No evidence for specific fluid therapy, diuretics or water restriction
Most patients rescued from drowning, circulation becomes adequate after oxygenation, rapid crystalloid infusion and restoration of normal body temp
Early cardiac dysfunction can occur in pts with a presentation of Grade 4-6 which adds a cardiogenic component to the non-cardiogenic pulmonary oedema
No evidence supports the use of a specific fluid therapy, diuretics or water restriction in pts rescued from drowning in salt water or fresh water
If vol replacement with crystalloid infusion fails to restore haemodynamic adequacy, ECHO can help inform decisions about inotrope and vasopressor use

34. Aim for normal Glc, paO2, pCO2
Neurologic:
Aim for normal Glc, paO2, pCO2
Induced hypothermia – core temp 32-34°C may be neuroprotective
Recent reports on drowning documented good outcomes with the use of therapeutic induction of hypothermia after resuscitation, despite a predicted poor outcome
Vanden et al. Part 12: cardiac arrest in special situations: drowning:2010 American Heart AssociationGuidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 2010;122:Suppl 3:S847-8
Guenether U et al.Extended theraeutic hypothermia for several days during extra-corporeal membrane-oxygenation after drowning and cardiac arrest: two cases of survival with no neurological sequelae. Resuscitation 2009;80:379-81
Permanent neurologic damage is the most worrisome outcome
According to recommendations from a consensus group (WARNER et al. Recommendations and consensus brain resuscitation in the drowning victim. Bierens JJLM, ed. Handbook on drowning: prevention, rescue and treatment. Berlin: Springer-Verlag, 2006:436-9)
Persons who are comatose or have neurologic deterioration should undergo intensive assessment and care
Goals are to achieve normal Glc, pp art O2, and ppCO2, with avoidance of any situation that increases brain metabolism
Indced hypotermia with the core temperature maintained between 32 and 34°C for 24hrs may be neuroprotective
In some cases, hypothermia reflects prolonged submersion time and a poor Pgx.
In others, early hypothermia is an iportant reasn why survival without neurological damage is possible
Recent reports on drowning have documented good outcomes with the use of therapeutic induction of hypothermia after resuscitation, despite a predicted poor outcome
The paradox being that a hypothermic patient needs to be warmed initially in order to be effectively resuscitated but may then benefit from induced hypothermia after successful resuscitation

35. Unusual Complications
SIRS after resuscitation has been reported
Should not be misinterpreted as infection
Sepsis and DIC in first 72hrs
Renal insufficiency or failure rare
Renal insufficiency/failure is rare but can occur as a result of anoxia, shock, myoglobinuria or haemoglobinuria

36. Most important predictors of outcome after resuscitation

37. Prognostic factors, patients <20 years Quan L, Kinder D
Prognostic factors, patients <20 years Quan L, Kinder D. Pediatric submersions: prehospital predictors of outcome [see comments]. Pediatrics 1992;90:909±913. & Cummings P, Quan L. Trends in unintentional drowning: the role of alcohol and medical care. JAMA 1999;281:2198±2202.
100% mortality
Submersion duration > 25 min
Resuscitation duration >25 min
Pulseless cardiac arrest on arrival to ED
Other
VT/VF on initial ECG (93%)
Fixed pupils in ED (89%)
Severe acidosis (89%)
Respiratory arrest in ED (87%)
Unresponsive in ED

38. Who Lives or Dies Good Prognostic Indicators Bad Prognostic Indicators
Short submersion
BLS/ALS on scene
Good response to initial resuscitation
Alert on admission
Older child or adult
Water temp < 5-10°C
Bad Prognostic Indicators
Submersion > 25 minutes
Cardiac arrest requiring > 25 minutes of ALS
Ongoing CPR in ED
Fixed, dilated pupils in ED
pH < 7.1
Age < 3 y/o
GCS < 5 in ED

39. Other Ineffective Treatments
No head down positioning
No Heimlich maneuver
No diuretics 
No prophylactic antibiotics
No steroids

40. 1-10-1

41. Beware of Diving Eur Spine J. 2010 Apr;19(4):552-7. Epub 2009 Dec 3.
Cervical spine injuries resulting from diving accidents in swimming pools: outcome of 34 patients.
Borius PY, Gouader I, Bousquet P, Draper L, Roux FE.
Source
Pôle Neuroscience (Neurochirurgie), Centres Hospitalo-Universitaires, Université Paul-Sabatier, Toulouse, France.
Abstract
Cervical spine injuries after diving into private swimming pools can lead to dramatic consequences. We reviewed 34 patients hospitalized in our center between 1996 and Data was collected from their initial admission and from follow-up appointments. The injuries were sustained by young men in 97% (mean age 27) and the majority happened during the summer (88%). Fractures were at C5-C7 in 70%. American Spinal Injury Association class (ASIA) on admission was A for 8 patients, B for 4, C for 4, D for 1, and E for 17. There were 23 surgical spine stabilizations. Final ASIA class was A for 6 patients, B for 1, C for 3, D for 5, and E for 18. The mean duration of hospitalization was 21.3 days in our neurosurgical center (mean overall cost: 36,000 Euros/patient) plus 10.6 months in rehabilitation center for the 15 patients admitted who had an ASIA class A to C. Mean overall direct cost for a patient with class A is almost 300,000 Euros, compared to around 10,000 Euros for patients with class D and E. In addition, a profound impact on personal and professional life was seen in many cases including 11 divorces and 7 job losses. Dangerous diving into swimming pools can result in spinal injuries with drastic consequences, including permanent physical disability and a profound impact on socio-professional status. Moreover, there are significant financial costs to society. Better prevention strategies should be implemented to reduce the impact of this public health problem.
Cervical injuries due to diving occur mainly in swimming pools, with a peak incidence during the summertime.
Misjudgments of the water depth and reckless behavior have been cited as common factors in these accidents [5].
Alcohol consumption is also an important risk factor, thought to be contributory in 38 to 49% of injuries in previously published series [2, 3, 8, 10, 14, 15]. Kluger et al. [14] report that 22 patients among 45 who were
injured in swimming pools had blood alcohol levels higher than 100 mg/dl. In our study, blood alcohol levels were not available in all the medical reports.

42. Every drowning signals the failure of the most effective intervention – PREVENTION
This table summarises recreational safety messages that are based on evidence and expert opinion.
Its estimated that >85% of cases of drowning can be prevented by supervision, swimming instruction, technology, regulation and public education