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Key Features

Essentials of Diagnosis

  • The first requirement of rescue is immediate rescue breathing and CPR

  • Patient must also be assessed for hypothermia, hypoglycemia, concurrent injuries, and medical conditions

  • Clinical manifestations are hypoxemia, pulmonary edema, and hypoventilation

General Considerations

  • The World Health Organization defines drowning as the "process resulting in primary respiratory impairment from submersion in a liquid medium"

  • The panel recommended previously used terms such as near-drowning, wet-drowning, dry-drowning, silent drowning be eliminated from use

  • Drowning may result in aspiration, laryngospasm, hypoxemia, acidemia

  • Outcomes from drowning range from life without morbidity to death

  • Asphyxia of drowning usually due to aspiration of fluid (previously known as "wet" drowning)

  • May result from airway obstruction caused by laryngeal spasm while victim is gasping under water (previously called "dry" drowning)

  • The primary effect is hypoxemia due to perfusion of poorly ventilated alveoli, intrapulmonary shunting, and decreased compliance

Clinical Findings

Symptoms and Signs

  • Asymptomatic

  • Abnormal vital signs

  • Dyspnea, cough, wheezing, trismus

  • Cyanosis

  • Chest pain, dysrhythmia

  • Hypotension

  • Vomiting, diarrhea

  • Headache, altered level of consciousness, neurologic deficit

  • Apnea

  • A pink froth from the mouth and nose indicates pulmonary edema

  • With prolonged or cold-water immersion, hypothermia is likely

Differential Diagnosis

  • Alcohol or drug intoxication

  • Myocardial infarction

  • Seizure

  • Suicide attempt

  • Head or spinal cord injury from diving

  • Decompression sickness

Diagnosis

Laboratory Tests

  • Metabolic acidosis is common

  • Arterial blood gas results may be helpful in determining the degree of injury since initial clinical findings may appear benign

  • Urinalysis shows

    • Proteinuria

    • Hemoglobinuria

    • Acetonuria

  • Leukocytosis is usually present

  • PaO2 is usually decreased and PaCO2 increased or decreased

  • The blood pH is decreased

  • Bedside blood sugar must be checked rapidly

  • Other testing is based on clinical scenario and may include

    • Serum electrolytes

    • Creatinine, estimated glomerular filtration rate

    • Lactate

    • Troponin

    • Complete blood count

    • Coagulation studies

    • Urinalysis

    • Alcohol and toxicology levels

Imaging Studies

  • Chest radiographs may show pneumonitis, atelectasis, or pulmonary edema

Treatment

Medications

  • Bronchospasm from aspirated material may require use of bronchodilators

  • Antibiotics given only with clinical evidence of infection, not prophylactically

  • Central venous pressure (or, better, pulmonary artery wedge pressure) guides use of vascular fluid replacement, pressors, diuretics

  • Metabolic acidosis in 70% of near-drowning victims

    • Usually corrects with adequate ventilation and oxygenation

    • Glycemic control improves outcome

Therapeutic Procedures

First aid

  • Immediate CPR

  • Always suspect hypothermia and associated trauma, especially brain and cervical spine injury

  • Do not attempt to drain water from lungs

  • Heimlich maneuver used only if foreign body airway obstruction suspected

  • Immobilize cervical spine if neck injury possible

  • Do not stop basic life support for "hopeless" patients until core temperature is ...

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