Sections View Full Chapter Figures Tables Videos Full Chapter Figures Tables Videos Supplementary Content + Print Section ++ For further information, see CMDT Part 37-09: Drowning + Key Features Print Section ++ ++ 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 asphyxiation (from fluid aspiration or laryngospasm), hypoxemia, hypothermia, and acidemia Outcomes from drowning range from life without morbidity to death Asphyxia of drowning Is 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 Print Section ++ ++ Symptoms and Signs ++ Asymptomatic Abnormal vital signs Dyspnea, cough, wheezing, apnea, trismus Cyanosis Chest pain, dysrhythmia Hypotension Vomiting, diarrhea Headache, altered level of consciousness, neurologic deficit Hypothermia (from cold water or prolonged submersion) A pink froth from the mouth and nose indicates pulmonary edema ++ Differential Diagnosis ++ Alcohol or drug intoxication Myocardial infarction Seizure Suicide attempt Head or spinal cord injury from diving Decompression sickness + Diagnosis Print Section ++ ++ 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 Print Section ++ ++ Medications ++ Bronchospasm from aspirated material may require use of bronchodilators Antibiotics are 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 Occurs 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 is 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 32°C Complete recovery has been reported after prolonged resuscitation ++ Hospital care ++ Admit all patients Continuous monitoring of cardiorespiratory function, neurologic and renal and metabolic function, and urinary output Serial determination of arterial blood gases (ABGs), serum creatinine, and electrolytes Administer oxygen immediately at highest concentration and maintain oxygen saturation at ≥ 90% Pulmonary edema may not appear for 24 h Continuous positive airway pressure (CPAP) and positive end-expiratory pressure (PEEP) effectively reverse hypoxia in patients with spontaneous respirations and patent airways Endotracheal intubation and mechanical ventilation are indicated for patients unable to maintain open airway, adequate oxygenation or ventilation Nasogastric intubation to remove swallowed water and prevent aspiration Extracorporeal membrane oxygenation has been used in acute respiratory distress syndrome following near-drowning Perform serial physical examinations, chest radiographs to detect possible pneumonitis, atelectasis, pulmonary edema Some cases progress to irreversible CNS damage despite adequate treatment of hypoxia and shock Hypothermia: measure and manage core temperature as appropriate (see Hypothermia) + Outcome Print Section ++ ++ Prognosis ++ As the duration of submersion lengthens, the probability of worse outcome increases Favorable prognosis is related to a duration of submersion of < 5 minutes Victims of near drowning who have had prolonged hypoxemia should remain under close hospital observation for 2–3 days after all supportive measures have been withdrawn and clinical and laboratory findings have been stable Long-term complications of near drowning may include neurologic impairment, seizure disorder, and pulmonary or cardiac damage A few patients may be deceptively asymptomatic during the recovery period, only to deteriorate or die as a result of acute respiratory failure within the following 12–24 h There is a direct correlation between prognosis and the patient's age, submersion time, rapid prehospital resuscitation and rapid transport to a medical facility, clinical status at time of arrival to hospital, Glasgow Coma Scale score, pupillary reactivity, and overall health assessment (APACHE II score) ++ Prevention ++ Clinicians must provide patient education and guidance about drowning prevention Physical barriers (ie, fences) must be placed around pools and other accessible bodies of water Closely supervise those who cannot swim Avoid alcohol during recreational swimming or boating Swimming lessons early in life Use of personal flotation devices when boating or water skiing ++ When to Admit ++ Most patients Inpatient monitoring includes Continuous monitoring of cardiorespiratory, neurologic, renal and metabolic function Maintenance of oxygenation Serial determination of arterial blood gases, pH, kidney function (serum creatinine), and electrolytes Measurement of urinary output Pulmonary edema may not appear for 24 hours + References Print Section ++ + +Dowd MD. Dry drowning: myths and misconceptions. Pediatr Ann. 2017 Oct 1;46(10):e354–7. [PubMed: 29019627] + +Idris AH et al. 2015 revised Utstein-style recommended guidelines for uniform reporting of data from drowning-related resuscitation: an ILCOR advisory statement. Resuscitation. 2017 Sep;118:147–58. [PubMed: 28728893] + +Mott TF et al. Prevention and treatment of drowning. Am Fam Physician. 2016 Apr 1;93(7):576–82. [PubMed: 27035042] + +Pajunen T et al. Unintentional drowning: role of medicinal drugs and alcohol. BMC Public Health. 2017 May 19;17(1):388. [PubMed: 28521790] + +Quan L et al. Predicting outcome of drowning at the scene: a systematic review and meta-analyses. Resuscitation. 2016 Jul;104:63–75. [PubMed: 27154004] + +Schmidt A et al. Drowning in the adult population: emergency department resuscitation and treatment. Emerg Med Pract. 2015 May;17(5):1–18. [PubMed: 26301918]