Drowning

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

  • Asphyxiation

    • 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)

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

  • Hypoxemia

  • Hypothermia

  • Acidemia

• Outcomes from drowning range from life without morbidity to death

Clinical Findings

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 in the mouth and nose from pulmonary edema

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 glucose 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

  • Pulmonary edema

• Initial chest radiograph

  • May not correlate with arterial blood gas measurements or outcome

  • Should not be relied upon to determine prognosis

Treatment

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, vasopressors, 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 ...