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Formerly, submersion injuries that resulted in death in <24 hours were termed “drowning,” and those that survived >24 hours were termed “near drowning.” Currently, all submersion injuries should be termed “drowning.”1 As with other causes of accidental death, submersion injuries typically involve otherwise healthy, young individuals.

Worldwide, drowning accounts for >500,000 deaths annually and is the leading cause of death by injury among children <15 years of age. In the U.S., there are >500,000 submersion events each year, which makes drowning the fourth leading cause of accidental death overall and the second leading cause of death in those <15 years of age. The vast majority of victims survive submersion events, with effects ranging from minimal or transient injury to profound neurologic insult.

There are three age-related peaks in drowning incidence: the first is in toddlers and young children, the second in adolescents and young adults, and the third in the elderly. In addition to drowning in pools and bodies of water, infants and toddlers can drown in toilets, buckets, and bathtubs. The elderly also have an increased risk of bathtub drowning. Even in coastal areas most submersion events take place in warm, freshwater bodies of water (especially swimming pools).

Additional injuries or disorders that either precipitate or are associated with submersion events are shown in Table 209-1.

Table 209-1 Injuries and Disorders Associated with Submersion Events

After submersion, the degree of pulmonary and, in particular, central nervous system (CNS) insult determines the ultimate outcome. It was previously thought that parasympathetic activation of the diving reflex (i.e., bradycardia, apnea, peripheral vasoconstriction, and central shunting of blood flow) provided transient protection during submersion. However, the diving reflex may not provide as much protection in humans as was once thought. The diving reflex is strongest in infants <6 months of age, but the effects decrease with age.2 In adults, vertical immersion (head out) and vertical submersion (head under) activates both the sympathetic and parasympathetic systems, which blunts any effect of the diving reflex.3 Physiologic stress associated with submersion undoubtedly also activates the sympathetic nervous system. Cerebral protection in cold water submersions most likely results from rapid CNS cooling before significant cardiac dysrhythmia.

“Dry drowning,” which accounts for 10% to 20% of submersion injuries, occurs when there is laryngospasm, followed by hypoxia leading to loss of consciousness. More commonly, “wet drowning” occurs, in which water is aspirated into the lungs. The effect is dilution and washout of the pulmonary surfactant with resultant diminished ...

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