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  » First Aid  »  Drowning And Near Drowning
• Typical incidents involve a toddler left unattended temporarily or under the supervision of an older sibling, an adolescent found floating in the water, or a victim diving and not resurfacing.
• The submersion time, water temperature, water tonicity, symptoms, associated injuries (especially cervical spine and head), type of rescue, and response to initial resuscitation are all relevant factors.
* Thermal conduction of water is 25-30 times that of air. The temperature of thermally neutral water, in which a nude individual's heat production balances heat loss, is 33°C.
  * Physical exertion increases heat loss secondary to convection/conduction up to 35-50% faster.
  * A significant risk of hypothermia usually develops in water temperatures less than 25°C, which is the temperature found in most US natural waters during the majority of the year.
• Other important historical factors include the following:
  * Shortness of breath, difficulty breathing, cessation of breathing
  * Persistent cough
  * In stream, lake, or salt water immersion, possible aspiration of foreign material
  * Level of consciousness at presentation, history of loss of consciousness
  * Vomiting
  * Coincident alcohol or drug use
  * Pertinent past medical history, particularly seizure disorder, diabetes mellitus, psychiatric history, severe arthritis, or neuromuscular disorder
In the US: Drowning deaths number more than 6500 per year. A bimodal distribution of deaths is observed, with an initial peak in the toddler age group and a second peak in adolescent to young adult males.

Despite preventive measures, drowning is second only to motor vehicle accidents (MVAs) as the most common cause of injury and death in children aged 1 month to 14 years. Morbidity from submersion occurs in 12-27% of survivors in this age group. Preschool-aged boys are at greatest risk of submersion injury. A survey of 9420 primary school children in South Carolina estimated that approximately 10% of children younger than 5 years had an experience judged a "serious threat" of near drowning. Residential swimming pools are the most common submersion site in this age group.

An additional 1200 reported immersion deaths are boating related (90% of boating deaths), 500 are motor vehicle associated, and 1000 reported drownings are of undetermined etiology. Scuba diving accounts for an estimated 700-800 deaths per year (etiologies include inadequate experience/training, exhaustion, panic, carelessness, and barotrauma).

Submersion-related injuries are the fifth leading cause of accidental death in the US in all age groups; incidence is approximately 2.5-3.5 per 100,000 population. California reports approximately 25,000 ocean rescues on its beaches each year. True incidence of near drowning has yet to be defined accurately, however, since many cases are not reported.
Internationally: Annually, approximately 140,000 deaths occur worldwide from drowning. Several of the most densely populated nations in the world fail to report near drowning incidents. This, along with the fact that many cases are never brought to medical attention, renders accurate worldwide incidence approximation virtually impossible.

Incidence of near drowning has an estimated range of 20-500 times the rate of drowning.
Mortality/Morbidity: Morbidity and death in immersion injuries are due primarily to laryngospasm and pulmonary injury, resulting hypoxemia, and its effects on the brain and other organ systems.

Prevention is as important as any measures that can be taken after the fact.
• A high risk of death exists secondary to the development of adult respiratory distress syndrome (ARDS), which has been termed postimmersion syndrome or secondary drowning. Morbidity is due to neurologic insult, as well as to multiple organ system failure.

• Adult mortality rate is difficult to quantify because of poor reporting and inconsistent record keeping.

• Thirty-five percent of immersion episodes in children are fatal; 33% result in some degree of neurologic impairment, 11% in severe neurologic sequelae.
  • Male-to-female ratios are approximately 12:1 for boat-related drownings and 5:1 for non–boat-related drownings.

• Only in bathtub incidents do girls predominate in incidence.
          Age: Peak incidences of submersion injury occur in the following 2 age groups:
  • Children younger than 4 years

• Young adults aged 15-24 years
          Physical:A victim of a submersion incident may be classified initially into 1 of the following 4 groups:
  • Asymptomatic

• Symptomatic
    * Altered vital signs (eg, hypothermia, tachycardia, bradycardia)
* Anxious appearance
* Tachypnea, dyspnea, or hypoxia: If dyspnea occurs, no matter how slightly, the patient is considered symptomatic
* Metabolic acidosis (may exist in asymptomatic patients as well)
* Altered level of consciousness, neurologic deficit
  • Cardiopulmonary arrest
    * Apnea
* Asystole (55%), ventricular tachycardia/fibrillation (29%), bradycardia (16%)
* Immersion syndrome
  • Obviously dead
    * Normothermic with asystole
* Apnea
* Rigor mortis
* Dependent lividity
* No apparent CNS function
  • Bathtub drowning is most common in children younger than 1 year.
    * A majority of these victims drown during a brief (<5 min) lapse in adult supervision.
* Bathtub and pail drownings may represent child abuse; carefully examine the child for other evidence of injury and review the details of the incident very carefully with the child's parent or guardian.
  • In the preschool-aged children, drownings occur most commonly to residential swimming pools.
    * Many residential pools have no physical barrier between the pool and the home.
* Open gates are involved in up to 70% of drownings in cases involving fenced-in pools.
  • Young adults typically drown in ponds, lakes, rivers, and oceans.
    * Cervical spine injuries and head trauma, which result from diving into water that may be shallow or contain rocks and other hazards, have been implicated.
* Alcohol and, to a lesser extent, other recreational drugs are implicated in many cases. Australian, Scottish, and Canadian data showed that 30-50% of older adolescents and adults who drowned in boating incidents were inebriated, as determined by blood alcohol concentrations.
  • Consider underlying disease/illness in all age groups.
    * Seizure disorder
* Myocardial infarction (MI) or syncopal episode
* Poor neuromuscular control, such as that seen with significant arthritis, Parkinson, or other neurologic disorders
* Major depression/suicide
* Anxiety/panic disorder
* Diabetes, hypoglycemia
  • Water sports hazards
    * Poor judgment and substance abuse (alcohol or other recreational drugs) in conjunction with boat operation
* Cervical spine injury and head trauma associated with surfing, water skiing, and jet skiing
* Scuba diving accidents and other injuries (eg, bites, stings, and lacerations)

Evaluation Of Rescuer's Skills:
Plunging into the water to save someone who is drowning or has apparently drowned should be approached with extreme caution. Few nonswimmers can rescue a drowning person; frequently both the original victim and the would-be rescuer drown together. If you cannot swim or if you doubt your ability to get the drowning victim out of the water, it is far better to summon help or try some other tactic other than unthinkingly jumping into the water.

Pulling the Victim out of the Water: Where swimming to a drowning victim in the water is beyond your swimming capability, the Coast Guard recommends a technique called "throw, row, or tow."

1. From a float, shoreside dock, or moored boat, attach a long rope to a buoyant object such as a life jacket, life preserver, or a large empty plastic bottle that is securely closed and throw it to the floundering swimmer and then pull her to shore.

2. If it is not possible to throw something to the swimmer and a rowboat or other boat is available, row out to the victim as quickly as possible.

3. Give the person an extra oar, rope, or life preserver to hold on to, and tow him or her to shore. Don't try to haul the person into the boat; this may cause it to capsize and you'll both be in the water.

1. If there is a chance the near-drowning victim has a neck or back injury (e.g., from a diving, water-skiing, or boating accident), special care in maintaining neck and back alignment will be needed in getting him to shore. If possible, float the victim onto a board and then pull to shore. If the victim is breathing and a spinal injury is suspected, keep him in the water floating on his back until a board or other support can be brought to you.

2. If the victim has fallen through ice into the water, do not walk on the ice to rescue him. Instead, have the victim, if conscious, try to rest on the edge of the ice, rather than trying to climb out, which may only result in breaking more ice. Throw a rope from shore, or use a long board or stick and try to pull the victim out and across the ice on his belly, to distribute the weight as evenly as possible. If the victim is unconscious, tie the rope around your waist, secure the other end, and slide out on the ice on your belly. If other rescuers are present, form a human chain, with everyone lying down, to reach the victim.

3. If breathing has stopped, begin mouth-to-mouth respiration. This can be done even while the victim is still in the water by giving 4 quick breaths and then a breath every 5 seconds while you are pulling the victim to shore.

1. Once the victim is out of the water, determine if there is a pulse. If not, begin CPR at once and continue until help arrives. Do not attempt to drain water from the lungs. If a back injury is suspected, do not transport the victim except to remove him from the water, and then use a board if possible.

2. Even if the victim is revived, observe carefully for possible complications, such as cardiac arrest, and take the person to a hospital as soon as possible. Water in the lungs decreases their ability to function; the body's salt and fluid balance also may be upset, leading to further complications that may not be immediately apparent. Hospital personnel should be informed as to whether the drowning took place in fresh or salt water; these circumstances may influence the type of medical aftercare.

3. Transfer the victim to hospital for possible further medical care ASAP.

Deterrence/Prevention: • Children, especially toddlers, should be supervised at all times when they are around water, including a bathtub or bucket full of water.

• All pools should be fenced appropriately, with the gate to the area locked when not in use under adult supervision. Parents who own pools or who take their children to pools are encouraged to learn cardiopulmonary resuscitation (CPR).

• All individuals involved in boating should be able to swim, should use personal flotation devices when on the boat or in the water, and should avoid the use of alcohol or other recreational drugs. Boaters should be taught to anticipate wind, waves, and water temperature, and to use protective suits and other insulating garments in cold weather.

• All children should be taught to check the water carefully for depth and possible injurious objects before diving in. Children also should be taught their swimming limitations and to not play dangerously in pools or on the decks surrounding pools.

• All individuals should be taught not to drink alcohol or use other recreational drugs when swimming.

• Individuals with underlying medical illnesses that may place them at risk when swimming, such as seizure disorders, diabetes mellitus, significant coronary artery disease, severe arthritis, and disorders of neuromuscular function, should swim under the observation of another adult who can rescue them should they get into trouble.


• Patients who are alert or mildly obtunded at presentation have an excellent chance for full recovery.

• Patients who are comatose, receiving CPR at presentation to the ED, or have fixed and dilated pupils and no spontaneous respirations have a poor prognosis.

Patient Education:

• Prevention is key. Community education is the key to prevention.

• Adults should know their own, and their children's, swimming limits.

• Parents should be warned not to swim unsupervised and always to supervise children carefully around water.

• Children should be taught safe conduct around water and during boating and jet- or water-skiing.

• Use of alcohol or other recreational drugs is not appropriate when swimming or engaging in other water sports.

• Appropriate boating equipment should be used, including personal flotation devices, and all boaters must understand weather and water conditions.

• Appropriate barriers must be used around pools, wading pools, and other water-containing devices at home.

• Parents should seriously consider learning CPR and water safety training in case rescue and resuscitation are needed.

Medical/Legal Pitfalls:

• Management of hypoxemia is the key to the management of immersion injury. A surprising degree of hypoxia may be present in a relatively asymptomatic individual. Obtain pulse oximetry and ABGs on all individuals with any history of submersion injury. Early use of intubation and PEEP, or CPAP/BIPAP in the awake, cooperative, and less hypoxic individual, is warranted in any patient who remains hypoxic or dyspneic on 100% oxygen.

• Remember that cervical spine trauma may be present in any victim of shallow- or rocky-water immersion injury. If the victim is unable to give a clear history of the events, has evidence of head or facial injury, or is found unresponsive in a pool or other shallow body of water, protect the cervical spine until injury is excluded.

• Remember that most US waters usually are below thermal neutrality, and early temperature recording with appropriate rewarming is essential.