Drowning

Outlines
• Introduction
• Risk Factors
• Pathophysiology
• Assessment
• Investigations
• Management
• Outcome

Case Scenario
On a hazy, warm summer Sunday afternoon, the EMS call
goes off, you get the brief story: 12-year-old jumped into the
Lake and did not resurface, patient was found by bystander
submerged in water after 10 minutes and family started CPR
immediately until EMTs arrived to site. Arrival time is 4
minutes.

Definition
• “Drowning is the process of experiencing respiratory
impairment from submersion/immersion in liquid.” – WHO
• The drowning process begins with respiratory impairment as
the person’s airway goes below the surface of the liquid
(submersion) or water splashes over the face (immersion).
Szpilman, D., Bierens, J. J., Handley, A. J., & Orlowski, J. P. (2012).
Drowning. New England journal of medicine, 366(22), 2102-2110.

Risk Factors
• Inadequate adult supervision
• Inability to swim or overestimation of swimming capabilities
• Risk-taking behaviour.
• Use of alcohol and illicit drugs (>50 percent of adult drowning
deaths)
• Hypothermia, which can lead to rapid exhaustion or cardiac
arrhythmias.
Chandy, D., & Weinhouse, G. L. (2019). Drowning (submersion injuries). UpToDate.

Risk Factors
• Concomitant trauma, stroke, or myocardial infarction.
• Seizure disorder or developmental/behavioural disorders in
children
• Undetected primary cardiac arrhythmia (Congenital long QT
syndrome)
• Hyperventilation prior to shallow dive
Chandy, D., & Weinhouse, G. L. (2019). Drowning (submersion injuries). UpToDate

Pathophysiology
• The next conscious response is to hold one’s breath, but this lasts
for no more than about a minute.
• When the inspiratory drive is too high to resist, some amount of
water is aspirated into the airways, and coughing occurs as a
reflex response.
• When a drowning person can no longer keep his or her airway
clear, water entering the mouth is voluntarily spat out or
swallowed.

• After a short period of time, the laryngospasm subsides and fluid
is aspirated into the lungs.
• If the person is not rescued, aspiration of water continues, and
severe hypoxemia quickly leads to loss of consciousness and
apnea.
• The sequence of cardiac rhythm deterioration is usually
tachycardia followed by bradycardia, pulseless electrical activity,
and, finally, asystole.
• Fluid is inhaled and on touching the glottis causes immediate
laryngospasm.
Pathophysiology

• Hypoxia is the key pathological process that ultimately leads
to death.
• Water in the alveoli causes surfactant dysfunction and
washout.
• The effect of the osmotic gradient on the very delicate
alveolar–capillary membrane disrupts the integrity of the
membrane, increases its permeability, and exacerbates fluid,
plasma, and electrolyte shifts.
• Pulmonary edema decreases the exchange of oxygen and
carbon dioxide
Hypoxia
Drowning. New England journal of medicine, 366(22), 2102-2110

• The combined effects of fluids in the lungs, loss of surfactant,
and increased permeability of the alveolar–capillary
membrane result in decreased lung compliance, increased
regions of very low or zero ventilation to perfusion in the
lungs, atelectasis, and bronchospasm.
• Immersion in severely contaminated water and foreign bodies
is associated with infections and can lead to severe acute
respiratory distress syndrome (ARDS)
Hypoxia

• Hypothermia may have a protective effect against the
neurological sequelae following hypoxia and ischaemia.
• Hypothermia can reduce the consumption of oxygen in the
brain, delaying cellular anoxia and ATP depletion.
• Hypothermia reduces the electrical and metabolic activity of
the brain.
• However, it is associated with life‐threatening dysrhythmias,
coagulation disorders and susceptibility to infections。
Hypothermia

Pulmonary
• Noncardiogenic pulmonary edema and ARDS
Cardiovascular
• Arrhythmias secondary to hypothermia and hypoxemia
• Changes in the ECG following submersion injury that suggest
myocardial ischemia may be due to takotsubo
cardiomyopathy, coronary artery spasm, or hypothermia.
End Organ Effects

Neurologic
• Hypoxemia and ischemia cause neuronal damage, which can
produce cerebral edema and elevations in ICP.
• Progressive rise in ICP reflect the severity of the neurologic
insult.
Acid-base and electrolytes
• A metabolic and/or respiratory acidosis is often observed.
• Major electrolyte abnormalities are seldom significant and are
usually transient unless there is significant hypoxia, central
nervous system depression.
End Organ Effects

Renal
• Renal failure rarely can occur after submersion.
• Usually due to acute tubular necrosis resulting from hypoxemia,
shock, hemoglobinuria, or myoglobinuria
Coagulation
• Hemolysis and coagulopathy are rare potential complications of
nonfatal drowning.
• Disseminated intravascular coagulation can be a complicating
factor in drowning outcome but usually occurs following severe
hypoxic insult.
End Organ Effects

History
• Length of submersion
• Type of water, contamination and water temperature
• Other associated trauma
• Other factors involved such as alcohol and drugs
• Underlying conditions
• Pre hospital care provided, including vital signs and GCS on
arrival of EMS

Investigations
• ECG
• Core temperature
• ABG
• Electrolytes and blood sugar
• Blood culture
• CXR
• X-rays/CT-imaging where there is a suspicion of
head, neck or spinal injuries
Wayne W. (2020). Drowning. Rcem Learning.

Management
• Three phases:
 Prehospital care
 Emergency department (ED) care
 Inpatient care

PREHOSPITAL CARE
Rescue and In
Water Resus
Initial Resuscitation On
Land
Advanced
Prehospital Care

Rescue and In water Resuscitation
 Safe rescue techniques
 Call for EMS
 If conscious -> brought to land -> BLS
 If unconscious -> in-water resuscitation
 Lifted out of the water in a horizontal position to prevent
venous pooling and sudden cardiovascular collapse
 ?Cervical spine protection

Routine stabilization of the cervical spine in the absence of
circumstances that suggest a spinal injury is not recommended
(Class III, LOE B)
Lavonas, E. J., Drennan, I. R., Gabrielli, A., Heffner, A. C., Hoyte, C. O., Orkin, A. M., ...
& Donnino, M. W. (2015). Part 10: special circumstances of resuscitation: 2015 American
Heart Association guidelines update for cardiopulmonary resuscitation and emergency
cardiovascular care. Circulation, 132(18_suppl_2), S501-S518.
Cervical Spinal Cord Injury is uncommon in nonfatal drowning
victims, unless there are clinical signs of injury of a concerning
mechanism
Vanden Hoek, T. L., Morrison, L. J., Shuster, M., Donnino, M., Sinz, E., Lavonas, E. J., ...
& Gabrielli, A. (2010). Part 12: cardiac arrest in special situations: 2010 American Heart
Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular
care. Circulation, 122(18_suppl_3), S829-S861.
Routine Cervical Spine Immobilization can interfere with airway
management and is NOT recommended

Initial Resuscitation on Land
 Supine position
 Unconscious + breathing -> Recovery position
 Unconscious + not breathing normally -> Rescue ventilation
 A-B-C sequence
 European Resuscitation Council : 5 initial rescue breaths instead
of 2 because the initial ventilations can be more difficult to
achieve, since water in the airways can interfere with effective
alveolar expansion

Most frequent complication during resuscitation attempt is
REGURGITATION of stomach contents
Lavonas, E. J., Drennan, I. R., Gabrielli, A., Heffner, A. C., Hoyte, C. O., Orkin, A.
M., ... & Donnino, M. W. (2015). Part 10: special circumstances of resuscitation:
2015 American Heart Association guidelines update for cardiopulmonary
resuscitation and emergency cardiovascular care. Circulation, 132(18_suppl_2),
S501-S518.

Advanced Prehospital Care
 Alert advanced life support teams ASAP
 Six grades Classifications : higher numbers indicating more
severe impairment, to help stratify risk and guide
interventions
 Calculate the likelihood of survivability on the basis of time
from site of drowning until hospital discharge

 Peripheral venous access is the preferred route for drug administration in
the prehospital setting.
 IO is an alternative route
 Hypotension -> if not corrected by oxygenation, a rapid crystalloid infusion
should be administered
 Usual presenting rhythm in cases of cardiac arrest after drowning (grade
6) -> asystole or PEA
 Consider IV adrenaline, at an individual dose of 1 mg (or 0.01 mg per kg of
body weight) during CPR in the absence of cardiac activity despite ongoing
ventilation and chest compression

Emergency Department Care
• Management of fresh and saltwater drowning is the same
• ABCDE approach
• Determine core temperature
• Routine cervical immobilization and CT brain are not necessary
because cervical injury is rare without a history of diving or
associated trauma
Tintinalli, J. E., Stapczynski, J. S., Ma, O. J., Cline, D., Meckler, G.
D., & Yealy, D. M. (Eds.). (2016). Tintinalli's emergency medicine: a
comprehensive study guide. New York: McGraw-Hill Education.

Emergency Department Care
• Conscious patients + able to protect airway : may benefit from
a trial of NIV
• If high-flow oxygen (FiO2 40%-60%) cannot maintain an
adequate PaO2 (>60 mmHg in adults, >80 mmHg in children)
-> intubate + provide positive-pressure ventilation
Tintinalli, J. E., Stapczynski, J. S., Ma, O. J., Cline, D., Meckler, G. D.,
& Yealy, D. M. (Eds.). (2016). Tintinalli's emergency medicine: a

Ventilation Strategies
• Aim: to maintain oxygenation while minimising ventilator associated
lung injury
• Care should be taken to avoid lung overdistention and ventilator-
associated barotrauma
• FiO2: ideally be maintained <0.50, higher concentrations -> absorption
atelectasis + have a direct toxic effect on lung parenchyma.
• Tidal Volume: 6ml/kg
• Insufficient evidence to support a target PaCO2

Ventilation Strategies
• PEEP: maintained at ≥5cm H2O
-> to prevent shear stress
->can be increased to maximise oxygen delivery, as long
as not compromising cardiac output.
-> should be left unchanged for at least 48-hours to permit
adequate surfactant regeneration & ensure alveolar
recruitment before weaning is attempted.
->Early weaning may cause the return of pulmonary oedema,
a prolonged stay, and further morbidity

Respiratory Issues
• Bronchospasm
-treat similarly to acute asthma
-usually rapidly improved with inhaled beta-adrenergic agonists
• Pulmonary Infection
-no good evidence of prophylactic antibiotics
-only used in cases of clinical pulmonary infection or if submersion
in grossly contaminated water
-high suspicion for water borned pathogens (Aeromonas,
pseudomonas, and proteus) in patients with pneumonia

• ARDS
-Patients presenting with significant aspiration or cardiovascular
collapse are predisposed to develop ARDS
• Acute pulmonary edema
• CXR
-may not reflect the severity of pulmonary involvement
-indicated if got signs and symptoms of increased respiratory
distress, declining pulse oximetry, or hypercarbia

• Surfactants?
• Prophylactic
glucocorticoids?
• ECMO?

• Cold diuresis
• usually correctable with oxygenation, crystalloid infusion, and
restoration of normal body temperature.
• may require continuous infusion of adrenaline or dopamine as
hemodynamic response to adrenaline is frequently short lived
post resuscitation.
• ECHO : measurement of ventricular function -> to assist in
optimal fluid replacement and inotropic support
• Continuous cardiac monitoring, pulse oximetry, temperature
monitoring, and frequent reassessments should be performed
for all patients
Hypotension
D., & Yealy, D. M. (Eds.). (2016). Tintinalli's emergency medicine:
a comprehensive study guide. New York: McGraw-Hill Education.

Hypotension
• Hemodynamic recovery, when it occurs, can be expected within
48 hours.
• Patients demonstrating no hemodynamic recovery after 48
hours may slowly improve over the first week but are more likely
to have long-term neurologic damage
Tintinalli, J. E., Stapczynski, J. S., Ma, O. J., Cline, D., Meckler, G. D.,
& Yealy, D. M. (Eds.). (2016). Tintinalli's emergency medicine: a

• usually corrected by patient’s spontaneous effort to increase
minute ventilation
OR
Setting higher minute ventilation or at higher Pip (35cm of
water) on mechanical ventilator
• Routine use of sodium bicarbonate not recommended
Metabolic Acidosis

Neurologic Injuries
Goal: To prevent secondary neurologic injuries due to ongoing
ischemia, cerebral edema, hypoxemia, fluid and electrolyte
imbalances, acidosis, and seizure activity
Treatments:
 Elevate the head of the bed to 30⁰
 Diuretics
 Hyperventilation
 Non-sedating anticonvulsants (phenytoin) to control seizures
 Maintain euglycemia
 The role of therapeutic (induced) hypothermia in the post
resuscitation period following drowning remains unclear

Hypothermia
• The core body temperature is less than 35°C.
• It can be classified as:
 Mild 32–35°C
 Moderate 30–32°C
 Severe <30°C
• Assess core temperature with a low reading thermometer
Banerjee A, Oliver C. Surgery. In: Revision Notes for the FRCEM
Intermediate SAQ Paper, Chapter 6. Oxford, UK: Oxford University Press; 2017

Hypothermia
• The elderly and very young are more prone to hypothermia due
to impaired thermoregulation
• Hypothermia can exert a protective effect on the brain after
cardiac arrest.
• Confirmation of death should not be made until the patient has
been rewarmed, or attempts to rewarm the patient have failed.

Hypothermia with Pulse
• Rewarmed with active and passive rewarming techniques,
depending on the severity and duration of hypothermia
• Aim for a rate of 0.5–2°C per hour. Rapid rewarming may
precipitate pulmonary and cerebral oedema, especially in the
elderly
• ECG monitoring is necessary to detect the development of
arrhythmias.
• Most arrhythmias other than VF tend to revert spontaneously as
the core temperature increases and do not usually require
immediate treatment

Hypothermia with Pulse
• Monitor for hypoglycaemia and corrected with D50% if
present
• IV fluids may be required as the patient rewarms.
• If hypotensive, 300–500 ml of warmed 0.9% sodium chloride
should be given.
• There is a risk of pulmonary oedema and unstable patients
should be monitored with a central venous pressure (CVP) line
and urinary catheter.

Rewarming Techniques
• Passive
 Remove cold or wet clothing
 Dry the patient
 Cover with blankets/hot air
blanket
 Warm room (overhead
heaters, if available)
 Forced-air warming system
(e.g. Bair Hugger)
• Active
 Warmed, humidified oxygen
 Warmed IV fluids
 Gastric, peritoneal, pleural,
or bladder lavage with
warmed fluids
 Cardiopulmonary bypass.

Modifications to the ALS algorithm in
a hypothermic cardiac arrest
• Palpate a major artery for a pulse and look for signs of life for up
to one minute.
• Modified drug regime
• Withhold cardioactive drugs until the core temperature is
>30°C.
• Once 30°C has been reached, double the interval between
doses until the temperature returns to normal (>35°C).

• VF/VT : attempt 3 defibrillations, however if further attempts is
needed, defibrillation should be postponed until the
temperature is >30°C
• Interventions e.g intubation should be performed by an expert
• Rewarm the patient to 32–34°C, a target temperature of 36°C is
an alternative

Disposition
• All drowning victims who require ED resuscitation should be
admitted to ICU for continuous cardiopulmonary and
neurologic monitoring
D., & Yealy, D. M. (Eds.). (2016). Tintinalli's emergency medicine:
a comprehensive study guide. New York: McGraw-Hill Education.

Outcome
• Factors at presentation associated with a poor prognosis:
 Duration of submersion >5 minutes (most critical factor)
 Time to effective basic life support >10 minutes
 Resuscitation duration >25 minutes
 Age >14 years
 Glasgow coma scale <5 (ie, comatose)
 Persistent apnea and requirement of cardiopulmonary resuscitation
in the emergency department
 Arterial blood pH <7.1 upon presentation

Drowning

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Editor's Notes