Drowning is a major public health issue worldwide, accounting for over 500,000 deaths per year. It is a leading cause of accidental death for those under age 45. The pathophysiology of drowning involves hypoxemia from aspiration of water into the lungs, which affects multiple organ systems. Management involves early rescue and CPR, with a focus on ventilation. In the hospital, patients may develop pulmonary edema, neurological impairment, or other end-organ effects and require monitoring and support. Standardizing definitions and reporting of drowning incidents can help improve outcomes.

1. Drowning ( Submersion injuries )
Dr Ashutosh Bhardwaj
MD,IDCCM,EDIC
Clinical Lead & Senior Consultant ,
Critical Care Medicine ,
Dharmshila Narayana Superspeciality Hospital ,
Vasundhara Enclave, Delhi -96

2. Introduction
• Every year, drowning accounts for at least
500,000 deaths worldwide
– Low and middle-income countries-highest rates of
fatal drowning (over 90 percent of such fatalities)
• Major cause of accidental death- under the age
of 45 years and in children under five years of age
– The age distribution of submersion injury is bimodal
• Statistics for nonfatal drowning - difficult to
obtain, may occur several hundred times as
frequently as reported drowning deaths
 Papa L, Hoelle R, Idris A. Systematic review of definitions for drowning incidents. Resuscitation 2005;65:255
 Bierens JJ, Knape JT, Gelissen HP. Drowning. Curr Opin Crit Care 2002; 8:578
 DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;13:477
2

3. < 100 350-400
100-150 400-450
150-200 450-500
200-250 500-600
250-300 600-700
300-350 >700
Age-standardised Disability-Adjusted Life Year (DALY) rates from Drownings by
country (per 100,000 inhabitants)
 DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;13:477
3

4. Terminology
• Multiple definitions of drowning, nonfatal
drowning, and submersion injury - creating
confusion
• Nonfatal drowning - survival, at least temporarily,
after aspiration of fluid into the lungs ("wet
nonfatal drowning") or after a period of asphyxia
secondary to laryngospasm ("dry nonfatal
drowning")
• The Utstein definitions & methods of data
reporting for drowning and related event - to
improve consistency
 Idris AH, Bierens JJLM, Perkins GD, et al. 2015 revised Utstein-style recommended guidelines for uniform reporting of data from drowning-related
resuscitation: An ILCOR advisory statement. Resuscitation 2017;118:147.
 Youn CS, Choi SP, Yim HW, Park KN. Out-of-hospital cardiac arrest due to drowning: An Utstein Style report of 10 years of experience from St. Mary's
Hospital. Resuscitation 2009; 80:778.
4

5. Terminology
• Utstein guidelines, drowning refers to: "a process
resulting in primary respiratory impairment from
submersion or immersion in a liquid medium"
• Suggest to remove ambiguous or confusing
terms such as "near-drowning," "secondary
drowning," and "wet drowning"
 Idris AH, Bierens JJLM, Perkins GD, et al. 2015 revised Utstein-style recommended guidelines for uniform reporting of data from drowning-related
resuscitation: An ILCOR advisory statement. Resuscitation 2017;118:147.
 Youn CS, Choi SP, Yim HW, Park KN. Out-of-hospital cardiac arrest due to drowning: An Utstein Style report of 10 years of experience from St. Mary's
Hospital. Resuscitation 2009; 80:778.
5

6. Risk factors
• Inadequate adult supervision
• Inability to swim or overestimation of swimming
capabilities.
• Risk-taking behavior ,Use of alcohol and illicit
drugs
 DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;13:477
 Olshaker JS. Near drowning. Emerg Med Clin North Am 1992; 10:339
 Diekema DS, Quan L, Holt VL. Epilepsy as a risk factor for submersion injury in children. Pediatrics 1993;91:612.6

7. • Hypothermia,Concomitant trauma, stroke, or
myocardial infarction
• Seizure disorder or developmental/behavioral
disorders in children
• Undetected primary cardiac arrhythmia
• Hyperventilation prior to a shallow dive
 DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;13:477
 Olshaker JS. Near drowning. Emerg Med Clin North Am 1992; 10:339
 Diekema DS, Quan L, Holt VL. Epilepsy as a risk factor for submersion injury in children. Pediatrics 1993;91:612.7

8. 8
Causes
Salt Water 1-2%
Fresh water 98%
swimming pools: public 50%
swimming pools: private 3%
lakes, rivers, streams, storm drains 20%
bathtubs 15%
buckets of water 4%
fish tanks or pools 4%
toilets 1%
washing machines 1%
 DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults. Crit Care Clin 1997;13:477
 Olshaker JS. Near drowning. Emerg Med Clin North Am 1992; 10:339
 Diekema DS, Quan L, Holt VL. Epilepsy as a risk factor for submersion injury in children. Pediatrics 1993;91:612.

9. Pathophysiology
• Fatal and nonfatal drowning- begins with a period
of panic, loss of the normal breathing pattern,
breath-holding, air hunger
• Reflex inspiratory efforts - hypoxemia by means
of either aspiration or reflex laryngospasm
• Hypoxemia-affects every organ system especially
brain
 Kenny D, Martin R. Drowning and sudden cardiac death. Arch Dis Child 2011; 96:5.
 Ibsen LM, Koch T. Submersion and asphyxial injury. Crit Care Med 2002; 30:S402.
 Karpovich, PV. Water in the lungs in drowned animals. Arch Pathol 1933; 15:828.
 Giammona ST. Drowning: pathophysiology and management. Curr Probl Pediatr 1971; 1:1.
9

10. Pathophysiology
 Kenny D, Martin R. Drowning and sudden cardiac death. Arch Dis Child 2011; 96:5.
 Ibsen LM, Koch T. Submersion and asphyxial injury. Crit Care Med 2002; 30:S402.
10

11. • The event-- part 1
– Voluntary breath-holding
– Aspiration of small amounts into larynx
– Involuntary laryngospasm
– Swallow large amounts
– Laryngospasm abates (due to hypoxia)
– Aspiration into lungs
Pathophysiology
 Karpovich, PV. Water in the lungs in drowned animals. Arch Pathol 1933; 15:828.
 Giammona ST. Drowning: pathophysiology and management. Curr Probl Pediatr 1971;
1:1.
11

12. • The event-- part 2
– Decrease in sats
– Decrease in cardiac output
– Intense peripheral vasoconstriction
– Hypothermia
– Bradycardia
– Circulatory arrest, while VF rare
– Extravascular fluid shifts, diuresis
 Karpovich, PV. Water in the lungs in drowned animals. Arch Pathol 1933; 15:828.
 Giammona ST. Drowning: pathophysiology and management. Curr Probl Pediatr 1971;
1:1.
12

13. 13

14. 14

15. Pathophysiology – Fresh vs Salt water
• Hypertonic vs hypotonic - No longer considered
important
• More apparent among persons who are dead on
arrival
• Aspiration of >11 mL/kg must before blood
volume changes & > 22 mL/kg before electrolyte
changes
• Unusual for nonfatal drowning victims to aspirate
more than 3 to 4 mL/kg
• Both result in decreased lung compliance, V/Q
mismatch and intrapulmonary shunting -
hypoxemia  Orlowski JP, Szpilman D. Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am
2001;48:627
 Harries MG. Drowning in man. Crit Care Med 1981; 9:407
 Harries M. Near drowning. BMJ 2003; 327:1336.
15

16. End organs effects
• Tissue hypoxia
• Pulmonary
– Fluid aspiration-hypoxemia
– Both salt water and fresh water wash out surfactant -
noncardiogenic pulmonary edema and ARDS
– Pulmonary insufficiency - shortness of breath,
crackles, and wheezing
– Chest radiograph or CT - normal to localized, perihilar,
or diffuse pulmonary edema
 DeNicola LK, Falk JL, Swanson ME, et al. Submersion injuries in children and adults.
CritCare Clin 1997;13:477
 Olshaker JS. Near drowning. Emerg Med Clin North Am 1992; 10:339.
16

17. • Neurologic -
– Hypoxemia and ischemia - neuronal damage, cerebral
edema and elevations in intracranial pressure
– 20 percent of nonfatal drowning victims sustain
neurologic damage
• Cardiovascular –
– Arrhythmias secondary to hypothermia and
hypoxemia
– In some pts ECG may show s/o MI
– Initial arrhythmias-sinus tachycardia, sinus bradycardia
and atrial fibrillation
– Diving can precipitate fatal ventricular arrhythmias in
patients with congenital long QT syndrome
End organs effects
 Sarnaik AP, Preston G, Lieh-Lai M, Eisenbrey AB. Intracranial pressure and cerebral perfusion pressure in near-drowning. Crit Care Med 1985; 13:224
 Gonzalez-Rothi RJ. Near drowning: consensus and controversies in pulmonary and cerebral resuscitation.Heart Lung 1987; 16:474
 Rivers JF, Orr G, Lee HA. Drowning. Its clinical sequelae and management. Br Med J 1970; 2:157
17

18. • Acid-base and electrolytes -
– Metabolic and/or respiratory acidosis
– Significant electrolyte imbalances rare in nonfatal
drowning survivors except those submerged in
unusual media, such as the Dead Sea - extremely
concentrated seawater
• Renal –
– Rare & due to acute tubular necrosis resulting from
hypoxemia, shock, hemoglobinuria, or myoglobinuria
• Coagulation –
– Hemolysis and coagulopathy are rare
End organs effects
 Yagil Y, Stalnikowicz R, Michaeli J, Mogle P. Near drowning in the dead sea. Electrolyte imbalances and therapeutic implications. Arch
Intern Med 1985; 145:50.
 Fandel I, Bancalari E. Near-drowning in children: clinical aspects. Pediatrics 1976; 58:573.
 Bonnor R, Siddiqui M, Ahuja TS. Rhabdomyolysis associated with near-drowning. Am J Med Sci 1999;318:201.
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19. Management
• Prehospital care and acute interventions
• Emergency department management
• Patient disposition
• Inpatient management
19

20. Prehospital care and acute interventions
• Rescue and immediate resuscitation by
bystanders improves the outcome of drowning
victims
• CPR - as soon as possible
– without compromising the safety of the rescuer or
delaying the removal of the victim from the water
– Ventilation is the most important initial treatment
– Follow ABC & NOT CAB
• Cervical spinal cord injury is uncommon
– Unless clinical signs or history suggestive
– As per ACLS- routine cervical spine immobilization not
recommended
 Venema AM, Groothoff JW, Bierens JJ. The role of bystanders during rescue and resuscitation of drowning victims. Resuscitation 2010; 81:434.
 Watson RS, Cummings P, Quan L, et al. Cervical spine injuries among submersion victims. J Trauma 2001; 51:658.
20

21. • Pulses may be very weak and difficult to palpate
– May be because of hypothermia or arrythmias
– Check for at least one min before initiating chest
compressions
• The Heimlich maneuver or other postural
drainage technique – no proven value
– Don’t delay rescue breaths
• Give supplemental oxygen
• Initiate rewarming in hypothermic pt ( <33⁰C)
 Rosen P, Stoto M, Harley J. The use of the Heimlich maneuver in near drowning: Institute of Medicine report. J Emerg Med 1995; 13:397.
 Lavonas EJ, Drennan IR, Gabrielli A, et al. Part 10: Special Circumstances of Resuscitation: 2015American Heart Association Guidelines Update for Cardiopulmonary
Resuscitation and EmergencyCardiovascular Care. Circulation 2015; 132:S501.
Prehospital care and acute interventions
21

22. Immediate hospital management
• Assess and manage ABC
• 100% oxygen
• Pulse oximetry (watch for false readings caused
by peripheral shutdown and acidosis)
• ABGs, FBC, U&E
• CXR
• Observation
• Management of associated hypothermia
22

23. Emergency department management
• Prehospital resuscitative efforts to be continued
• Indications for O2,NIV & intubation –
GCS,PaO2,PaCO2
• Frequent vital sign measurements and clinical
reassessment
• Trauma evaluation and appropriate imaging
studies
• Rewarm the hypothermic patients
• Importance of prolonged resuscitative efforts
 Jolly BT, Ghezzi KT. Accidental hypothermia. Emerg Med Clin North Am 1992; 10:311.
 Quan L, Mack CD, Schiff MA. Association of water temperature and submersion duration and drowning outcome. Resuscitation 2014; 85:790.
 Kieboom JK, Verkade HJ, Burgerhof JG, et al. Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide
retrospective cohort study. BMJ 2015;350:h418.
23

24. Predicting Ability for ED Discharge
• Several studies support selected ED discharge
• Observe in ED for minimum 4-6 hours if:
– Submersion > 1 min.
– Cyanosis on extraction
– CPR required
• Admit if: CNS or respiratory symptoms
• Child can safely be discharged home if at 6 hours
after ED presentation:
– GCS > 13
– Normal physical exam/respiratory effort
– Room air pulse oximetry oxygen saturation > 95%
 Jolly BT, Ghezzi KT. Accidental hypothermia. Emerg Med Clin North Am 1992; 10:311.
 Quan L, Mack CD, Schiff MA. Association of water temperature and submersion duration and drowning outcome. Resuscitation 2014; 85:790.
 Kieboom JK, Verkade HJ, Burgerhof JG, et al. Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide
retrospective cohort study. BMJ 2015;350:h418.
24

25. Patient disposition
Drowning classification system
Adapted from Orlowski JP, Szpilman D. Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am. 2001;48:627-646.
[BMJ Best Practice: drowning classification system
25

26. Inpatient management
• Respiratory
– Ventilation
– Treatment of bronchospasm
– Steroids: no benefits
– Bronchoscopy
– Prophylactic abx: no benefits
• Pneumonia – Grossly contaminated water, Gastric juices
• Thinks of water borne bugs
– Surfactant: no beneficial
• Cardiovascular
– Restore adequate oxygen delivery to tissues
– Hypotension – cold diuresis -
 Pearn J. Pathophysiology of drowning. Med J Aust 1985; 142:586.
 Anker AL, Santora T, Spivey W. Artificial surfactant administration in an animal model of near drowning. Acad Emerg Med 1995; 2:204.
26

27. Inpatient management
• Neurological
• Outcome
– GCS on presentation, duration of LOC
• Goal is to prevent secondary neurologic injuries
– Brain CT – not indicated, unless TBI suspected
– ICP monitoring - not indicated, typically irreversible
hypoxic cellular injury
– Mild hyperventilation?
– Osmotherapy – not indicated
– Corticosteroids (dexamethasone) - no proven benefit
-
 Moler FW, Hutchison JS, Nadkarni VM, et al. Targeted Temperature Management After Pediatric Cardiac
Arrest Due To Drowning: Outcomes and Complications. Pediatr Crit Care Med 2016; 17:712.
 Tipton MJ, Golden FS. A proposed decision-making guide for the search, rescue and resuscitation of submersion (head under) victims based on expert opinion.
Resuscitation 2011; 82:819.
 Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte
abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution.
Resuscitation 2010; 81:1400.
27

28. Inpatient management
– Shivering or random, purposeless movements can
increase ICP
– Seizures - treat aggressively
– Hypothermia and barbiturate coma - highly
controversial & unlikely to benefit the patient
– Avoid NMBs
– Maintain Euglycemia
• Therapeutic (induced) hypothermia in the
postresuscitation period – Equivocal data
 Moler FW, Hutchison JS, Nadkarni VM, et al. Targeted Temperature Management After Pediatric Cardiac
Arrest Due To Drowning: Outcomes and Complications. Pediatr Crit Care Med 2016; 17:712.
 Tipton MJ, Golden FS. A proposed decision-making guide for the search, rescue and resuscitation of submersion (head under) victims based on expert opinion.
Resuscitation 2011; 82:819.
 Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in special circumstances: Electrolyte
abnormalities, poisoning, drowning, accidental hypothermia, hyperthermia, asthma, anaphylaxis, cardiac surgery, trauma, pregnancy, electrocution.
Resuscitation 2010; 81:1400.
28

29. Prognosis
29

30. Prognosis predictors
• Poor outcomes
– Age >14 yrs
– Submersion time: >5 min
– Time to effective BLS >10 min
– Serum pH: <7.1 on presentation
– CPR >25 min
– Initial core temp <33ºC
– GCS <5 ie comatose
– No association between water temperature & outcome
-
Quan L, Mack CD, Schiff MA. Association of water temperature and submersion
duration and drowning outcome. Resuscitation 2014; 85:790.
30

31. Prognosis predictors
-
Submersion time survival Fatality
0-5 min 7/67 10%
6-9 min 5/9 56%
10-25 min 21/25 88%
>25 min 4/4 100%
Quan L, Mack CD, Schiff MA. Association of water temperature and submersion
duration and drowning outcome. Resuscitation 2014; 85:790. 31

32. Neurologic prognosis
• Absence of spontaneous respiration,Poor GCS,
duration of LOC are ominous sign associated with
severe neurologic sequelae
• Permanent neurologic sequelae persist in ~20%
of victims who present comatose
– Minimal brain dysfunction, spastic quadriplegia,
extrapyramidal syndromes, optic and cerebral atrophy,
and peripheral neuromuscular damage
 Orlowski JP. Prognostic factors in pediatric cases of drowning and near-drowning. JACEP 1979; 8:176.
 Biggart MJ, Bohn DJ. Effect of hypothermia and cardiac arrest on outcome of near-drowning accidents in children. J Pediatr 1990; 117:179. 32

33. Safety Recommendations
• Never leave a child alone in or near water, even
for a minute
• Limit pool access.
• Children with Epilepsy
– Child can swim in lifeguard-supervised swimming pool
- no open water
– Older child should shower in a non-glass cubicle - no
bath
– Leave bathroom unlocked
– Supervision!
 O'Flaherty JE, Pirie PL. Prevention of pediatric drowning and near-drowning: a survey of members of the American Academy
of Pediatrics. Pediatrics 1997; 99:169.
 Modell JH. Prevention of needless deaths from drowning. South Med J 2010; 103:650. 33

34. Safety Recommendations
• Learn CPR
• Use approved personal flotation devices
• Teach safe water behaviour
• The Best Approach Therefore:
• P revention !
• P revention !
• P revention !
 O'Flaherty JE, Pirie PL. Prevention of pediatric drowning and near-drowning: a survey of members of the American Academy
of Pediatrics. Pediatrics 1997; 99:169.
 Modell JH. Prevention of needless deaths from drowning. South Med J 2010; 103:650. 34

35. Summary
• Ventilation is the most important initial
treatment for victims of submersion injury –
ventilation strategies are standard
• Rescue breathing should begin as soon as the
rescuer reaches shallow water or a stable surface
• In critically ill patients, standard practices are
employed to reduce the risk of brain injury
• The role of therapeutic hypothermia remains
unclear
• There is no good evidence to support the routine
use of glucocorticoids or prophylactic antibiotics
in nonfatal drowning victims
35

36. 36

37. 37