1. Drowning is defined as respiratory impairment from submersion in a liquid medium and is a major cause of accidental death, especially in children ages 1-14. 2. Management of drowning victims involves resuscitation, treatment of hypoxic-ischemic encephalopathy, and prevention of complications. 3. Prevention strategies focus on supervision during water activities, swimming lessons, CPR training, and safety measures around pools.

1. DR CH. HAREEN

2. Overview
Definition
Epidemiology
Accidental vs. Non-accidental drowning
Pathophysiology
Management
Prevention

3. Definition
2002 World congress on drowning defined drowning
as
 “a process resulting in primary respiratory
impairment from submersion in a liquid medium”
Near drowning refers to survival (even if temporary)
beyond 24 hours after a submersion episode.
Shepard, Suzanne et al. Drowning. Emedicine.medscape.com/article/772753-overview. Updated 6/9/2009 .

4. Fatal Drowning Statistics
In 2005, 3,582 fatal unintentional drownings in U.S.
1 in 4 drownings were children < 14 years old
Drowning is the second-leading cause of unintentional
injury-related death for children ages 1 to 14 years
India has a drowning mortality rate of 8.5/100000
population.
Water Injuries-Fact Sheet. www .cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet Accessed
25 Sept 2009.

5. Location of Drowning
Brenner et al. looked at death certificates from
victims of unintentional drownings in 1995
Infant drownings: 55% in bathtubs
Age 1-4 years, 56% in artificial pools and 26% in other
bodies of freshwater
Children 63% of drownings were in natural bodies of
freshwater
Brenner RA, Trumble AC, Smith GS, Kessler EP, Overpeck MD. Where children drown,
United States, 1995. Pediatrics 2001;108(1):85 ﾐ

6. Features which differentiate between accidental, non-accidental, and homicidal
submersion injuries to children
 Accidental submersion:
 Typically a baby momentarily left alone or with a sibling in the bath
 Majority of children 8-15 months of age
 Child the youngest in the family
 No features suggesting child abuse
 Epilepsy related:
 Child with history of epilepsy
 Bathing alone
 A child older than 24 months
 Non-accidental submersion:
 Atypical submersion description, with inconsistent details
 Late referral to hospital
 Associated history of child abuse
 Child outside 8-24 month age span
 Child left with unsuitable carer
 Homicidal drowning:
 Maternal history of mental illness
 Child outside the 8-24 month age range
 Previous history of child abuse
Kemp, Alison et al. Accidents and child abuse in bathtub submersions. Archives of Disease in Childhood 1994; 70: 435-438.

7. Signs & symptoms
75% of kids who develop sxs do so within 7 hours of event
Coma to agitated alertness
Cyanosis, coughing, and the production of frothy pink
sputum
Tachypnea, tachycardia
Low-grade fever
Rales, rhonchi & less often wheezes
Signs of associated trauma to the head and neck should be
sought

8. “Hypoxic March of Drowning”
A pathophysiology summary
1. Involuntary submersion
 Voluntary apnea, tachycardia, hypoxia, hypercarbia
1. Involuntary inspiration
 Triggered by hypercarbia and hypoxia
 arterial hypoxemia, tissue hypoxia, tissue acidosis, and
tachycardia
1. Water enters lungs
 Increased peripheral airway resistance, pulmonary
vessel vasoconstriction/hypertension with shunting of
blood, decreased lung compliance, decreased
surfactant
Pearn, John. The management of near drowning. BMJ 1995. (291) 1447-1452

9. “Hypoxic March of Drowning”
continued
4. Decompensation
-gasping with further inhalation
-swallowing with emesis
-loss of consciousness
4. Neuronal dysfunction
-blood brain barrier breaks down
4. Cardiac dysfunction
-bradycardia, arrhythmias, asystole
7. Brain Death
8. Somatic Death

10. Diving Reflex
Infants and young children
Sudden contact with water less than 20 degrees
Celsius
Causes:
Bradycardia
vasoconstriction of nonessential vascular beds
shunting of blood to the coronary and cerebral
circulation

Shepard, Suzanne et al. Drowning. Emedicine.medscape.com/article/772753-overview. Updated 6/9/2009 .

11. Dry Drowning
10-20% of patients experience a laryngospasm
that prevents aspiration of fluid into the lungs
Tight spasm often persists until cardiac arrest
Lungs remain dry
Large volumes of fluid ingested into stomach
Major cause for electrolyte abnormalities in
children (hyponatremia from fresh water,
hypernatremia from salt water)

12. Wet Drowning
1-3 mL/kg water aspirated hinders gas exchange
When fluid is in the lungs, vagus nerve stimulates
vasoconstriction pulmonary vessels and
pulmonary hypertension
Freshwater diffuses rapidly across alveolar-
capillary membrane and saltwater damages the
membrane
Surfactant is denatured by freshwater and washed
away by salt water
In both salt water and freshwater aspiration,
compliance is decreased

13. Hypoxic-Ischemic Encephalopathy
Initial phase
Energy failure from hypoxia/ischemia
Reperfusion Injury
6-24 hours later
Cerebral edema, apoptosis

14. Mechanism of Hypoxic-Ischemic Encephalopathy
Excitatory amino acids, glutamate and aspartate, are
released in response to hypoxia/ischemia
Activation receptors, NMDA, AMPA, Kainate
 Ion channels open
 Influx of calcium into cells
 Cell death
Lipid peroxidation of cell membranes
 Destruction of Na+/K+ ATPase
 Cerebral edema, neuron death
Increased rate of apoptosis
 Related to influx of calcium into cell and nucleus

15. Complications of hypoxic-Ischemic
Encephalopathy
Autonomic instability
Hypertension
Tachycardia
Diaphoresis
Agitation
Muscle rigidity

16. Aspiration
Chemical Pneumonia
pH less than 2.5
Volume greater than 0.3mL/Kg
Inflammatory reaction by cytokines
 TNF-alpha, IL-8
Bacterial Pneumonia
Anaerobic organisms

17. Other organ involvement
Occur 24-72 hours after initial insult
Heart: decreased contractility, dilation, tricuspid
regurgitation, stress induced cardiomyopathy
Renal: acute tubular necrosis, oliguria, anuria
Hepatic: increased LFT’s, hypoalbuminemia,
coagulopathy, hyperbilirubinemia
Rhabdomyolysis

18. Differentials
Child Abuse & Neglect: Physical Abuse
Child Abuse & Neglect: Sexual Abuse
Munchausen Syndrome by Proxy

19. WORKUP-Laboratory Studies
The following studies are indicated in near
drowning:
Blood gas analysis with co-oximetry to detect
methemoglobinemia and carboxyhemoglobinemia
CBC count, prothrombin time with international
normalized ratio (INR), partial thromboplastin
time, fibrinogen, D-dimer, fibrin split products

20. Serum electrolytes (with glucose)
Liver enzymes, especially aspartate aminotransferase
and alanine aminotransferase
Renal function tests (BUN, creatinine)

21. Drug screen and ethanol level (consider)
Continuous pulse oximetry and cardiorespiratory
monitoring (may be needed)
Cardiac troponin I testing (may be useful as a marker
to predict children who have an elevated risk of not
surviving to hospital discharge)

22. Imaging Studies
Chest radiography
Head CT and cervical spine imaging if trauma
suspected
Extremity, abdominal, pelvic imaging if clinically
indicated
Echocardiography if myocardial dysfunction present

23. Other Tests
Consider electrocardiography if the patient has
arrhythmias. Monitor the patient if rewarming is
necessary, because dysrhythmias are common when
rewarming patients who suffer cold-water immersion
injuries.

24. Swan-Ganz catheter for monitoring cardiac output
and related hemodynamic parameters may be useful
in patients with unstable cardiovascular status or in
those who require multiple inotropic and vasoactive
medication requirements.

25. Labs & testschanges
Very mild electrolyte
Moderate leukocytosis
Hct and Hgb usually normal initally
Fresh water aspiration, the Hct may fall slightly in the
first 24 hrs due to hemolysis
Increase in free Hgb without a change in Hct is
common
DIC occasionally
ABG – metabolic acidosis & hypoxemia

26. EKG-Sinus tachycardia & nonspecific ST-segment
and T-wave changes
Reverts to normal within hours
Ominous - ventricular arrhythmias, complete
heart block
CXR-May be normal initially despite severe
respiratory disturbances
Patchy infiltrates
Pulmonary edema

27. Management: necessary
Bystander resuscitation CPR
30% pediatric cardiac arrest patients receive bystander
CPR
PUSH HARD, PUSH FAST
Minimize interruptions
Some bystander CPR, better than none
Heimlich maneuver contraindicated because it can
cause emesis, aspiration
Rescue breaths at rates > 20 breaths/min
contraindicated because venous return can be
obstructed

28. Arrival to the hospital
• General Assessment:
• Appearance
• Work of Breathing
• Circulation
• Primary Assessment:
• Airway
• Breathing
• Circulation
• Disability
• Exposure
Pediatric Advanced Life Support Provider Manual

29. Management
ET intubation:
 Cannot maintain PaO2 > 80 mm Hg on 100% O2 by face
mask
 Inability to protect airway or handle secretions
 Respiratory failure - PaCO2 >45 mm Hg
 Worsening ABG results
Peep:
 shifts interstitial pulmonary water into the capillaries
 increases lung volume by preventing of alveolar collapse
 provides better alveolar ventilation and decreases
capillary blood flow

30. Management
ECMO
 If despite intubation, cannot oxygenate
Broncoscopy
 Removal of vomit, debris in lungs
Albuterol
 For bronchospasm
Aspiration Pneumonia
 Clindamycin for bacterial pneumonia is drug of choice
Manage electrolyte abnormalities
 hypoglycemia

31. Management of Hypothermia
Two types:
1. Rapid immersion in cold water, rapid onset of
hypothermia, core temperature < 86 degrees F
 Neuroprotective, preferential shunting of blood to heart, brain
2. Gradual onset of hypothermia
Rapidly re-warm patients with gradual onset of
hypothermia
patients at risk for ventricular fibrillation and neuronal
injury

32. Guidelines for treating cold-water
drowning
Patients with severe hypothermia may appear dead
because of profound bradycardia and
vasoconstriction.
Resuscitation should continue while aggressive
attempts are made to restore normal body
temperature.

33. Management
Do not stop resuscitation of a patient until their core
temperature is at least 30 degrees Celsius!

34. Guidelines for treating warm-
water drowning:
Patients arriving at the emergency department in
cardiopulmonary arrest after a warm-water
submersion have a dismal prognosis. The benefits of
resuscitative efforts should be continuously
reassessed in such situations

35. Connpatients, the Conn classification system may be
For other
classification system:
used as a guideline to quantify the extent of cerebral
hypoxia.
Category A – Alert
Category B - Blunted consciousness; admit and observe for
pulmonary compromise, which may result in hypoxemia
and worsen CNS injury
Category C - Comatose (C1 - decorticate, C2 - decerebrate,
and C3 - flaccid [worse prognosis than C1])

36. Prognosis
Related to duration of submersion
Time greater than 25 min, prognosis is poor
Indicators of poor outcome:
Fixed, dilated pupils
Low GCS
coma
Survivors of resuscitation have good neurological
outcomes if they show purposeful movement
within 24 hours

37. Prevention
Designate a responsible adult to supervise
water related activities
Adults should not be doing other tasks at the same
time as supervision, no alcohol while supervising
Swim with a buddy
No alcohol before, during swimming
Learn to swim
AAP does not recommend swimming lessons as a
primary prevention method for children under 4
years old
Learn CPR
Water Injuries-Fact Sheet. www .cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet Accessed 25
Sept 2009

38. Prevention
Fence swimming pools on 4 sides, at least 4 feet
tall
Do not use air or foam filled water toys in place of
life-jackets