Drowning

Drowning is a topic covered in the 5-Minute Pediatric Consult.

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Basics

Description

  • Drowning is defined as respiratory impairment from submersion in a liquid medium.
  • The term “drowning” does not imply outcome; drowning can be fatal or nonfatal.
  • Historically “near drowning,” or submersion injury, was defined as survival, at least temporarily, after suffocation by submersion in water.
    • The World Congress on Drowning and the World Health Organization advocate abandoning confusing terms such as “near drowning,” “wet drowning,” “dry drowning,” and “secondary drowning”; they suggest that the literature should only use the term “drowning.”

Epidemiology

  • Drowning is second only to motor vehicle collisions as the most common cause of death from unintentional injury in childhood.
  • For every drowning death, another five children present to emergency departments for nonfatal submersion events.
  • Bimodal age distribution, with peak in children <5 years of age and again among adolescents 15 to 19 years of age
  • Bathtub drowning is common in babies; child neglect or abuse should be considered.
  • Adolescent submersion injuries usually involve substance abuse or risk-taking behavior.

Risk Factors

  • Males, children <5 years of age, African Americans, and children of low socioeconomic status are at greatest risk.
  • Other significant risk factors include the following:
    • Direct access to swimming pools (There are more drowning in southern states.)
    • Poor swimming ability or overestimation of ability
    • Use of alcohol and illicit drugs
    • Inadequate adult supervision
    • Underlying medical conditions such as seizure disorders or primary cardiac arrhythmias like long QT syndrome

General Prevention

  • Most drownings are preventable.
  • Quality prevention efforts include:
    • Legislation to require adequate four-sided isolation fencing and rescue equipment for public and residential pools
    • Restriction of sale and consumption of alcohol in boating areas, pools, and beaches
    • Life vests for children of all ages near bodies of water
    • Parental education regarding adequate supervision during bathing and around bodies of water
    • Cardiopulmonary resuscitation (CPR) courses for pool owners, parents, and older children
    • Parental education about dangers of bathtubs, buckets, and inflatable pools for babies and toddlers
    • Swimming lessons and lifeguard supervision

Pathophysiology

  • Drowning begins with a loss of the normal breathing pattern as panic ensues and subsequent apnea, laryngospasm, or aspiration occurs.
  • Water aspirated into the trachea and lungs washes out surfactant and leads to atelectasis, intrapulmonary shunting, poor lung compliance, increased capillary permeability, and hypoxemia, ultimately resulting in acute respiratory distress syndrome (ARDS).
  • Severe hypoxemia is the final common pathway and results in multisystem organ failure.
  • Cerebral hypoxia results in cerebral edema and increased intracranial pressure (ICP) and causes the majority of morbidity and mortality associated with drowning.

Commonly Associated Conditions

  • Cervical spine injuries should be considered in older children who have experienced diving accidents but are otherwise relatively rare in drowning events.
  • Signs of child abuse or neglect should be sought in young children.
  • Adolescents may have associated toxic ingestions.
  • Hypothermia (see management below)

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