Drowning

Jana Stockwell, MD

Statistics
1995 data:
2000 CDC data:
>1000 kids <14 years old drown 60% <4 years old 3,281 unintentional drownings in USA (adults & kids) averaging 9 people/day - not including boatingrelated incidents For every child who drowns, 3 need ED care for nonfatal submersion injuries >40% of these children require hospitalization

2003 CDC data:

2002 World Congress on Drowning

Drowning = process resulting in primary
respiratory impairment from submersion/immersion in a liquid medium Regardless of survival Drowning without aspiration does not occur Terms which are out
Dry, wet, active, silent, secondary, near-drowning

1989-1998 CDC data

>75%ile of National avg 50-75%ile of National avg 25-50%ile of National avg <25%ile of National avg

Groups at Risk (2001 data)

Males: 78% of drownings in the United States Children: 859 children ages 0-14 years died
from drowning
Drowning rates have slowly declined 2nd-leading cause of injury-related death for kids ages 1-14 years

African Americans: age-adjusted drowning rate

for African Americans was 1.4 X higher
(CDC 2003)

Morbidity & Mortality

15% of children admitted for drowning die in

the hospital As many as 20% of drowning survivors suffer severe, permanent neurological disability

Drowning modalities
Infants (age <1)

bathtubs, buckets & toilets Children ages 1-4 years swimming pools, hot tubs & spas Children ages 5-14 years - swimming pools & open water sites

(Brenner 2001)

Bucket drownings
~300 children in the US since

1984 7-15 months of age 24 to 31 inches tall Bucket may contain water or nasty cleaning fluid

Tub drownings
Approximately 10% of childhood drownings Typically lacking adult supervision Do tub seats help?

Bathtub seats - ? or ?
Not intended or marketed as safety devices Bathtub drowning deaths of infants aged 6-10 mo
from 1994-1998 40 infant drowning deaths associated with bath seats 78 deaths not associated with bath seats ~45% of infants in this age group use bath seats Data suggests seats either have no effect or they may provide some slight protection against unintentional bathtub drowning risks Odds ratio 0.6 [95% CI 0.4-0.9]

Data: US Consumer Product Safety Commission & National Center for Health Statistics for US resident infants (1994-1998)

Tub seat use

Baby swim classes

Done to teach babies to float No reported drownings in class Several reports of hyponatremic seizures
following class (How was school today?) False sense of security?

Pool/Spa drownings
Most residential pool drownings are in kids <4 yo 3,000 pool drownings require hospital ED treatment
each year
last seen inside the home missing from sight <5 minutes in the care of one or both parents at the time of the drowning

>50% occur in the child's home pool 1/3 occur at homes of friends, neighbors or family Since 1980, ~230 kids <4 yrs in spas & hot tubs
(Present 1987, Brenner 2001)

Cochran Review Pool fencing

Meta analysis of casecontrol studies evaluating
pool fencing Results:
Pool fencing significantly reduces the risk of drowning

Odds ratio (OR) for the risk of drowning or near drowning in a fenced pool
compared to an unfenced pool is 0.27 (95% CI 0.16 0.47)

Isolation fencing (enclosing pool only) is superior to perimeter fencing (enclosing property and pool)

OR for the risk of drowning in a pool with isolation fencing compared to a

pool with three sided fencing is 0.17 (95% CI 0.07 0.44).

In-ground swimming pools without complete 4-

sided isolation fencing are 60% more likely to be involved in drownings than those with 4-sided isolation fencing

Boat-related drownings
2002 Coast Guard data, all ages:
5,705 boating incidents: 4,062 injured, 750 killed 70% of fatalities due to drowning 30% of fatalities due to trauma, hypothermia, CO poisoning, or other causes Alcohol was involved in 39% of fatalities Open motor boats - 41% Personal watercraft 28%

Alcohol
Involved in 25-50% of teen and adult deaths
Hingson 1988)

associated with water recreation (Howland 1995; Howland &

Alcohol influences balance, coordination, and

judgment, and its effects are heightened by sun exposure and heat (Smith and Kraus 1988) Relative risk of drowning was 31.8 in persons with a markedly elevated alcohol level (>21.7 mmol/L) and 4.6 for levels <21.6 mmol/L
(Cummmings JAMA 281:2198, 1999)

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

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

Diving reflex
Bradycardia, apnea, vasoconstriction Relatively quite weak in humans
better in kids

Occurs when the face is submerged in very cold

water (<20C) Extent of neurologic protection in humans due to diving reflex is likely very minimal

Pathogenesis 1
Asphyxia, hypoxemia, hypercarbia, & metabolic

acidosis Fresh water vs salt water - little difference (except for drowning in water with very high mineral content, like the Dead Sea) Hypoxemia
Occlusion of airways with water & particulate debris Changes in surfactant activity Bronchospasm Right-to-left shunting increased Physiologic dead space increased

Pathogenesis 2

Cardiac arrhythmias Hypoxic encephalopathy Renal insufficiency Global brain anoxia & potential diffuse cerebral edema

Findings at autopsy


Wet, heavy lungs Varying amounts of hemorrhage and edema Disruption of alveolar walls ~70% of victims had aspirated vomitus, sand, mud, and aquatic vegetation Cerebral edema and diffuse neuronal injury Acute tubular necrosis

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

Prevalence of concomitant traumatic injuries

143 drowned & near-drowned

kids Median age 3.8 years (1 mo 18.7 yrs) 30% with pre-existing disease
CHD, sz, MR/CP, DD

5% with traumatic injuries

All boys Older, mean age 13.5 years 6 of 7 had C-spine injury from diving
(H Shofer, Ann Emerg Med 2004)

Labs & tests

Very mild electrolyte

changes 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

EKG

CXR

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

DIC occasionally ABG metabolic acidosis &

hypoxemia

Therapy for the lungs

CPAP or PEEP Aerosolized -agonists for bronchospasm Bronchoscopy Prophylactic antibiotics have not been shown to be beneficial Steroids:
No controlled human studies to support use Animal models and retrospective studies in humans have failed to demonstrate benefit

Surfactant
Beneficial
Porcine surfactant (Curosurf) 0.5 ml/kg (40 mg/kg) IT for ARDS 8h after freshwater neardrowning in a 12yo

Not beneficial
Submerged rabbits
(A Anker, Acad Emerg Med 1995)

Kids
(F Perez-Benavides, Ped Emerg Care 1995)

(Acta Anaesthesiol Scand 2004)

Brain therapy
ICP monitoring - not indicated, typically irreversible

hypoxic cellular injury Brain CT not indicated, unless TBI suspected Mild hyperventilation? Osmotherapy not indicated Corticosteroids (dexamethasone) - no proven benefit Seizures - treat aggressively Shivering or random, purposeless movements can increase ICP Hypothermia and barbiturate coma - highly controversial & unlikely to benefit the patient (31 comatose kids, J Modell, NEJM
1993)

Bad prognostic indicators

Submerged >10 min Time till BLS >10 min CPR >25 min Initial GCS <5

Age <3 years CPR in ER Initial ABG pH <7.1 Initial core temp <33o

Will the child die?

Neurologic prognosis
Absence of spontaneous respiration is an
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

Cold vs icy water immersion

Usually hypothermia is an unfavorable sign Several case reports of dramatic neurologic
recovery after prolonged (10-150 min) icy water submersions
Freezing-temperature water (<5C) Core body temperature less than 28-30C, or much lower

For hypothermia to be protective, core

body temperature must fall rapidly, decreasing cellular metabolic rate, before significant hypoxemia begins

Hypothermia easier in kids

High BSA/mass ratio and subcutaneous fat
insulation Moderate hypothermia (core 32-35C) VO2 due to shivering thermogenesis & increased sympathetic tone Severe hypothermia (core <32C) shivering stops & the cellular metabolic rate (~7%/C)

Hypothermia & brain protection

Effective in protecting the brain and other
organs from anoxia for 75-110 min in controlled circumstances where core body temperature is cooled first to 18C and then the heart is stopped
Deep hypothermic circulatory arrest (DHCA)

Once cell death from hypoxemia occurs (~5-6

min), no protective hypothermic effect or improve recovery

Hypothermia surface cooling

Surface cooling alone is cannot core temp fast enough
to yield protection

Cooling rate in drowning victims is difficult to estimate as Cardiac anesthesia literature:

patient may also be swallowing or breathing in cold water

Surface cooling of anesthetized naked infants with ice packs and ice cold water decreases rectal temperature by ~2.5 C in the first 10 minutes Another 32 minutes for the temperature to fall to 24-26C During surface cooling in flowing water at 1C the nasopharyngeal temperature of a naked infant (4 kg) falls 1C every 5 minutes

Hypothermic protection involving surface cooling only

would seem to require submersion in icy (not cold) water

Does aspiration of icy water will accelerate the cooling process?

80-90% of animals & human submersion victims
in warm or cold water drownings aspirate very little (<2.2 ml/kg) Theoretically, a very large quantity of icy water would have to be aspirated or swallowed Immersion in icy water results in involuntary reflex hyperventilation and a decreased breath holding ability to <10 sec, increasing the likelihood of aspiration and rebreathing of icy water in some victims

Ice water submersion - dogs

Rapid & violent hyperventilation lasts ~70 sec Control animals submerged (ice water, head out
of the water) carotid artery temp fell 0.8C in 2 min Completely submerged dogs temp fell ~8.0C during the first 2 min in both ice-water (4C) Rectal temp lagged behind in carotid temp Victims of ice-water submersions more likely to have involuntary breathing & aspiration Brain may be cooled to a protective level (~<30C) provided the water aspirated was icy & cardiac output lasts long enough for sufficient heat exchange to occur

Cold water submersion - humans

Few cold water victims have significant brain
protection Hypothermia is more commonly an unfavorable prognostic sign King County, WA (water is cold, but rarely icy)

Finnish study:

Hypothermic protection has not been observed 92% of good survivors had initial core temp of >34C 61% of those who died or had severe neurologic injury had core temp <34C Median water temp 16C Submersion duration <10 minutes had greatest sensitivity in predicting good outcome, even in kids

Re-warming
Re-warm 1-2oC per hour to range 33-36oC Mild (32-35o) passive rewarming Moderate (28-32o)
Shivering fails J wave Active internal/external rewarming (not extremities) Appears dead, pupils dilated/NR VFib, extreme brady, pulseless Deep rectal or esophageal temps Maintain CPR until core temp >32o

Severe (<28o)

Warm water data - site

274 patients Age 6 months-15 years (mean 32 mos, median

24 mos) 63% males Submersion witnessed in 12% cases Submersion site data (126 patients)
80% backyard pool or spa 11% in a bathtub 5% in a lake or pond 3% in other sites

Warm water data - response

Bystander resuscitation 80% patients Average EMS respose time - 6.8 minutes Upon EMS arrival
76 (28%) children were in cardiac arrest 13 (5%) with PEA

Paramedic CPR - 87/89 children 18 (20% of those w/ CPR) no longer needed CPR in ED Paramedics intubated 19 children Epinephrine in 30 patients

Warm water outcomes

Cardiac
71 (80% of those in arrest @ scene) arrived to ED in cardiac arrest 13 PEA 5 deteriorated & required CPR All 89 received Epi - (average duration 8.9 minutes, range 2 to 105 minutes) 41 (46% of codes) survived (8 intact, 33 vegetative) Longest CPR duration in an intact survivor was 47 minutes 125 (46%) patients were intubated 7 were apneic, 26 were breathing but comatose

Respiratory

Warm water outcomes

CNS
Persistent deficits in 15 of the 185 functionally intact survivors Initial ED GCS 3 in 100 kids 14 survived intact 165 patients having GCS 4 upon arrival in the ED 2 survived in PVS all others survived intact
Withdrawal 22 Brain death 23 All intact survivors demonstrated functional recovery within 48 hours

51 patients who subsequently died

Warm water survival in kids

6 studies reported functional recovery 17% (overall
average) of victims who required CPR in the ED Withholding or withdrawal of therapy from kids who have low probability of functional survival after warm water submersion injury has been suggested
Failure to respond to advanced life support within 25 minutes Lack of purposeful movements or normal brain stem function @ 24 hrs Anecdotal experience with spectacular recoveries & the small numbers of severely injured patients in most studies raises uncertainty about their predictive accuracy

Graf et al. suggested that outcome for pediatric

submersion victims can be predicted with 4 measures: coma, absence of pupillary light reflex, admission blood glucose concentration (high) and sex

Recommendations
Pre-hospital resuscitation, including early
intubation, ventilation, vascular access, and administration of advanced life support medications Continued resuscitation and stabilization in the ED Full supportive care in the ICU for a minimum of 48 hrs Consider withdrawal of support if no neurologic improvement is detected after 48 hours

Ancillary testing such as brainstem evoked responses, EEG, and MRI (not CT) may prove helpful to corroborate the neurologic Pediatrics, 1997 Christenson, Jansen, Perkins examination

You cant make this stuff up

67 year old with pulmonary fibrosis S/P lung resection On ward, with O2 POD#2 developed distress, to ICU, intubated, ARDS Finally extubates

(CHEST 2001; 120:1021-1022)

Part deaux a better history

Day after extubation, RN noticed patient's friend

attempting to submerge the patient's face in a waterfilled basin On questioning, patient indicated that he was aspirating water to clean sinuses and lungs, explaining that this was a daily routine for cleaning airways in his family He noted that on POD 1, while performing this ritual, he had a severe coughing and choking spell while his face was submerged This "technique" was witnessed by the housestaff, but not reported until directly questioned