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Drowning

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Today News Reference Education Log Out My Account Dr. K Fredyanto

Author: G Patricia Cantwell, MD, FCCM; Chief Editor: Joe Alcock, MD, MS more... Updated: Apr 29, 2013

Background
Drowning remains a significant public health concern, as it is a major cause of disability and death, particularly in children.
[1]

At least one third of survivors sustain moderate to severe neurologic sequelae.


[2]

Exact definitions of drowning have varied widely. Drowning was previously defined as death secondary to asphyxia while immersed in a liquid, usually water, or within 24 hours of submersion. At the 2002 World Congress on Drowning, held in Amsterdam, a group of experts suggested a new consensus definition for drowning in order to decrease the confusion over the number of terms and definitions (>20) referring to this process that have appeared in the literature. The group believed that a uniform definition would allow more accurate analysis and comparison of studies, allow researchers to draw more meaningful conclusions from pooled data, and improve the ease of surveillance and prevention activities. The new definition states that drowning is a process resulting in primary respiratory impairment from submersion in a liquid medium. Implicit in this definition is that a liquid-air interface is present at the entrance to the victim's airway, which prevents the individual from breathing oxygen. Outcome may include delayed morbidity, delayed or rapid death, or life without morbidity. The terms wet drowning, dry drowning, active or passive drowning, near-drowning, secondary drowning, and silent drowning would be discarded. Drowning usually occurs silently and rapidly. The classic image of a victim helplessly gasping and thrashing in the water rarely is reported. A more ominous scenario of a motionless individual floating in the water or quietly disappearing beneath the surface is more typical. Drowning may be further classified as cold-water or warm-water injury. Warm-water drowning occurs at water temperatures of 20C or higher, and cold-water drowning occurs at water temperatures of less than 20C. Although ice-cold water has been reported to be protective, especially in young children, the effect of temperature on survivability
[5] [4] [3]

prolonged immersions can nullify

Additional classification may include the type of water in which the submersion occurred, such as freshwater and saltwater, or natural bodies of water versus man made. Although initial treatment of submersion victims is not affected by the type of water, serum electrolyte derangements may be related to the salinity of the water (particularly if large amounts of water are ingested), while long-term infectious complications are primarily related to whether the victim was submersed in a natural or a man-made body of water
[6]

Immediate threats include effects on the central nervous and cardiovascular systems (see Workup). Thus, the most critical actions in the immediate management of drowning victims include prompt correction of hypoxemia and acidosis (see Treatment). The degree of CNS injury depends on the severity and duration of hypoxia. Posthypoxic cerebral hypoperfusion may occur. Long-term effects of cerebral hypoxia, including vegetative survival, are the most devastating (see Treatment). Prevention is key for reducing morbidity and mortality from drowning. Community education is the key to prevention (see Patient Education and Deterrence/Prevention.)

Pathophysiology
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The most important contributory factors to morbidity and mortality from drowning are hypoxemia and acidosis and the multiorgan effects of these processes. Central nervous system (CNS) damage may occur because of hypoxemia sustained during the drowning episode (primary injury) or may result from arrhythmias, ongoing pulmonary injury, reperfusion injury, or multiorgan dysfunction (secondary injury), particularly with prolonged tissue hypoxia. After initial breath holding, when the victim's airway lies below the liquid's surface, an involuntary period of laryngospasm is triggered by the presence of liquid in the oropharynx or larynx. At this time, the victim is unable to breathe in air, causing oxygen depletion and carbon dioxide retention. As the oxygen tension in blood drops further, laryngospasm releases, and the victim gasps, hyperventilates, possibly aspirating variable amounts of liquid. This leads to further hypoxemia. Lunetta et al reviewed the autopsies of 578 individuals who had apparently drowned and found evidence of water in the lungs of 98.6% of those studied. As they noted, active ventilation while submerged is required to aspirate water, as water does not passively flow into the lungs once the victim is dead.
[7]

Depending upon the degree of hypoxemia and resultant acidotic change in acid-base balance, the person may develop myocardial dysfunction and electrical instability, cardiac arrest, and CNS ischemia. Asphyxia leads to relaxation of the airway, which permits the lungs to take in water in many individuals, although most patients aspirate less than 4 mL/kg of fluid. Fluid aspiration of at least 11 mL/kg is required for alterations in blood volume to occur, and aspiration of more than 22 mL/kg is required before significant electrolyte changes develop. Ingestion of large volumes of freshwater, rather than aspiration, is the likely cause of clinically significant electrolyte disturbances, such as hyponatremia, in children after drowning. Approximately 10-20% of individuals maintain tight laryngospasm until cardiac arrest occurs and inspiratory efforts have ceased. These victims do not aspirate any appreciable fluid (previously referred to as "dry drowning") (see the chart below).
[8]

Mechanism of hypoxia in submersion injury.

In young children suddenly immersed in cold water (< 20C), the mammalian diving reflex may occur and produce apnea, bradycardia, and vasoconstriction of nonessential vascular beds with shunting of blood to the coronary and cerebral circulation.

Pulmonary effects
The target organ of submersion injury is the lung. Aspiration of as little as 1-3 mL/kg of fluid leads to significantly impaired gas exchange. Injury to other systems is largely secondary to hypoxia and ischemic acidosis. Additional CNS insult may result from concomitant head or spinal cord injury. Fluid aspirated into the lungs produces vagally mediated pulmonary vasoconstriction and hypertension. Freshwater moves rapidly across the alveolar-capillary membrane into the microcirculation. Freshwater is considerably hypotonic relative to plasma and causes disruption of alveolar surfactant. Destruction of surfactant produces alveolar instability, atelectasis, and decreased compliance, with marked ventilation/perfusion (V/Q) mismatching. As much as 75% of blood flow may circulate through hypoventilated lungs. Saltwater, which is hyperosmolar, increases the osmotic gradient and therefore draws fluid into the alveoli, diluting surfactant (surfactant washout). Protein-rich fluid then exudates rapidly into the alveoli and pulmonary interstitium. Compliance is reduced, the alveolar-capillary basement membrane is damaged directly, and shunting occurs. This results in rapid induction of serious hypoxia. Fluid-induced bronchospasm also may contribute to hypoxia. The distinction between fluid type is somewhat

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academic and primarily of epidemiologic importance, as the initial treatments are similar. Pulmonary hypertension may occur secondary to inflammatory mediator release. In a minor percentage of patients, aspiration of vomitus, sand, silt, stagnant water, and sewage may result in occlusion of bronchi, bronchospasm, pneumonia, abscess formation, and inflammatory damage to alveolar capillary membranes. Postobstructive pulmonary edema following laryngeal spasm and hypoxic neuronal injury with resultant neurogenic pulmonary edema may also play roles. Acute respiratory distress syndrome (ARDS) from altered surfactant effect and neurogenic pulmonary edema commonly complicate drowning in survivors. Commonly, these edematous, noncompliant lungs may be further compromised by ventilator-associated lung injury (VALI). Newer modes of ventilation, including high-frequency oscillatory ventilation and airway pressure release ventilation, or an open-lung approach that limits tidal volumes to 6-8 mL/kg while using positive end-expiratory pressure (PEEP) to support optimal respiratory compliance, can help support oxygenation and ventilation with less risk of VALI than is associated with older methods of ventilation. Pneumonia is a rare consequence of submersion injury and is more common with submersion in stagnant warm and fresh water. Uncommon pathogens, including Aeromonas, Burkholderia, and Pseudallescheria, cause a disproportionate percentage of cases of pneumonia. Because pneumonia is uncommon early in the course of treatment of submersion injuries, the use of prophylactic antimicrobial therapy has not proven to be of any benefit. Chemical pneumonitis is a more common sequela than pneumonia, especially if the submersion occurs in a chlorinated pool or in a bucket containing a cleaning product.

Central nervous system effects


CNS injury remains the major determinant of subsequent survival and long-term morbidity in cases of drowning. Two minutes after immersion, a child will lose consciousness. Irreversible brain damage usually occurs after 4-6 minutes. Most children who survive are discovered within 2 minutes of submersion. Most children who die are found after 10 minutes. Primary CNS injury is initially associated with tissue hypoxia and ischemia. If the period of hypoxia and ischemia is brief or if the person is a very young child who rapidly develops core hypothermia, primary injury may be limited, and the patient may recover with minimal neurologic sequelae, even after more prolonged immersion. In contrast, drowning that is associated with prolonged hypoxia or ischemia is likely to lead to both significant primary injury and secondary injury, especially in older patients who cannot rapidly achieve core hypothermia. Sources of secondary injury include the following: Reperfusion Sustained acidosis Cerebral edema Hyperglycemia Release of excitatory neurotransmitters Seizures Hypotension Impaired cerebral autoregulation Although cerebral edema is a common consequence of prolonged submersion (or submersion followed by prolonged circulatory insufficiency), retrospective reviews and animal studies have not demonstrated any benefit from the use of intracranial pressure monitoring with diffuse axonal injury. However, as submersion injuries may be associated with trauma (especially to the head, neck, and trunk), focal or persistent neurologic deficit may indicate mass lesions or other injury amenable to surgical intervention. Autonomic instability (diencephalic/hypothalamic storm) is common following severe traumatic, hypoxic, or ischemic brain injury. These patients often present with signs and symptoms of hyperstimulation of the sympathetic nervous system, including the following: Tachycardia Hypertension Tachypnea Diaphoresis Agitation Muscle rigidity Autonomic instability has also been found to present as takotsubo stress-induced cardiomyopathy, with associated

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electrocardiographic changes, apical ballooning on echocardiogram, and elevated serum troponin levels.

[9]

Seizures may be the result of acute cerebral hypoxia, but they may also be inciting events that lead to loss of consciousness and inability to protect the airway.

Cardiovascular effects
Hypovolemia is primarily due to fluid losses from increased capillary permeability. Profound hypotension may occur during and after the initial resuscitation period, especially when rewarming is accompanied by vasodilatation. Myocardial dysfunction may result from ventricular dysrhythmias, pulseless electrical activity (PEA), and asystole due to hypoxemia, hypothermia, acidosis, or electrolyte abnormalities (less common). In addition, hypoxemia may directly damage the myocardium, decreasing cardiac output. Pulmonary hypertension may result from the release of pulmonary inflammatory mediators, increasing right ventricular afterload and thus decreasing both pulmonary perfusion and left ventricular preload. However, although cardiovascular effects may be severe, they are usually transient, unlike severe CNS injury. Primary arrhythmias, including long-QT syndromes (particularly type I) and catecholaminergic polymorphic ventricular tachycardia (CPVT), may predispose patients to fatal arrhythmias during swimming. Sudden, severe cardiovascular collapse in otherwise healthy patients with brief, witnessed immersion may be the result of existing cardiac conduction defects and may not represent secondary effects of immersion injury.
[10]

Infection
Infection in the sinuses, lungs, and CNS, as well as other less common sites, may result from unusual soil and waterborne bacteria, amebas, and fungi, including Pseudallescheria boydii and Scedosporium apiospermum,Naegleria, Balamuthia, as well as Burkholderia and Aeromonas organisms, and newly discovered These infections are usually insidious in onset, human pathogens (Francisella philomiragia). typically occurring more than 30 days after the initial submersion injury. P boydii- complex infections are difficult to treat and are often fatal.
[18, 13, 19] [11, 12, 6, 13] [14, 15, 16, 17]

Several investigators have suggested that the finding of evidence of seawater organisms, such as bioluminescent bacteria and plankton DNA, or normal inhabitants of the trachea in the bloodstream may be utilized as an additional indicator to support the conclusion of death by drowning in bodies discovered in aquatic environments.
[20, 21]

Other effects
The clinical course may be complicated by multiorgan system failure resulting from prolonged hypoxia, acidosis, rhabdomyolysis, acute tubular necrosis, or the treatment modalities. Disseminated intravascular coagulation (DIC), hepatic and renal insufficiency, metabolic acidosis, and GI injuries must be considered and appropriately managed.

Etiology
Drowning may be a primary event or may be secondary to events such as the following: Seizures Head or spine trauma Cardiac arrhythmias Hypothermia Alcohol and drug ingestion Syncope Apnea Hyperventilation Suicide Hypoglycemia Causes tend to vary with the persons age.

Infants
Infants most often drown in bathtubs or buckets of water. Most of these victims drown during a brief (< 5 min) lapse in adult supervision.

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Bathtub and pail drownings may represent child abuse; carefully examine the child for other evidence of injury, review the child's history for previous events, and review the details of the incident very carefully with the child's parent or guardian.
[22, 23]

Children aged 1-5 years


Residential swimming pools are the most common venue. The US Consumer Product Safety Commission reports that a swimming pool is 14 times more likely than a motor vehicle to be involved in the death of a child younger than 5 years. Many residential pools have no physical barrier between the pool and the home. Open gates are involved in up to 70% of drownings in cases involving fenced-in pools. Pools may also be accessed through unlocked windows when the pool area abuts the house. A study from Australia on drowning in water tanks
[27] [26] [24, 25, 23]

and one from Bangladesh on drowning in ditches, canals, and

illustrate that water exposure is both culturally and geographically related. Limiting access to such areas is ponds an important target for prevention strategies.

Young adults agead 15-19 years


Young adults typically drown in ponds, lakes, rivers, and oceans. Approximately 90% of drownings occur within 10 yards of safety. Cervical spine injuries and head trauma, which result from diving into water that may be shallow or contain rocks and other hazards, have been implicated. Alcohol and, to a lesser extent, other recreational drugs are implicated in many cases. Australian, Scottish, and Canadian data showed that 30-50% of older adolescents and adults who drowned in boating incidents were inebriated, as determined by blood alcohol concentrations.

All age groups


Any of the following may lead to drowning episodes in people of any age: Seizure disorder Myocardial infarction (MI) or syncopal episode Poor neuromuscular control, such as that seen with significant arthritis, Parkinson disease, or other neurologic disorders Major depression/suicide Anxiety/panic disorder Diabetes, hypoglycemia Water sports hazards, especially with personal watercraft Poor judgment and substance abuse (alcohol or other recreational drugs) in conjunction with boat operation Cervical spine injury and head trauma associated with surfing, water skiing, and jet skiing Scuba diving accidents and other injuries (eg, bites, stings, lacerations) A study by the European Alliance Against Depression reviewed gender-specific suicide methods in 16 European countries. They found that women were more likely to choose drowning as a suicide method. They suggested that gender-specific prevention strategies should be developed.
[28]

Natural disasters
Drowning is a well-recognized complication of natural disasters, such as hurricanes and earthquakes, which produce tidal waves (tsunamis) and flooding. A study of loss of life from Hurricane Katrina analyzed 771 fatalities. Most involved elderly individuals and were caused by drowning due to the direct physical impact of flooding. Mortality was highest near severe levee breaches where water was moving at rapid velocity and in areas with increased water depth.
[29]

Epidemiology
United States statistics
While drowning deaths have shown a gradual decline, in 2007 there were 3,443 fatal unintentional drownings (non-boating related) in the United States and an additional 496 drowning deaths in boating-related incidents.

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Drowning is the sixth leading cause of accidental death for people of all ages and the second leading cause of death for children ages 1 -14 years, after motor vehicle collisions.
[30, 31, 1]

This averages out to about 10 deaths per day.

Approximately one quarter of these deaths occur in children 14 years of age or younger. Four times as many children receive emergency department care for nonfatal injuries for every child that dies. A bimodal distribution of deaths is observed, with an initial peak in the toddler age group and a second peak in adolescent to young adult males. Fifteen percent of children admitted for drowning die in the hospital. Drownings tend to occur most frequently on weekends (40%) in the summertime months (May through August). Drownings are seen more commonly in rural areas and in the southern and western United States (62%). California, Arizona, and Florida, drowning is the number one cause of injury-related death.
[32]

In

In 2005, of all children aged 1-4 years who died, almost 30% died from drowning. Morbidity from submersion occurs in 12-27% of survivors aged 1-14 years. Preschool-aged boys are at greatest risk of submersion injury. A survey of 9,420 primary school children in South Carolina estimated that approximately 10% of children younger than 5 years had an experience judged a "serious threat" of drowning. In 2008, the US Lifesaving Association reported more than 70,000 rescues from drowning at beach venues. California alone reports approximately 25,000 ocean rescues on its beaches each year. More than 4.5 million preventive actions, including moving swimmers from areas of rip currents and other hazards, were reported during this same period of time. Approximately 1 in 8 males and 1 in 23 females experience some form of water-associated event but never seek medical attention.
[33]

International statistics
Annually, approximately 150,000 deaths are reported worldwide from drowning; the actual incidence is probably closer to 500,000. No annual international incidence of associated neurological injury has been reported. Several of the most densely populated nations in the world fail to report nonfatal drowning incidents. This, along with the fact that in many instances no attempt is made to resuscitate at the scene and that many cases are never brought to medical attention, renders accurate worldwide incidence approximation and classification virtually impossible.
[35] [34]

The overall incidence of drowning has an estimated range of 20-500 times the rate of fatal drowning.
[36]

British data suggest that approximately 10% of their drownings occur in the domestic setting, most frequently during baths, in water-filled containers both indoors and outdoors, and in garden ponds. Structures overhanging water
[36, 37, 38]

posed a particular risk. Young children (< 5 years) and older adults were shown to be at highest risk.
[34, 39]

Drowning site appears to be a function of availability. In areas of the world where bathing occurs in nearby streams, rivers, and lakes, data collected suggest that the incidence is more similar to that found in industrialized nations in the adolescent and young adult groups (aged 15-24 y), where most incidents occur in natural bodies of water. Hong et al suggest that this risk is due not only to rural residence and lower socioeconomic status but also to the education level of parents, which would suggest that targeted public health intervention strategies might prove to be effective in decreasing this incidence.
[39, 40]

Boating and related water sports, combined with alcohol consumption, increase both the likelihood and severity of submersion injuries. Risk-taking behaviors, especially in males, are similarly associated with increased morbidity and mortality. An Australian study that focused on drowning risks at surf beaches found that in the 204 individuals studied, adolescent and adult males spent longer amounts of time in the water, were more likely to use surfing equipment, were more likely to consume more alcoholic beverages, and spent more time in deeper water. The authors hypothesized that over-representation of males in drowning statistics is in part a function of this greater exposure to deeper waters further from shore.
[41]

A second study, by the same authors, found that males visited surf beaches less frequently and spent longer times alone and in deeper water and that more of them utilized alcohol within 2 hours of visiting the beach. Males also felt more confident about their swimming abilities and their ability to return to shore if caught in a rip current.
[42]

The authors found no gender difference in the likelihood of holding a first aid qualification, cardiopulmonary resuscitation (CPR) certification, or prior swimming lesson participation. They suggested that larger, controlled studies should address the role of overconfidence, self-rated versus measured swimming competency, surf experience, ability to judge swimming conditions, and the use of flotation devices in relation to drowning risk.
[42]

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This later study provided somewhat different data from that in a previous, smaller 2008 study by Morgan et al that indicated no difference in gender or age on likely surf-drowning risk, including preexisting medical conditions, presence of drugs or alcohol, or the likelihood of swimming without a buddy or in rip current conditions.
[44] [43]

Scuba diving accounts for an estimated 700-800 deaths per year; etiologies include inadequate experience/training, Denoble et al studied 947 recreational diving accidents from exhaustion, panic, carelessness, and barotrauma. 1992-2003, during which 70% of the victims drowned. Drowning was usually secondary to a disabling injury, equipment problems, problems with air supply, and cardiac events in these individuals.
[45]

A 2009 Western Australian study reviewed 24 diving fatalities and found that the lack of formal certification (30%) was associated with the breach of more safety practices. The authors noted that existing regulations required training certification only for those dives made from commercial boats and that shore dives or dives from private crafts were fatal 3 times as often; they therefore suggested a change in these regulations to require certification for all divers. These researchers also found that dive depth, ignoring a preexisting medical condition, nonadherence to the buddy system, poorly planned dives, and the lack of establishment of positive buoyancy when in distress contributed to diving fatalities. Only twice was faulty equipment the cause, once during scuba and once during a "hookah" dive (ie, with surface-supplied air). Seventy percent occurred during the day. Twenty five percent involved tourists.
[46]

A study of 19 reported fatalities in Australia in 2008 concluded that the causes of death included apnoeic hypoxia, trauma, and cardiac related issues. The study concluded that trauma from a marine creature, snorkelling or diving alone, apnoeic hypoxia, and preexisting medical conditions were factors in several deaths.
[47]

A Danish occupational medical study of 114 drowning fatalities in the period 1989-2005 among fishing industry seamen found that approximately one half of the deaths occurred during vessel disasters in rough weather, with capsizing and foundering, or collisions. One third occurred during other occupational accidents that caused the victim to go overboard. One third occurred when the victim underwent difficult disembarkation during nighttime hours in foreign ports or was intoxicated.
[48]

A Swedish study emphasized the contribution of alcohol and drugs to drowning deaths and the importance of considering such information in developing prevention programs. Although the number of drowning deaths has significantly decreased, men and middle aged and older people had a higher incidence. Among women, suicidal drowning was common.
[49]

A Canadian study of drowning during work-related and recreational helicopter crashes over water found that educational strategies to increase survival likelihood included wearing survival gear during the trip, prior escape training, ensuring that crew and passengers possessed appropriate knowledge of escape routes, and assuming appropriate crash positioning. They suggested that companies using helicopter transport over water should focus on regular and repeated safety training and improvement in safety measures on helicopters. Accidental death, such as drowning, complicate tourism in many countries.
[51, 52] [50]

An Australian study found


[53]

accidental drowning to be the cause of approximately 5% of all deaths in the 1068 visitor deaths reviewed.

Race-related demographics
Between 2000 and 2007, the rate of fatal accidental drowning for African Americans across all ages was 1.3 times that of whites; for Native Americans and Alaskan Natives, this rate was 1.7 times that of whites. However, the relative rates vary with age. African-American children aged 0-4 years exhibit a lower rate of drowning (2.32 per 100,000), probably secondary to less pool access. In older pediatric age groups, the incidence is 2-5 times higher. In indigenous children and teenagers in the United States and Canada, injuries account for 71% of childhood deaths. In Alaska, drowning is the leading cause of death among indigenous children. Focused interventions have targeted indigenous groups in Alaska. Over a 20-year period (1982-84 vs 2002 vs 2004), the age-adjusted mortality rate declined 28%, compared with a 5% decline for the United States as a whole. This author suggests that developmentally and culturally appropriate interventions and community-based educational interventions, such as a requirement for wearing personal flotation devices, 4-sided fencing of pools, and the prohibition of alcohol sale to minors, can be highly effective.
[54] [30]

Between 1994 and 2005, drowning rates demonstrated an increase among white males 65 years and older and middle-aged white females (45-64 y) but showed a decrease in black boys, adolescents, and young adult males (5-24 y), black girls and adolescents (5-14 y), and white adolescents and young women (15-24 y).
[55]

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Sex- and age-related demographics


Males are approximately 4 times more likely than females to have submersion injuries. This rate is consistent with increased risk-taking behavior in boys, especially in adolescence. Males are also 12 times more likely than females to be involved in a boat-related drowning; alcohol use is frequently a contributing factor. Only in bathtub incidents do girls predominate in incidence. A bimodal age distribution is noted in persons with a submersion injury. Children younger than 4 years and adolescents aged 15-19 years are at highest risk. This bimodal distribution is predominantly observed in males, who have a much higher incidence of submersion injuries during adolescence than females do. Most toddlers drown in swimming pools and bathtubs, whereas most adolescents drown in natural bodies of water.

Prognosis
Patients who are alert or mildly obtunded at presentation have an excellent chance for full recovery. Patients who are comatose, those receiving CPR at presentation to the emergency department (ED), or those who have fixed and dilated pupils and no spontaneous respirations have a poor prognosis. In a number of studies, 35-60% of individuals needing continued CPR on arrival to the ED die, and 60-100% of survivors in this group experience long-term neurologic sequelae. Pediatric studies indicate that mortality is at least 30% in children who require specialized treatment for drowning in the pediatric intensive care unit (PICU). Severe brain damage occurs in an additional 10-30%. The neuroprotective effects of cold-water drowning are poorly understood. Intact survival of comatose patients after cold-water submersion is still quite uncommon. Hypothermia profoundly decreases the cerebral metabolic rate, but neuroprotective effects seem to occur only if the hypothermia occurs at the time of submersion and only if very rapid cooling occurs in water with a temperature of less than 5C (eg, if the individual broke through ice into the water). Morbidity and death from drowning are caused primarily by laryngospasm and pulmonary injury, resulting hypoxemia and acidosis, and their effects on the brain and other organ systems. A high risk of death exists secondary to the subsequent development of adult respiratory distress syndrome (ARDS). The adult mortality rate is difficult to quantify because of poor reporting and inconsistent record keeping. Thirty-five percent of immersion episodes in children are fatal; 33% of episodes result in some degree of neurologic impairment, with 11% resulting in severe neurologic sequelae. Anecdotal reports of survival are noted in children with moderate hypothermic submersion (core temperature < 32C), but most persons experiencing cold-water submersion do not develop hypothermia rapidly enough to decrease cerebral metabolism before severe, irreversible hypoxia and ischemia occur.

Patient Education
Prevention is key, and community education is the key to prevention. Toddlers should not be allowed near bathrooms or buckets of water outside without immediate adult supervision. Children should never swim alone or unsupervised, and children younger than 4 years and any children who are unable to swim should be accompanied by a responsible adult within arm's reach. Adults should know their own and their children's swimming limits. Appropriate barriers must be used around pools, wading pools, and other water-containing devices at home. The US Consumer Product Safety Commission has published model regulations regarding pool fencing. Homeowners may consider installing a telephone poolside and teaching their children how to call 911. Children should be taught safe conduct around water and during boating and jet- or water-skiing. Use of alcohol or other recreational drugs is not appropriate when swimming or engaging in other water sports, as well as when operating or riding in motorized watercraft. Appropriate boating equipment should be used, including personal flotation devices, and all boaters must understand weather and water conditions. Parents should seriously consider learning CPR and water safety training in case rescue and resuscitation are needed. A 1990 study found that 86% of pool owners supported voluntary CPR training, while 40% of those surveyed supported mandatory training.
[56]

For patient education information, see the Public Health Center and Environmental Exposures and Injuries Center,

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as well as Cardiopulmonary Resuscitation (CPR) and Drowning.

Contributor Information and Disclosures


Author G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami, Leonard M Miller School of Medicine; Medical Director, Palliative Care Team, Director, Pediatric Critical Care Transport, Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Manager, FEMA, Urban Search and Rescue, South Florida, Task Force 2; Pediatric Medical Director, Tilli Kids Pediatric Initiative, Division of Hospice Care Southeast Florida, Inc G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society Disclosure: Nothing to disclose. Coauthor(s) Michael J Verive, MD, FAAP Medical Director, Pediatric Intensive Care, Department of Pediatrics, St Mary's Hospital for Women and Children Michael J Verive, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, Pediatric Sedation, and Society of Critical Care Medicine Disclosure: Nothing to disclose. William H Shoff, MD, DTM&H Director, PENN Travel Medicine; Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society Disclosure: Nothing to disclose. Specialty Editor Board Robert L Norris, MD Professor, Department of Surgery, Chief, Division of Emergency Medicine, Stanford University Medical Center

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Robert L Norris, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, California Medical Association, International Society of Toxinology, Society for Academic Emergency Medicine, and Wilderness Medical Society Disclosure: Nothing to disclose. Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Medscape Salary Employment Eddy S Lang, MDCM, CCFP(EM), CSPQ Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Canadian Association of Emergency Physicians, and Society for Academic Emergency Medicine Disclosure: Nothing to disclose. Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine Disclosure: Nothing to disclose. Chief Editor Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New Mexico Health Sciences Center; Chief, Emergency Medicine Service, New Mexico Veterans Affairs Health Care System Joe Alcock, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine Disclosure: Nothing to disclose. Additional Contributors James Martin, MD Fellow, Department of Emergency Medicine, Division of Hyperbaric Medicine, Hospital of the University of Pennsylvania Disclosure: Nothing to disclose. Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM Professor of Emergency Medicine, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine; Medical Director, Fast Track, Department of Emergency Medicine Suzanne Moore Shepherd is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society Disclosure: Nothing to disclose.

References
1. Health, United States 1996-97 and Injury Chartbook. DHHS Publication No (PHS) 96-1232. US Department of Health and Human Services. Hyattsville, Md: National Center for Health Statistics;. 1997. 2. Papa L, Hoelle R, Idris A. Systematic review of definitions for drowning incidents. Resuscitation. Jun 2005;65(3):255-64. [Medline]. 3. van Beeck EF, Branche CM, Szpilman D, Modell JH, Bierens JJ. A new definition of drowning: towards documentation and prevention of a global public health problem. Bull World Health Organ. Nov 2005;83(11):853-6. [Medline]. [Full Text].

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4. Orlowski JP. Drowning, near-drowning, and ice-water submersions. Pediatr Clin North Am. Feb 1987;34(1):75-92. [Medline]. 5. Suominen P, Baillie C, Korpela R, Rautanen S, Ranta S, Olkkola KT. Impact of age, submersion time and water temperature on outcome in near-drowning. Resuscitation. Mar 2002;52(3):247-54. [Medline]. 6. Garzoni C, Garbino J. Long-term risk of atypical fungal infection after near-drowning episodes. Pediatrics. Feb 2007;119(2):417; author reply 417-8. [Medline]. 7. Lunetta P, Modell JH, Sajantila A. What is the incidence and significance of "dry-lungs" in bodies found in water?. Am J Forensic Med Pathol. Dec 2004;25(4):291-301. [Medline]. 8. Dyson K, Morgans A, Bray J, Matthews B, Smith K. Drowning related out-of-hospital cardiac arrests: Characteristics and outcomes. Resuscitation. Jan 29 2013;[Medline]. 9. Citro R, Previtali M, Bossone E. Tako-tsubo cardiomyopathy and drowning syndrome: is there a link?. Chest. Aug 2008;134(2):469. [Medline]. 10. Choi G, Kopplin LJ, Tester DJ, Will ML, Haglund CM, Ackerman MJ. Spectrum and frequency of cardiac channel defects in swimming-triggered arrhythmia syndromes. Circulation. Oct 12 2004;110(15):2119-24. [Medline]. 11. Cortez KJ, Roilides E, Quiroz-Telles F, Meletiadis J, Antachopoulos C, Knudsen T, et al. Infections caused by Scedosporium spp. Clin Microbiol Rev. Jan 2008;21(1):157-97. [Medline]. [Full Text]. 12. Leechawengwongs M, Milindankura S, Liengudom A, Chanakul K, Viranuvatti K, Clongsusuek P. Multiple Scedosporium apiospermum brain abscesses after near-drowning successfully treated with surgery and long-term voriconazole: a case report. Mycoses. Nov 2007;50(6):512-6. [Medline]. 13. Mesfin FB, Tobin E, Adamo MA, Dirisio D. Fungal vertebral osteomyelitis due to Scedosporium apiospermum after near-drowning. J Neurosurg Spine. Jul 2008;9(1):58-61. [Medline]. 14. Tadi JM, Heming N, Serve E, Weiss N, Day N, Imbert A, et al. Drowning associated pneumonia: a descriptive cohort. Resuscitation. Mar 2012;83(3):399-401. [Medline]. 15. Leroy P, Smismans A, Seute T. Invasive pulmonary and central nervous system aspergillosis after near-drowning of a child: case report and review of the literature. Pediatrics. Aug 2006;118(2):e509-13. [Medline]. 16. Mangge H, Plecko B, Grubbauer HM, Popper H, Smolle-Jttner F, Zach M. Late-onset miliary pneumonitis after near drowning. Pediatr Pulmonol. Feb 1993;15(2):122-4. [Medline]. 17. Wenger JD, Hollis DG, Weaver RE, Baker CN, Brown GR, Brenner DJ, et al. Infection caused by Francisella philomiragia (formerly Yersinia philomiragia). A newly recognized human pathogen. Ann Intern Med. Jun 1 1989;110(11):888-92. [Medline]. 18. Kantarcioglu AS, Guarro J, de Hoog GS. Central nervous system infections by members of the Pseudallescheria boydii species complex in healthy and immunocompromised hosts: epidemiology, clinical characteristics and outcome. Mycoses. Jul 2008;51(4):275-90. [Medline]. 19. Tintelnot K, Wagner N, Seibold M, de Hoog GS, Horr R. Re-identification of clinical isolates of the Pseudallescheria boydii-complex involved in near-drowning. Mycoses. Sep 2008;51 Suppl 3:11-6. [Medline]. 20. Kakizaki E, Kozawa S, Sakai M, Yukawa N. Bioluminescent bacteria have potential as a marker of drowning in seawater: two immersed cadavers retrieved near estuaries. Leg Med (Tokyo). Mar 2009;11(2):91-6. [Medline]. 21. Suto M, Kato N, Abe S, Nakamura M, Tsuchiya R, Hiraiwa K. PCR detection of bacterial genes provides evidence of death by drowning. Leg Med (Tokyo). Apr 2009;11 Suppl 1:S354-6. [Medline]. 22. van Beelen ME, van Beeck EF, den Hertog P, Beirens TM, Raat H. Correlates of unsupervised bathing of infants: a cross-sectional study. Int J Environ Res Public Health. Mar 4 2013;10(3):856-66. [Medline]. 23. Jan MM. Pediatric near-drowning and drowning. Saudi Med J. Feb 2013;34(2):119-22. [Medline]. 24. U.S. Consumer Product Safety Commission. Safety Barrier Guidelines for Home Pools. Cited Mar 2007. Available at http://www.cpsc.gov/cpscpub/pubs/pool.pdf. 25. Brenner RA, Trumble AC, Smith GS, Kessler EP, Overpeck MD. Where children drown, United States,

11 of 14

08/02/2014 17:28

Drowning

http://emedicine.medscape.com/article/772753-overview

1995. Pediatrics. Jul 2001;108(1):85-9. [Medline]. 26. Byard RW. Rainwater tank drowning. J Forensic Leg Med. Nov 2008;15(8):533-4. [Medline]. 27. Rahman A, Shafinaz S, Linnan M, Rahman F. Community perception of childhood drowning and its prevention measures in rural Bangladesh: a qualitative study. Aust J Rural Health. Jun 2008;16(3):176-80. [Medline]. 28. Vrnik A, Klves K, van der Feltz-Cornelis CM, Marusic A, Oskarsson H, Palmer A, et al. Suicide methods in Europe: a gender-specific analysis of countries participating in the "European Alliance Against Depression". J Epidemiol Community Health. Jun 2008;62(6):545-51. [Medline]. [Full Text]. 29. Jonkman SN, Maaskant B, Boyd E, Levitan ML. Loss of life caused by the flooding of New Orleans after Hurricane Katrina: analysis of the relationship between flood characteristics and mortality. Risk Anal. May 2009;29(5):676-98. [Medline]. 30. Centers for Disease Control and Prevention. Unintentional Drowning: Fact Sheet. Accessed August 4, 2011. Available at http://www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.html. 31. Centers for Disease Control and Prevention. National Center for Injury Prevention and Control. Wisqars Details of Leading Causes of Death. National Center for Health Statistics (NCHS), National Vital Statistics System. Accessed June 2009. Available at http://webappa.cdc.gov/sasweb/ncipc/leadcaus10.html. 32. Safe Kids USA. Drowning Prevention. Accessed 2009. Available at http://www.safekids.org/our-work /research/fact-sheets/drowning-prevention-fact-sheet.html. 33. Culp WC Jr, Brewster BC, Wernicki P. Drowning: lifeguard rescue and resuscitation. Anesthesiology. Jan 2010;112(1):245; author reply 246. [Medline]. 34. Kanchan T, Menezes RG, Monteiro FN. Fatal unintentional injuries among young children--a hospital based retrospective analysis. J Forensic Leg Med. Aug 2009;16(6):307-11. [Medline]. 35. Papadakis M, Sharma S, Cox S, et al. The magnitude of sudden cardiac death in the young: A death certificate-based review in England and Wales. Europace. 2009;11:353-58. 36. National Water Safety Forum, UK. Water-related fatalities, 2005. 2005. [Full Text]. 37. Dean R, Mulligan J. Management of water incidents: drowning and hypothermia. Nurs Stand. Oct 21-27 2009;24(7):35-9. [Medline]. 38. Royal Society for the Prevention of Accidents. Accidental drowning 2005. 2005;. [Full Text]. 39. Hyder AA, Sugerman DE, Puvanachandra P, Razzak J, El-Sayed H, Isaza A, et al. Global childhood unintentional injury surveillance in four cities in developing countries: a pilot study. Bull World Health Organ. May 2009;87(5):345-52. [Medline]. [Full Text]. 40. Hong J, Lee B, Ha EH, Park H. Parental socioeconomic status and unintentional injury deaths in early childhood: consideration of injury mechanisms, age at death, and gender. Accid Anal Prev. Jan 2010;42(1):313-9. [Medline]. 41. Morgan D, Ozanne-Smith J, Triggs T. Direct observation measurement of drowning risk exposure for surf beach bathers. J Sci Med Sport. Jul 2009;12(4):457-62. [Medline]. 42. Morgan D, Ozanne-Smith J, Triggs T. Self-reported water and drowning risk exposure at surf beaches. Aust N Z J Public Health. Apr 2009;33(2):180-8. [Medline]. 43. Morgan D, Ozanne-Smith J, Triggs T. Descriptive epidemiology of drowning deaths in a surf beach swimmer and surfer population. Inj Prev. Feb 2008;14(1):62-5. [Medline]. 44. Ihama Y, Miyazaki T, Ferke C, et al. Scuba-diving related deaths in Okinawa, Japan, from 1982-2007. Legal Medicine. 2007;10:119-24. 45. Denoble PJ, Caruso JL, Dear Gde L, Pieper CF, Vann RD. Common causes of open-circuit recreational diving fatalities. Undersea Hyperb Med. Nov-Dec 2008;35(6):393-406. [Medline]. 46. Buzzacort P, Rosenberg M, Pikora T. Western Australian recreational scuba diving fatalities. Austral N Z Public Health. 1992-2005;2009;33:212-14. 47. Lippmann J, Walker D, Lawrence C, Fock A, Wodak T, Harris R, et al. Provisional report on diving-related

12 of 14

08/02/2014 17:28

Drowning

http://emedicine.medscape.com/article/772753-overview

fatalities in Australian waters 2008. Diving Hyperb Med. Mar 2013;43(1):16-34. [Medline]. 48. Laursen LH, Hansen HL, Jensen OC. Fatal occupational accidents in Danish fishing vessels 1989-2005. Int J Inj Contr Saf Promot. Jun 2008;15(2):109-17. [Medline]. 49. Ahlm K, Saveman BI, Bjrnstig U. Drowning deaths in Sweden with emphasis on the presence of alcohol and drugs - a retrospective study, 1992-2009. BMC Public Health. Mar 11 2013;13:216. [Medline]. [Full Text]. 50. Brooks CJ, MacDonald CV, Donati L, Taber MJ. Civilian helicopter accidents into water: analysis of 46 cases, 1979-2006. Aviat Space Environ Med. Oct 2008;79(10):935-40. [Medline]. 51. Wilks J. Injuries and injury prevention. In: Keystone J, Kozarsky P, et al. Travel Medicine. London: Mosby; 2004:453-59. 52. Guse CE, Corts LM, Hargarten SW, Hennes HM. Fatal injuries of US citizens abroad. J Travel Med. Sep-Oct 2007;14(5):279-87. [Medline]. 53. Leggat PA, Wilks J. Overseas visitor deaths in Australia, 2001 to 2003. J Travel Med. Jul-Aug 2009;16(4):243-7. [Medline]. 54. Berger LR, Wallace LJ, Bill NM. Injuries and injury prevention among indigenous children and young people. Pediatr Clin North Am. Dec 2009;56(6):1519-37. [Medline]. 55. Gramsbergen A, Hadders-Algra M. Development of postural control, a basic aspect of neuro-ontogeny. Neurosci Biobehav Rev. Jul 1998;22(4):463-4. [Medline]. 56. Wintemute GJ, Wright MA. Swimming pool owners' opinions of strategies for prevention of drowning. Pediatrics. Jan 1990;85(1):63-9. [Medline]. 57. Herman-Giddens ME, Smith JB, Mittal M, Carlson M, Butts JD. Newborns killed or left to die by a parent: a population-based study. JAMA. Mar 19 2003;289(11):1425-9. [Medline]. 58. Fugiwara T, Barber C, Schaechter J, Hemenway D. Characteristics of infant homicides: Findings from a US multisite reporting system. Pediatr. 2009;124:e210-17.. 59. Dias MS, Smith K, DeGuehery K, Mazur P, Li V, Shaffer ML. Preventing abusive head trauma among infants and young children: a hospital-based, parent education program. Pediatrics. Apr 2005;115(4):e470-7. [Medline]. 60. Giesbrecht GG, Pretorius T. Survey of public knowledge and responses to educational slogans regarding cold-water immersion. Wilderness Environ Med. Winter 2008;19(4):261-6. [Medline]. 61. Layon AJ, Modell JH. Drowning: Update 2009. Anesthesiology. Jun 2009;110(6):1390-401. [Medline]. 62. [Best Evidence] Bell GS, Gaitatzis A, Bell CL, Johnson AL, Sander JW. Drowning in people with epilepsy: how great is the risk?. Neurology. Aug 19 2008;71(8):578-82. [Medline]. 63. Kanchan T, Menon A, Menezes RG. Methods of choice in completed suicides: gender differences and review of literature. J Forensic Sci. Jul 2009;54(4):938-42. [Medline]. 64. Salib E. Trends in suicide by drowning in the elderly in England and Wales 1979-2001. Int J Geriatr Psychiatry. Feb 2005;20(2):175-81. [Medline]. 65. Purandare N, Voshaar RC, Rodway C, Bickley H, Burns A, Kapur N. Suicide in dementia: 9-year national clinical survey in England and Wales. Br J Psychiatry. Feb 2009;194(2):175-80. [Medline]. 66. Warner DS, Bierens JJ, Beerman SB, Katz LM. Drowning: a cry for help. Anesthesiology. Jun 2009;110(6):1211-3. [Medline]. 67. Varon J, Acosta P. Therapeutic hypothermia: past, present, and future. Chest. May 2008;133(5):1267-74. [Medline]. 68. Kyriacou DN, Arcinue EL, Peek C, Kraus JF. Effect of immediate resuscitation on children with submersion injury. Pediatrics. Aug 1994;94(2 Pt 1):137-42. [Medline]. 69. Quan L, Kinder D. Pediatric submersions: Pre-hospital predictors of outcome. Pediatr. 1992;90:909-13. 70. Youn CS, Choi SP, Yim HW, Park KN. Out-of-hospital cardiac arrest due to drowning: An Utstein Style

13 of 14

08/02/2014 17:28

Drowning

http://emedicine.medscape.com/article/772753-overview

report of 10 years of experience from St. Mary's Hospital. Resuscitation. Jul 2009;80(7):778-83. [Medline]. 71. Eich C, Russo SR, Heuer JF, et al. Characteristics of out-of-hospital pediatric emergencies attended by ambulanc and helicopter-based emergency physicians. Resuscitation. 2009;80:888-92. 72. Sayre MR, Berg RA, Cave DM, Page RL, Potts J, White RD. Hands-only (compression-only) cardiopulmonary resuscitation: a call to action for bystander response to adults who experience out-ofhospital sudden cardiac arrest: a science advisory for the public from the American Heart Association Emergency Cardiovascular Care Committee. Circulation. Apr 22 2008;117(16):2162-7. [Medline]. 73. Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med. Feb 21 2002;346(8):549-56. [Medline]. 74. Bernard SA, Gray TW, Buist MD, Jones BM, Silvester W, Gutteridge G, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med. Feb 21 2002;346(8):557-63. [Medline]. 75. Cubattoli L, Franchi F, Coratti G. Surfactant therapy for acute respiratory failure after drowning: two children victim of cardiac arrest. Resuscitation. Sep 2009;80(9):1088-9. [Medline]. 76. Onarheim H, Vik V. Porcine surfactant (Curosurf) for acute respiratory failure after near-drowning in 12 year old. Acta Anaesthesiol Scand. Jul 2004;48(6):778-81. [Medline]. 77. Mizobuchi M, Nakamura S, Muranishi H, Utsunomiya M, Funatsu A, Kobayashi T, et al. Hypothermia with extracorporeal membrane oxygenation for sudden cardiac death and submersion. Am J Emerg Med. Jan 2010;28(1):115.e1-4. [Medline]. 78. Kawati R, Covaciu L, Rubertsson S. Hypothermia after drowning in paediatric patients. Resuscitation. Nov 2009;80(11):1325-6. [Medline]. 79. Conn AW, Montes JE, Barker GA, Edmonds JF. Cerebral salvage in near-drowning following neurological classification by triage. Can Anaesth Soc J. May 1980;27(3):201-10. [Medline]. 80. Modell JH, Graves SA, Kuck EJ. Near-drowning: correlation of level of consciousness and survival. Can Anaesth Soc J. May 1980;27(3):211-5. [Medline]. 81. Ballesteros MA, Gutirrez-Cuadra M, Muoz P, Miambres E. Prognostic factors and outcome after drowning in an adult population. Acta Anaesthesiol Scand. Aug 2009;53(7):935-40. [Medline]. 82. Modell JH. Legal Aspects and Litigation in Aquatic Lifesaving. In: Bierens J. Handbook on Drowning. 1. Heidelberg, Germany: Springer-Verlag; 2006:645-47. 83. Wagner C. Pediatric submersion injuries. Air Med J. May-Jun 2009;28(3):116-9. [Medline]. 84. Brenner RA, Taneja GS, Haynie DL, et al. Association between swimming lessons and drowning in childhood: a case-controlled study. Arch Pediatr Adolesc Med. 2009;163:203-10. 85. Carr WD. Formal swimming lessons must be defined. Arch Pediatr Adolesc Med. 2009;163:962. 86. Branche CM, Stewart. Lifeguard effectiveness: A report of the working group. Atlanta: CDC National Center for Injury Prevention and Control. 2001. 87. [Guideline] Prevention of drowning in infants, children, and adolescents. Pediatrics. Aug 2003;112(2):437-9. [Medline]. 88. Samuelson H, Nekludov M, Levander M. Neuropsychological outcome following near-drowning in ice water: two adult case studies. J Int Neuropsychol Soc. Jul 2008;14(4):660-6. [Medline]. 89. Suominen PK, Vallila NH, Hartikainen LM, Sairanen HI, Korpela RE. Outcome of drowned hypothermic children with cardiac arrest treated with cardiopulmonary bypass. Acta Anaesthesiol Scand. Nov 2010;54(10):1276-81. [Medline]. 90. Topjian AA, Berg RA, Bierens JJ, Branche CM, Clark RS, Friberg H, et al. Brain Resuscitation in the Drowning Victim. Neurocrit Care. Sep 6 2012;[Medline]. Medscape Reference 2011 WebMD, LLC

14 of 14

08/02/2014 17:28