Drowning

Author: G Patricia Cantwell, MD, FCCM; Chief Editor: Joe Alcock, MD, MS

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.
Exact definitions of drowning have varied widely.[2] 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.[3] 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 icecold water has been reported to be protective, especially in young children, [4] prolonged immersions can nullify the effect
of temperature on survivability[5] .
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
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. [8] 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).
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 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, includingAeromonas, 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
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, includingPseudallescheria boydii and Scedosporium apiospermum,Naegleria,
Balamuthia, as well as Burkholderia and Aeromonas organisms, and newly discovered human pathogens (Francisella
philomiragia).[11, 12, 6, 13] [14, 15, 16, 17] These infections are usually insidious in onset, 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]
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.
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.[24, 25, 23] 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[26] and one from Bangladesh on drowning in ditches, canals, and
ponds[27] illustrate that water exposure is both culturally and geographically related. Limiting access to such areas is 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.[28] They found that women were more likely to choose drowning as a suicide method. They suggested that
gender-specific prevention strategies should be developed.

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.
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. [1, 30, 31] This averages out to about 10 deaths per day in the United
States.
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%). [32] In California,
Arizona, and Florida, drowning is the number one cause of injury-related death.
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. [33] 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.

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 [34] and that many cases are never brought to
medical attention, renders accurate worldwide incidence approximation and classification virtually impossible. [35] The
overall incidence of drowning has an estimated range of 20-500 times the rate of fatal drowning.
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. [36] Structures overhanging water posed
a particular risk. Young children (< 5 years) and older adults were shown to be at highest risk. [36, 37, 38]
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 [34, 39] 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 overrepresentation 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]
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. [43]
Scuba diving accounts for an estimated 700-800 deaths per year; etiologies include inadequate experience/training,
exhaustion, panic, carelessness, and barotrauma.[44] Denoble et al studied 947 recreational diving accidents from 19922003, 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 safety practices.[46] The authors noted that shore dives or dives from private crafts were
fatal 3 times as often as dives from commercial boats. 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. [50]
Accidental death, such as drowning, complicate tourism in many countries. [51, 52]An Australian study found accidental
drowning to be the cause of approximately 5% of all deaths in the 1068 visitor deaths reviewed. [53]

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. [30] 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]
Between 1994 and 2005, drowning rates demonstrated an increase among white males 65 years and older and middleaged 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]

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, as
well as Cardiopulmonary Resuscitation (CPR)and Drowning.

History
All aspects of the drowning episode should be determined, including the circumstances around the actual submersion.
Rarely does a patient present with the classic "Hollywood scenario" of a novice swimmer stranded in water, frantically
struggling and flapping his or her arms in desperation. Experienced snorkelers, for example, may experience syncope
secondary to hypoxia after hyperventilating to drive off carbon dioxide, and deep-water divers may succumb to "shallowwater blackout" as they ascend.
Most persons are found after having been submerged in water for an unobserved period.
Typical incidents involve a toddler left unattended temporarily or under the supervision of an older sibling, an adolescent
found floating in the water, or a victim diving and not resurfacing. Less typically, drowning may be a deliberate form of
child abuse and infant homicide, including Munchhausen syndrome by proxy.

Intentional newborn deaths

In an analysis of intentional newborn deaths (72 coroner cases < 1 year old), 2 of the major causes were asphyxiation
by strangulation (41%) and drowning (27%).[57]Studies have identified the following as risk factors for such newborn
deaths:

Young and unmarried mothers

Parental depression
Family financial problems
Residence of the mother and child in households with unrelated male adults
The infant often was found to be at home alone with the caretaker-perpetrator (93%) and was crying. The authors
suggest that these incidents may be impulsive, largely unintended, and result from stress. [58] A study by Dias et al,
suggested that targeted hospital-based education and social service involvement may be effective in reducing these
cases.[59]

Drowning factors
Relevant factors in drowning cases include the following:

Age of the victim

Submersion time
Water temperature
Water tonicity
Degree of water contamination
Symptoms
Associated injuries (especially cervical spine and head)
Coincident alcohol or drug use
Underlying medical conditions
Type and timing of rescue and resuscitation efforts
Response to initial resuscitation
Thermal conduction of water is 25-30 times that of air. The temperature of thermally neutral water, in which a nude
individual's heat production balances heat loss, is 33C. Physical exertion increases heat loss secondary to
convection/conduction up to 35-50% faster.
A significant risk of hypothermia usually develops in water temperatures less than 25C, which is the temperature found
in most US natural waters during the majority of the year.
During immersion in ice water, a person will become hypothermic in approximately 30 minutes. Cooling at this
temperature becomes life-threatening in approximately 60 minutes. [60]
Other important historical factors include the following:

Shortness of breath, difficulty breathing, apnea

Persistent cough, wheezing
In stream, lake, or saltwater immersion, possible aspiration of foreign material or exposure to fungi, bacteria,
and other microorganisms
level of consciousness at presentation, history of loss of consciousness, anxiety, fatigue, changes in usual
behavior; Modell suggests that most individuals will have some period of unconsciousness after drowning secondary
to cerebral hypoxia [61]
Vomiting, diarrhea
Coincident alcohol or drug use

Pertinent past medical history

Underlying medical conditions that are particularly more likely to lead to drowning include the following:

Seizure disorder
Diabetes mellitus
Psychiatric illness
Severe arthritis

Cardiac disease
Neuromuscular disorder
A United Kingdom study found a 15- to 19-fold increase in the risk of drowning in individuals with epilepsy.[62]
A number of studies worldwide have documented that drowning is a not infrequent method for suicide, especially among
older individuals. Cultural attitudes toward death, water source availability and accessibility, social acceptability of this
method, gender, and age may influence drowning as the method of choice. [63, 64, 65]
Cardiac history is important to obtain, especially that of dysrhythmias and syncope. Ion channelopathies and sudden
arrhythmic death syndromes, including Brugada syndrome and prolonged QT syndrome, should be considered [35] ;
however, this cause of drowning is probably uncommon. Lunetta et al looked for genetic mutations in 63 drowning
victims and failed to document one case of long QT founder gene mutation. [7]

Physical Examination
The clinical presentations of people who experience submersion injuries vary widely. A drowning victim may be
classified initially into 1 of the following 4 groups:

Asymptomatic
Symptomatic
Cardiopulmonary arrest
Obviously dead
Patients are especially likely to be asymptomatic if they experienced brief, witnessed submersions with immediate
resuscitation.
Symptomatic patients may exhibit the following:

Altered vital signs (eg, hypothermia, tachycardia or bradycardia)

Anxious appearance
Tachypnea, dyspnea, or hypoxia: If dyspnea occurs, no matter how slight, the patient is considered
symptomatic
Metabolic acidosis (may exist in asymptomatic patients as well)
Altered level of consciousness, neurologic deficit
Cough
Wheezing
Hypothermia
Vomiting, diarrhea, or both
Patients in cardiopulmonary arrest exhibit the following:
Apnea
Asystole (55%), ventricular tachycardia/fibrillation (29%), bradycardia (16%)
Immersion syndrome
In cases of obvious death due to drowning, the following are present:
Normothermia with asystole
Apnea
Rigor mortis
Dependent lividity
No apparent CNS function

Physical Examination
The clinical presentations of people who experience submersion injuries vary widely. A drowning victim may be
classified initially into 1 of the following 4 groups:

Asymptomatic
Symptomatic
Cardiopulmonary arrest
Obviously dead
Patients are especially likely to be asymptomatic if they experienced brief, witnessed submersions with immediate
resuscitation.
Symptomatic patients may exhibit the following:

Altered vital signs (eg, hypothermia, tachycardia or bradycardia)

Anxious appearance
Tachypnea, dyspnea, or hypoxia: If dyspnea occurs, no matter how slight, the patient is considered
symptomatic
Metabolic acidosis (may exist in asymptomatic patients as well)
Altered level of consciousness, neurologic deficit
Cough
Wheezing
Hypothermia
Vomiting, diarrhea, or both
Patients in cardiopulmonary arrest exhibit the following:
Apnea
Asystole (55%), ventricular tachycardia/fibrillation (29%), bradycardia (16%)
Immersion syndrome
In cases of obvious death due to drowning, the following are present:

Normothermia with asystole

Apnea
Rigor mortis
Dependent lividity
No apparent CNS function

Prehospital Care
Optimal prehospital care is a significant determinant of outcome in the management of immersion victims worldwide. [68, 69,
70]
Bystanders should call 911 immediately where this service, or similar service, is available. In developing countries,
children may be transported more frequently by family members, by taxi or private vehicle, and from a greater distance.
[39]

An individual may be rescued at any time during the process of drowning. No intervention may be necessary, or rapid
rescue and resuscitation may be warranted. No 2 cases are entirely alike. The type of water, water temperature,
quantity of water aspirated, time in the water, and individual's underlying medical condition all play a role.
The victim should be removed from the water at the earliest opportunity. Rescue breathing should be performed while
the individual is still in water, but chest compressions are inadequate because of buoyancy issues.
The patient should be removed from the water with attention to cervical spine precautions. If possible, the individual
should be lifted out in a prone position. Theoretically, hypotension may follow lifting the individual out in an upright
manner because of the relative change in pressure surrounding the body from water to air.
Bystanders and rescue workers should never assume the individual is unsalvageable unless it is patently obvious that
the individual has been dead for quite a while. If they suspect injury, they should move the individual the least amount
possible and begin cardiopulmonary resuscitation (CPR).
As in any rescue initiative, initial treatment should be geared toward ensuring adequacy of the airway, breathing, and
circulation (ABCs). Give attention to cervical spine stabilization if the patient has facial or head injury, is unable to give
an adequate history, or may have been involved in a diving accident or motor vehicle accident.
In the patient with an altered mental status, the airway should be checked for foreign material and vomitus. Debris
visible in the oropharynx should be removed with a finger-sweep maneuver. The abdominal thrust (Heimlich) maneuver
has not been shown to be effective in removing aspirated water; in addition, it delays the start of resuscitation and risks
causing the patient to vomit and aspirate. In any event, ventilation is achieved even if fluid is present in the lungs.
Supplemental oxygen, 100%, should be administered as soon as available. Immediately place the patient on 100%
oxygen by mask. The degree of hypoxemia may be difficult to determine on clinical observation. If available, continuous
noninvasive pulse oximetry is optimal. If the patient remains dyspneic on 100% oxygen or has a low oxygen saturation,
use continuous positive airway pressure (CPAP) if available. If it is not available, consider early intubation, with
appropriate use of PEEP.
Higher pressures may be required for ventilation because of the poor compliance resulting from pulmonary edema.

First responders, including emergency medical service (EMS) personnel and professional ocean lifeguards, should be
well versed in providing the time-critical institution of advanced interventions, such as airway management. As
drownings are not frequent, refresher training can play an excellent role in skill maintenance. [33, 71] With the current move
toward compression-only CPR, further study needs to be performed in the specific hypoxic and potentially hypothermic
milieu of drowning before this is routinely performed.[66, 72]
More traditional literature proposes that prehospital care providers should begin rewarming. Wet clothing is ideally
removed before the victim is wrapped in warming blankets. More recent studies have shown that therapeutic
cooling after out-of-hospital ventricular fibrillation cardiac arrest is actually beneficial in patients to reduce ischemic brain
injury and death. This area needs additional vigorous clinical research to determine the most effective treatment
strategy in drowning victims.[67, 73, 74]

Medication Summary
Cold-induced bronchorrhea or irritation of the tracheobronchial tree by inhaled water or particulate material can produce
cough and bronchospasm. Manage these aggressively because they may worsen hypoxia. The drug of choice is an
inhaled beta-agonist bronchodilator.
Corticosteroids have been shown to be of no benefit in the management of submersion injuries. Routine antibiotic
prophylaxis is not indicated unless the patient was submerged in grossly contaminated water or sewage.