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Pediatric Drowning: Current Management Strategies

for Immediate Care

Noel S. Zuckerbraun, MD, Richard A. Saladino, MD
This review will introduce new universal terminology recommended for drowning, review the
pathophysiology of drowning, and discuss current management strategies for treating the
drowning victim. Drowning is a major burden of injury for children. The drowning process
results in hypoxia, the degree of which ultimately determines clinical outcome. No single or
combination of variables has proven to be reliably predictive of poor outcome. Initial care is
focused on reversing the hypoxia and maintaining cardiovascular stability. Injuries
associated with drowning can be complicated by hypothermia as well as predisposing
medical and traumatic conditions, all of which will need to be addressed concomitantly.
Posthypoxic cerebral encephalopathy is a delayed outcome of drowning associated with the
greatest morbidity. Thus, early measures to prevent secondary brain injury are important.
Clin Ped Emerg Med 6:49-56 2005 Published by Elsevier Inc.
KEYWORDS pediatric drowning, hypoxia, hypothermia, cerebral encephalopathy

rowning is a major injury burden worldwide causing

an estimated 500 000 deaths annually [1]. In many
countries, including the United States, the incidence of
drowning is consistently highest among children younger
than 5 years and next highest in those 15 to 19 years old
[1]. In 2001, an estimated 4174 persons were treated in a
US emergency department (ED) for nonfatal unintentional drowning injuries in recreational settings (including pools and natural bodies of water), and 3372 persons
had fatal unintentional drowning injuries [2]. During this
period, children younger than 5 years accounted for
nearly 50% of US ED visits for drowning, and children 5 to
14 years, an additional 25%. Fatality rates were highest in
those children less than 5 years. The etiology of drowning
is multifactorial, varying with both age and geographic
location [3]. Despite being a leading cause of injury and
cardiac arrest in children, the average ED physician will
only treat a small number of drowning victims annually.

Division of Pediatric Emergency Medicine, Childrens Hospital of

Pittsburgh, Pittsburgh, PA 15213.
Reprint requests and correspondence: Dr. Noel S. Zuckerbraun, Division
of Pediatric Emergency Medicine, Childrens Hospital of Pittsburgh,
3705 Fifth Avenue, Pittsburgh, PA 15213.

1522-8401/$ - see front matter 2005 Published by Elsevier Inc.


The immediate care of drowning victims is challenging

because of the unique pathophysiological mechanisms
and management issues.
This discussion will introduce new universal terminology recommended for drowning, review the drowning
process, and outline current management strategies for
treating the drowning victim.

In 2002, the World Congress on Drowning published
expert consensus recommendations regarding drowning
definitions, prevention, rescue, and treatment. Two
recent reviews have summarized some of the expert
conclusions [4,5]. The final report, Handbook on Drowning, was published in 2004 [6].
Terminology describing drowning has varied for decades. Lack of uniformity has resulted in confusion among
clinicians and difficulty in interpreting and comparing
reported data. Thus, a major goal of the World Congress
on Drowning was to develop universal terminology for
drowning. bDrowning Q is now defined as the process resulting in primary respiratory impairment from submersion/immersion in a liquid medium [4]. Ultimate survival
is not considered for the definition; the victim may

survive or die after drowning. In addition, it is now
the consensus that drowning without aspiration does
not occur [4,7]. Previously used descriptive terminology relating to outcome or pathophysiology should
be abandoned, including bdry,Q bwet,Q bactive,Q bsilent,Q
bsecondary,Q and bnear-drowning.Q The International
Liaison Committee on Resuscitation advisory statement
includes a detailed discussion of these terminology
recommendations [4].

The Pathophysiology of the

Drowning Process
Understanding the drowning process provides rationale
for current rescue and treatment strategies. The drowning process begins when the victims airway lies below the
surface of a liquid medium (usually water). Typically,
voluntary breath-holding ensues. Small amounts of water
are aspirated from the oropharynx/larynx, which triggers
involuntary laryngospasm resulting in hypoxia. Large
amounts of water are subsequently swallowed. With
prolonged hypoxia, laryngospasm abates and more water
is aspirated into the lungs [4,8]. Aspiration of water leads
to destruction of surfactant, impaired alveolar capillary
gas exchange, intrapulmonary shunting, and pulmonary
edema [9,10]. These events then result in progressive
hypoxia, hypercarbia, and acidosis. In contrast to
previous beliefs based on animal research, the type
(freshwater vs saltwater) and amount of water aspirated
is now not thought to play a large role in the clinical
outcome of human drowning. As little as 1 to 3 mL /kg of
water aspiration can induce the pathophysiological
process described above, and rarely is enough water
aspirated to cause electrolyte disturbances [10-12].
Vomiting and aspiration of gastric contents can also
contribute to acute lung injury.
As the drowning process progresses, a gradual decrease
in arterial oxygen saturation is accompanied by a
simultaneous decrease in cardiac output [5]. Prolonged
hypoxia leads to intense peripheral vasoconstriction and
decreased cardiac output and arterial blood pressure [8].
In addition, victims often become hypothermic, causing
extravascular fluid shifts and renal diuresis resulting in
significant intravenous fluid loss. This in turn exacerbates
the decrease in systemic perfusion [13]. If the hypoxic
drowning process is not reversed within a few minutes,
vital organs such as the brain and heart become
permanently injured. Ultimately, profound bradycardia
and circulatory arrest occur. Given this progression of
events, cardiac arrest is usually not sudden. Ventricular
fibrillation due to drowning can occur, but is thought to
be rare [5].
Importantly, predisposing medical (hypoglycemia,
intoxication, seizures, and cardiac arrhythmias) or concomitant traumatic (head, cervical spine, and multi-

N.S. Zuckerbraun, R.A. Saladino

system) conditions associated with drowning pathophysiology may complicate the clinical picture.
Victim rescue can occur at any time after the initiation
of the drowning process. The extent of hypoxic insult will
ultimately determine outcome. Even in the face of
successful restoration of myocardial function and spontaneous circulation, delayed hypoxic effects such as acute
respiratory distress syndrome (ARDS), cerebral edema,
and myocardial failure may develop.
Additional unique pathophysiological features are
characteristic of cold-water (b108C) drowning, including
cold-induced myocardial dysfunction and arrhythmias
[14]. Remarkably, some victims of cold-water drowning
can survive without neurological deficits as a result of the
protective effects of the hypothermia [15-17]. The
bdiving reflex,Q a cold-water phenomenon prominent in
children, is triggered by exposure of the face to cold water
and is characterized by apnea, bradycardia, and intense
vasoconstriction. This reflex, in combination with hypothermia from surface cooling, is postulated to play a role
in protective hypometabolism that results in improved
survival after prolonged submersion in cold water [18].
Rapid cerebral cooling by pulmonary heat exchange
through repeated flushing of the lungs with cold water
is another proposed mechanism [19]. A definitive
physiological explanation for these rare, extraordinary
outcomes, though, remains elusive.

Predicting Outcomes
A great deal of research has focused on epidemiological,
clinical, and laboratory predictors of outcome for drowning victims. Four outcomes can occur in pediatric
drowning: (1) full recovery (neurologically intact), (2)
neurological impairment, (3) persistent vegetative state,
and (4) death [20]. Predictors studied to date include
demographic characteristics (age and sex), historical
factors (submersion time, time to resuscitation, and
cardiopulmonary resuscitation [CPR] at the scene), and
clinical factors (neurological examination, Glascow
Coma Scale score [GCS], Pediatric Risk of Mortality
score [PRISM], need for continued CPR, serum glucose,
and arterial pH) [21-29].
The likelihood of poor outcome has been shown to
increase with the duration of submersion [24]. Intact
survival is likely with submersion durations of shorter
than 5 minutes [22,24] to 10 minutes [22,23]. However,
for submersion durations of longer than 25 minutes, the
likelihood of a poor outcome approaches 100% [24].
Unfortunately, the duration of submersion is often not
accurately known. Although some studies have found the
need for continued CPR in the ED predictive of poor
neurological outcome [25,26], others have shown intact
survival in drowning victims requiring CPR in the ED
[27,28]. In 1979, Orlowski described 5 prognostic factors
based on age (3 years and younger), submersion time

Pediatric drowning: current management strategies for immediate care

(longer than 5 minutes), time to initial resuscitation (no
attempts for more than 10 minutes), and level of
consciousness (coma) and acidosis (pH V 7.10) upon
presentation to the ED [22]. Two or fewer poor prognostic
factors predicted a 90% chance of full recovery, whereas 3
or more predicted only a 5% chance of full recovery. More
recently, Christensen and colleagues in 1997 reported a
classification system that achieved 93% overall accuracy
in predicting intact survivors based on initial physical
examination findings (apnea, coma), need for CPR in the
ED, and pH (b7.0) [29]. Importantly, although highly
accurate, this clinical classification method predicted
death in 5 intact survivors.
Predicting outcome in drowning victims becomes more
reliable as time after the drowning event increases. GCS
alone (V5) upon arrival in the intensive care unit (ICU)
[27] has been shown to be more predictive than GCS upon
arrival to the ED [28]. Additional data from Orlowski
suggests that those who remain profoundly comatose
(flaccid or posturing) 2 to 6 hours after the drowning will
likely have brain death or moderate to severe neurological
impairment, whereas those who show definite signs of
neurological recovery (responding to painful stimuli) will
fare better with normal or near-normal recovery [30].
Unfortunately, no single or combination of variables
has proven to be reliably predictive of poor outcome.
Moreover, criteria that guide the withholding or cessation
of resuscitative efforts in the ED have not been described.
In particular, although the potential dramatic protective
role of hypothermia in icy cold-water drowning has been
recognized, hypothermia upon arrival to the ED is a
poor prognostic sign [31]. In addition, it is often difficult
to determine the temperature of the body of water and
whether cerebral cooling might have occurred before the
hypoxic insult.
Given these issues and lack of reliable predictors of
outcome, all drowning victims arriving in the ED should
have resuscitation attempted. All available historic and
clinical variables should be considered when determining
the extent of resuscitative efforts. Although not useful for
determining who should be resuscitated, the predictors
studied by Orlowski and Christensen may be used to
facilitate family counseling, serve as a triage instrument in
the event of a disaster, or help to determine those patients
that may benefit from experimental cerebral resuscitation
therapies [8,22,29].

Current Management Strategies

for Immediate Care
Scene Interventions
The immediate care of the drowning victim begins at the
scene (Table 1). The importance of bystander resuscitation to restore oxygenation cannot be overemphasized.
Mouth-to-mouth breathing should be initiated immedi-

Table 1
Key elements of management at the scene
of drowning.
Initiate CPR immediately.
Activate emergency medical system.
Emergency medical system personnel
Institute CPR.
Immediate institution of oxygen and pulmonary
resuscitation [8].
Consider early intubation.
Immobilize cervical spine if trauma is suspected [32].
Prevent further aspiration [8].
If spontaneously breathing, put in the right lateral
decubitus position, slight Trendelenburg positioning.
If positive-pressure ventilation is required, provide
cricoid pressure and consider early intubation.
Avoid Heimlich maneuver unless foreign body
obstruction is suspected [33].
Do not attempt to drain water from lungs [34].
Prevent further hypothermia [13].
Gently remove wet clothing (preferably cutting them off).
Consider initiating rewarming depending on severity of
hypothermia, available resources, and if transport
time is expected to be long.
Avoid cardiac decompensation in hypothermic victims by
minimizing rough handling [35].
Ensure speedy evacuation to appropriate facility (eg,
consider hospital capable of providing pulmonary
bypass in severely hypothermic victims) [35].

ately, even while the victim is still in the water [8]. Any
delay in pulmonary resuscitation exacerbates the existing
hypoxia and decreases the victims chances of intact
survival [22,36,37]. In fact, some studies have shown
survival only in those victims who received bystander
resuscitation [38,39].
Drowning victims who respond to minimal resuscitation at the scene will usually do well clinically, whereas
those who do not will likely require ongoing resuscitation
and monitoring for the development of pulmonary,
cardiovascular, and neurological complications [40].
Classification systems based on clinical characteristics
at the scene can help guide prehospital management [41].
Regardless of the victims initial appearance at the scene,
all drowning victims should be transferred to an ED for
evaluation and treatment [19].

Emergency Department Strategies

Emergency Department Resuscitation
Drowning victims may present to the ED in a variety of
clinical states ranging from asymptomatic appearance to
cardiac arrest (Figure 1). As is the case at the scene, the
first priority for managing drowning victims in the ED is
to reverse hypoxemia by restoring adequate oxygenation
and ventilation. All drowning victims should be presumed to be hypoxic, acidotic, and hypothermic. Initial
attention is directed to the ABCs of resuscitation,

N.S. Zuckerbraun, R.A. Saladino


Evaluation of Airway, Breathing, Circulation and



-Sao2 > 90%
-Pa02 > 90 torr

Consider Tracheal Intubation

and Assisted Ventilation

Rapid Sequence
Intubation (Table 1)

PEEP 5-15 cm H20

Treat Shock

Manage Hypothermia

Crystalloid bolus
20 ml/kg,
may repeat x 2

Passive rewarming for

T > 32C (Table 4)

Consider vasopressor
for cardiogenic shock

Active rewarming for

T < 32C (Table 4)
Goal: rewarm 1-2 C
per hour to 33-36 C

Figure 1 Emergency department resuscitation.

including consideration of the need for cervical spine

immobilization. Oxygen is the first line of therapy.
Spontaneously breathing patients who can maintain a
Sao2 N 90% and a Pao2 N 90 Ttorr on a Fio2 of b0.50 may
only need oxygen therapy [8]. It is important to note that
vomiting is common in drowning victims as more water
is swallowed than aspirated. Thus, those who remain
unconscious or have respiratory compromise are best
managed with tracheal intubation using a rapid sequence
induction technique [8,42]. Table 2 provides a rapid
sequence induction protocol.
For these patients, mechanical ventilation with positive
end-expiratory pressure is the single most effective
method for reversing hypoxemia and preventing further
aspiration. The development of pulmonary edema and
decreased lung compliance may make effective ventilation difficult. For this reason, positive end-expiratory
pressure, initially at 5 cm H2O, should be used with
careful attention to its effects on both oxygenation and
blood pressure. If oxygenation is inadequate, positive
end-expiratory pressure can be increased in 2 to 3 cm
H2O increments to 10 to 15 cm H2O as cardiac output or
blood pressure allows [8].
For drowning victims with evidence of shock or
respiratory embarrassment, rapid intravenous access is
Table 2

Rapid sequence induction medications.

1. Preparation
Lidocaine: 1 mg/kg IV
(a) V10 kg: 0.1 mg IV
(b) N10 kg: 0.01 mg/kg IV (maximum 0.4 mg)
2. Induction
Hypnotic: etomidate: 0.3 mg/kg IV
Paralytic agent: rocuronium: 1 mg/kg IV
3. Posttracheal intubation sedation
Midazolam: 0.1 mg/kg IV (maximum 5 mg)
Fentanyl: 1-2 l g/kg IV

needed. Intraosseus access should be considered for

patients in extremis or if obtaining intravenous access
in a timely manner is anticipated to be difficult (eg,
ongoing CPR, extreme vasoconstriction). Both freshwater
and saltwater drowning victims need aggressive fluid
resuscitation, preferably with a crystalloid solution such
as normal saline. Initial fluid boluses of 20 mL/kg are
appropriate. Acidosis should be corrected with restoration of adequate oxygenation, ventilation, and circulatory
volume expansion. Sodium bicarbonate infusion is
usually unnecessary [35].
Cardiac dysfunction may occur as a result of hypoxia
associated with drowning. This injury is characterized by
low cardiac output with high systemic and pulmonary
vascular resistance and may persist even after adequate
oxygenation, ventilation, and perfusion have been established [43]. Cardiogenic pulmonary edema may therefore
complicate the typical findings of ARDS. Furosemide is
not typically indicated for these patients, and additional
volume and inotropic agents may be necessary to restore
adequate tissue perfusion [8]. Dobutamine has been
suggested as a logical choice for these patients [8]. If
available, an echocardiogram can guide the decision of
which inotropic agent to use.
Management of Hypothermia
Hypothermia, defined as a core temperature lower than
358C [44], should be anticipated and treated in all
drowning victims, including warm-water drowning. In
cold-water drowning, the clinical effects of hypothermia
are more rapid and more profound. Impaired cognitive
and muscle function are the first clinical signs to manifest.
The main principles of the management of hypothermia are to prevent a further fall in core temperature,
and establish a safe and steady rewarming rate while
maintaining cardiovascular stability [13]. The degree of
hypothermia can be classified as mild, moderate, or
severe. Classification helps to predict clinical findings

Pediatric drowning: current management strategies for immediate care

and assists in choosing the appropriate method of
rewarming (Table 3) [44]. The goal should be to rewarm
the patient 18C to 28C per hour to a range of 338C to
368C [19]. If the patient is hemodynamically stable,
aggressive rewarming above this range should be avoided,
because hyperthermia has been shown to worsen underlying cerebral injury in postcardiac arrest patients [46].
Passive and active rewarming techniques (Table 4) are
used based on the severity of hypothermia, cardiovascular
status, and available resources [44,45]. Core temperature
should be continuously monitored with a deep rectal or
esophageal probe, as standard thermometers may only
measure to 348C. When active external rewarming is
used, care must be taken to avoid iatrogenic burns. In
addition, these techniques should be applied primarily to
the trunk, but not the extremities. Rewarming solely the
extremities may result in an bafterdropQ in core body
temperature, secondary to cold blood from the periphery
recirculating centrally [44,45].
The management of hypothermia may be complicated
by cardiac dysrhythmias, particularly ventricular tachycardia and ventricular fibrillation. When core temperature falls below 308C, cardioactive medications and
defibrillation attempts are typically ineffective. At these
temperatures, defibrillation should be attempted only
once and CPR should be continued until the temperature
is above 308C. If ventricular fibrillation or ventricular
tachycardia persists at temperatures above 308C, defibrillation or cardioversion should then be performed [19].
As discussed above, in some cases of rapid severe
hypothermia in icy cold water, cerebral protection can
occur. Attempts should be made to warm the patient to
higher than 328C while continuing resuscitative efforts
for up to 30 minutes [55]. Extracorporeal rewarming can
be considered for victims with profound hypothermia or
Table 3

Classification of hypothermia.

Mild hypothermia (32-358C): The patient may have

depressed mental status and shivering as the only
manifestations of hypothermia. Passive rewarming is
usually sufficient.
Moderate hypothermia (28-328C): Thermoregulatory mechanisms (shivering) fail and an unresponsive state ensues
at temperatures b 308C. Cyanosis, tissue edema, and
rigidity develop. Respirations and pulses may be difficult
to detect. An electrocardiograph may show a J (Osborn)
wave (a distinctive deflection occurring at the QRS-ST
junction) in patients with moderate hypothermia [45].
Atrial fibrillation and other dysrhythmias may occur. Active
internal and/or active external rewarming should be used.
Severe hypothermia (b 288C): The patient may appear dead
with no detectable vital signs and with dilated, unresponsive pupils. Ventricular fibrillation (spontaneous or
induced by mechanical stimuli), extreme bradycardia,
and asystole may occur. Active internal and/or external
rewarming should be used.
Data from reference [44].

Table 4

Rewarming techniques.

Passive rewarming
Remove wet, cold clothing.
Use warm blankets to insulate the patient.
Active rewarming
Active external rewarming
Hot packsa
Heat lampsa
Forced-air external rewarmers [47]
Active internal rewarming
Warmed humidified oxygen (via mask or
endotracheal tube) [48,49]
Warmed intravenous fluid (shortest possible length of
intravenous tubing must to be used to assure efficacy
of this method) [48,49]
Warm saline lavage (gastric, peritoneal, rectal, and
mediastinal lavage) [50,51]
Peritoneal dialysis [52]
Extracorporeal membrane rewarming techniquesb:
extracorporeal membrane oxygenation/warming and
cardiopulmonary bypass [45,53]

These techniques must be applied cautiously (see text ).

Extracorporeal rewarming is the most efficient warming
method (18C to 28C per 5 minutes) and is the preferred
treatment for victims in cardiac arrest, those with persistent
cardiac instability, and those with a core temperature of less
than 258C, irrespective of cardiac rhythm. Data from
references [5,53,54].

cardiac arrest in the context of rapid immersion in cold

water. CPR should be initiated in all drowning victims,
regardless of initial core temperature, and should be
maintained until effective circulatory function has
returned. CPR and advanced life support interventions
may be terminated in patients who have been sufficiently
warmed (eg, core temperature N328C) and have failed to
respond to resuscitative care.
Consideration of Predisposing Events
Although drowning should be considered the primary
event, a number of predisposing conditions may impact
resuscitative management of the drowning victim. Seizures are the most common predisposing event in all age
groups [3,56]. Although more common in adults, cardiac
disorders such as long QT syndrome and associated
dysrhythmias may also be responsible for drowning in
children. Long QT syndromes should be specifically
considered in unexplained drowning during swimming
because exertion, cold-water exposure, voluntary breath
holding, and face immersion appear to be arrhythmogenic triggers [57]. Postmortem gene testing is available
for family members and may be lifesaving [58].
Unintentional and intentional traumatic injuries (cervical spine, head, and multisystem) are sometimes
associated with drowning and may not always be readily recognizable secondary to hypothermia and altered
mental status. Early consultation with the trauma service
should be considered. A 22-year cohort study of drown-

N.S. Zuckerbraun, R.A. Saladino

ing victims in Washington State found the prevalence
of cervical spine injury to be low (11/2244, 0.49%) [32].
All cervical spineinjured victims were older than 15
years, had high-impact mechanisms (diving, falls from
heights, or motor vehicle crashes) in open bodies of
water, and had physical signs of severe injury (death at
the scene or unresponsive upon arrival in the ED). Use of
cervical spine immobilization should be based on the
mechanism of injury and clinical status of the victim.
Preadolescents and adolescents are also at risk for
intoxication, secondary to alcohol and other drugs that
impair judgment [3].
Emergency Department Diagnostic Evaluation
Minimal laboratory and radiographic evaluations are
needed for drowning victims who are alert, spontaneously
breathing, and without respiratory symptoms. For symptomatic patients, the most useful tests include blood
glucose, arterial blood gas, chest radiography, and electrocardiography. Of note, serial arterial blood gas measurements can be useful because a declining Pao2 is a sign of
impending ARDS. Regardless of water type (freshwater vs
saltwater), electrolyte and hematocrit levels are rarely
abnormal [8]. However, patients who are hypothermic or
have had significant hypoxic events should have baseline
renal and hematologic functions measured. Urine or
blood screens for drugs of abuse should be considered
for preadolescent and adolescent victims. Finally, patients
with known or suspected blunt trauma will require
additional laboratory and radiographic imaging studies
as a part of their trauma assessment.
Preventing Secondary Brain Injury
The most common cause of death and disability in
hospitalized drowning victims is posthypoxic encephalopathy. Thus, resuscitating the brain and preventing
further neurological injury is imperative in early management of these patients [8]. To date, though, supportive
data regarding effective cerebral resuscitation therapies are
limited. ED management should focus on preventing
hypoxia, hypercapnia, and hyperthermia, all known to
exacerbate neurological damage [46]. Avoiding further
hypoxia is accomplished by early airway control, positivepressure ventilation, and measures to prevent aspiration
(tracheal intubation and gastric decompression with an
orogastric tube). To prevent hyperthermia, the victims
temperature should be closely monitored, and in hypothermic patients, active rewarming should be discontinued
at 338C to 368C. In drowning victims, cerebral and
pulmonary insults often must be managed concomitantly.
Ventilation strategies for the patient with acute lung injury
(allowing permissive hypercapnia) may not be appropriate
for the patient with brain injury for which achieving
normocapnia or mild hypocapnia is often desired.
Reduction of increased intracranial pressure has not
been proved an effective cerebroprotective strategy in the

management of drowning victims [8,59-61]. Monitoring

for the development of cerebral edema should take place
in an ICU setting. Although a recent review by Bierens
and colleagues recommends consideration of induced
hypothermia in the treatment of drowning victims who
remain comatose after restoration of spontaneous circulation [5] and current data suggest that it may have
use in adults with spontaneous return of circulation
after cardiac arrest [62,63], there are no current data to
support its use in children.

Prophylaxis Against Infection

Pneumonia and sepsis may complicate the clinical course
of drowning victims, but the routine use of antibiotics is
not recommended, excepting only exposure to grossly
contaminated water (eg, sewage) [8,64]. Antibiotic
therapy is instituted at the onset of signs of infection,
and therefore, is not an element in the acute management
of drowning [8].
Disposition from the ED includes discharge home,
hospitalization on a monitored inpatient unit, or admission to an ICU. This decision is based upon consideration
of the history of the drowning event, physiological status,
and the results of diagnostic testing as outlined above. All
drowning victims should be observed for a minimum
time of 6 to 8 hours [40]. Admission to a monitored
inpatient unit is recommended for those patients who
sustained a significant hypoxic exposure (submerged
more than 1 minute, experienced apnea or cyanosis, or
required pulmonary resuscitation) or those who after the
observation period have a persistent oxygen requirement
or remain symptomatic [8,40]. Symptoms of aspiration
include cough, tachypnea, chest pain, and fever [19].
Admission to the ICU should be considered for patients
who required pulmonary or cardiac resuscitation, experienced moderate to severe hypothermia, or have an
abnormal chest radiograph or arterial blood gas [8].

Prevention is the key link in the chain of survival [40]. A
recent review of unintentional drowning deaths in the
United States found that 78% of drowning deaths among
infants were in bathtubs. Of drowning injuries in children
1 to 4 years, 56% were in artificial pools, and among
those occurring in children older than 5 years, 63%
occurred in fresh bodies of water [65]. Most pool
drowning episodes occurred in the childs own home.
The use of 4-sided pool fencing has been shown to reduce
the incidence of drowning [66]. Other preventative
measures include water safety training, constant close
parental/adult supervision of children near water, and
safe water recreation including avoidance of alcohol and
use of properly fitted personal flotation devices [8].

Pediatric drowning: current management strategies for immediate care

The immediate care of drowning victims is challenging
because of unique pathophysiological mechanisms and
complex management issues. Current resuscitation strategies focus on restoring oxygenation and perfusion and
preventing secondary pulmonary and neurological
injury. Hypothermic patients should be rewarmed to
more than 328C, recognizing that rewarming may be
difficult in the absence of normal circulation. Extracorporeal rewarming can be considered for victims with
profound hypothermia or cardiac arrest in the context of
rapid immersion in cold waters.

1. Peden MM, McGee K. The epidemiology of drowning worldwide. Inj
Control Saf Promot 2003;10:19529.
2. Nonfatal and fatal drownings in recreational water settings United
States, 2001-2002. MMWR Morb Mortal Wkly Rep 2004;53:447252.
3. Quan L, Cummings P. Characteristics of drowning by different age
groups. Inj Prev 2003;9:16328.
4. Idris AH, Berg RA, Bierens J, et al. Recommended guidelines for
uniform reporting of data from drowning: the bUtstein styleQ.
Resuscitation 2003;59:45257.
5. Bierens JJ, Knape JT, Gelissen HP. Drowning. Curr Opin Crit Care
6. Bierens JJ, editor. Handbook on drowning. The Netherlands: Springer;
7. Modell JH, Bellefleur M, Davis JH. Drowning without aspiration:
is this an appropriate diagnosis? J Forensic Sci 1999;44:1119223.
8. Orlowski JP, Szpilman D. Drowning: rescue, resuscitation, and
reanimation. Pediatr Clin North Am 2001;48:627246.
9. Halmalgyi DF. Ventilation and circulation after fluid aspiration. J Appl
Physiol 1966;16:681296.
10. Giammona ST, Modell JH. Drowning by total immersion: effects on
pulmonary surfactant of distilled water, isotonic saline, and sea water.
Am J Dis Child 1967;114:61226.
11. Modell JH, Gaub M, Moya F, et al. Physiologic effects of near
drowning with chlorinated fresh water, distilled water and isotonic
saline. Anesthesiology 1966;27:33241.
12. Modell JH, Davis JH. Electrolyte changes in human drowning victims.
Anesthesiology 1969;30:414220.
13. Giesbrecht GG. Emergency treatment of hypothermia. Emerg Med
(Fremantle) 2001;13:9216.
14. Tipton MJ. The initial responses to cold-water immersion in man. Clin
Sci (Lond) 1989;77:58128.
15. Bolte RG, Black PG, Bowers RS, et al. The use of extracorporeal
rewarming in a child submerged for 66 minutes. JAMA
16. Siebke H, Rod T, Breivik H, Link B. Survival after 40 minutes
submersion without cerebral sequelae. Lancet 1975;1:127527.
17. Thalmann M, Trampitsch E, Haberfellner N, et al. Resuscitation in near
drowning with extracorporeal membrane oxygenation. Ann Thorac
Surg 2001;72:60728.
18. Gooden BA. Why some people do not drown: hypothermia versus the
diving response. Med J Aust 1922;157:629232.
19. Golden FS, Tipton MJ, Scott RC. Immersion, near-drowning and
drowning. Br J Anaesth 1997;79:214225.
20. Bell TS, Ellenberg L, McComb JG. Neuropsychological outcome after
severe pediatric near-drowning. Neurosurgery 1985;17:60428.
21. Graf WD, Cummings P, Quan L, et al. Predicting outcome in pediatric
submersion victims. Ann Emerg Med 1995;26:31229.
22. Orlowski JP. Prognostic factors in pediatric cases of drowning and
near-drowning. JACEP 1979;8:17629.

23. Bierens JJ, van der Velde EA, van Berkel M, van Zanten JJ.
Submersion in The Netherlands: prognostic indicators and results of
resuscitation. Ann Emerg Med 1990;19:139025.
24. Quan L, Wentz KR, Gore EJ, Copass MK. Outcome and predictors of
outcome in pediatric submersion victims receiving prehospital care in
King County, Washington. Pediatrics 1990;86:586293.
25. Nichter MA, Everett PB. Childhood near-drowning: is cardiopulmonary resuscitation always indicated? Crit Care Med 1989;17:99325.
26. Petersen B. Morbidity of childhood near-drowning. Pediatrics
27. Lavelle JM, Shaw KN. Near drowning: is emergency department
cardiopulmonary resuscitation or intensive care unit cerebral resuscitation indicated? Crit Care Med 1993;21:368273.
28. Allman FD, Nelson WB, Pacentine GA, McComb G. Outcome
following cardiopulmonary resuscitation in severe pediatric neardrowning. Am J Dis Child 1986;140:57125.
29. Christensen DW, Jansen P, Perkin RM. Outcome and acute care
hospital costs after warm water near drowning in children. Pediatrics
30. Orlowski JP. Drowning, near-drowning, and ice-water submersions.
Pediatr Clin North Am 1987;34:75292.
31. Biggart MJ, Bohn DJ. Effect of hypothermia and cardiac arrest on
outcome of near-drowning accidents in children. J Pediatr
32. Watson RS, Cummings P, Quan L, et al. Cervical spine injuries among
submersion victims. J Trauma 2001;51:658262.
33. Rosen P, Stoto M, Harley J. The use of the Heimlich maneuver in near
drowning: Institute of Medicine report. J Emerg Med 1995;13:
34. Orlowski JP, Szpilman D. Drowning: rescue, resuscitation, and
reanimation. Pediatr Clin North Am 2001;48:627246.
35. Harries M. Near drowning. BMJ 2003;327:133628.
36. Suominen PK, Korpela RE, Silfvast TG, Olkkola KT. Does water
temperature affect outcome of nearly drowned children. Resuscitation
37. Causey AL, Tilelli JA, Swanson ME. Predicting discharge in
uncomplicated near-drowning. Am J Emerg Med 2000;18:9211.
38. Pepe PE, Wigginton JG, Mann DM, et al. Prospective, decade-long,
population-based study of pediatric drowning related incidents. Acad
Emerg Med 2002;9:516227.
39. Goh SH, Low BY. Drowning and near-drowningsome lessons
learned. Ann Acad Med Singapore 1999;28:18328.
40. Quan L. Near-drowning. Pediatr Rev 1999;20:255260.
41. Szpilman D. Near-drowning and drowning classification: a proposal to
stratify mortality based on the analysis of 1,831 cases. Chest
42. Gerardi MJ, Sacchetti AD, Cantor RM, et al. Rapid-sequence
intubation of the pediatric patient. Ann Emerg Med 1996;28:55274.
43. Lucking SE, Pollack MM, Fields AI. Shock following generalized
hypoxic-ischemic injury in previously healthy infants and children.
J Pediatr 1986;108:359264.
44. Danzl DF, Pozos RS. Accidental hypothermia. N Engl J Med
45. Biem J, Koehncke N, Classen D, Dosman J. Out of the cold:
management of hypothermia and frostbite. CMAJ 2003;168:305211.
46. Hickey RW, Kochanek PM, Ferimer H, et al. Hypothermia and
hyperthermia in children after resuscitation from cardiac arrest.
Pediatrics 2000;106:118222.
47. Steele MT, Nelson MJ, Sessler DI, et al. Forced air speeds rewarming
in accidental hypothermia. Ann Emerg Med 1996;27:479284.
48. Weinberg AD. The role of inhalation rewarming in the early management of hypothermia. Resuscitation 1998;36:10124.
49. Shields CP, Sixsmith DM. Treatment of moderate-to-severe hypothermia in an urban setting. Ann Emerg Med 1990;19:109327.
50. Hall KN, Syverud SA. Closed thoracic cavity lavage in the treatment
of severe hypothermia in human beings. Ann Emerg Med 1990;

51. Kristensen G, Gravesen H, Benveniste D, Jordening H. An oesophageal
thermal tube for rewarming in hypothermia. Acta Anaesthesiol Scand
52. Troelsen S, Rybro L, Knudsen F. Profound accidental hypothermia
treated with peritoneal dialysis. Scand J Urol Nephrol 1986;20:22124.
53. Walpoth BH, Walpoth-Aslan BN, Mattle HP, et al. Outcome of
survivors of accidental deep hypothermia and circulatory arrest treated
with extracorporeal blood warming. N Engl J Med 1997;337:150025.
54. Vretenar DF, Urschel JD, Parrott JC, Unruh HW. Cardiopulmonary
bypass resuscitation for accidental hypothermia. Ann Thorac Surg
55. Hodge D. Environmental emergencies. In: Gausche-Hill M, editor.
Advanced Pediatric Life Support: The Pediatric Emergency Medicine
Resource. 4th ed. Sudbury (Mass): Jones & Bartlett; 2004. p. 220233.
56. Diekema DS, Quan L, Holt VL. Epilepsy as a risk factor for
submersion injury in children. Pediatrics 1993;91:61226.
57. Ackerman MJ, Tester DJ, Porter CJ. Swimming, a gene-specific
arrhythmogenic trigger for inherited long QT syndrome. Mayo Clin
Proc 1999;74:1088294.
58. Ackerman MJ, Schroeder JJ, Berry R, et al. A novel mutation in
KVLQT1 is the molecular basis of inherited long QT syndrome
in a near-drowning patients family. Pediatr Res 1998;44:148253.

N.S. Zuckerbraun, R.A. Saladino

59. Sarnaik AP, Preston G, Lieh-Lai M, Eisenbrey AB. Intracranial
pressure and cerebral perfusion pressure in near-drowning. Crit Care
Med 1985;13:22427.
60. Frewen TC, Sumabat WO, Han VK, et al. Cerebral resuscitation
therapy in pediatric near-drowning. J Pediatr 1985;106:61527.
61. Bohn DJ, Biggar WD, Smith CR, et al. Influence of hypothermia,
barbiturate therapy, and intracranial pressure monitoring on morbidity and mortality after near-drowning. Crit Care Med 1986;
62. Bernard SA, Gray TW, Buist MD, et al. Treatment of comatose
survivors of out-of-hospital cardiac arrest with induced hypothermia.
N Engl J Med 2002;346:557263.
63. The Hypothermia After Cardiac Arrest Study Group. Mild therapeutic
hypothermia to improve the neurologic outcome after cardiac arrest.
N Engl J Med 2002;346:549256.
64. Modell JH, Graves SA, Ketover A. Clinical course of 91 consecutive
near-drowning victims. Chest 1976;70:23128.
65. Brenner RA, Trumble AC, Smith GS, et al. Where children drown,
United States, 1995. Pediatrics 2001;108:8529.
66. Thompson DC, Rivara FP. Pool fencing for preventing drowning in
children. Cochrane Database Syst Rev 2000; CD001047.