NONFATAL

DROWNING
 DROWNING AND SUBMERSION INJURY

 The process of experiencing respiratory impairment from

submersion/immersion in liquid (World Congress of Drowning definition)
 The term drowning does not imply the final outcome—death or survival
• The outcome should be denoted as fatal or nonfatal drowning
 School-age children are at increased risk of drowning in natural bodies of
water such as lakes, ponds, rivers, and canals.

Source: Nelson Textbook of Pediatrics 21st Edition

 DROWNING: PATHOPHYSIOLOGY

 Drowning victims drown silently and do not signal distress or call for help.
 Vocalization is precluded by efforts to achieve maximal lung volume to
keep the head above the water or by aspiration leading to laryngospasm.
 Young children can struggle for only 10-20 sec and adolescents for 30-60
sec before final submersion.
 A swimmer in distress is vertical in the water, pumping the arms up and
down. This splashing or efforts to breathe are often misconstrued by nearby
persons as merely playing in the water, until the victim sinks.

Source: Nelson Textbook of Pediatrics 21st Edition

 DROWNING: PATHOPHYSIOLOGY

Period of panic

Loss of the normal breathing pattern, breath-holding, air

hunger, and a struggle by the victim to stay above the water

Reflex inspiratory efforts

Aspiration or reflex laryngospasm

Hypoxemia

Source: Drowning (submersion injuries). UpToDate

 DROWNING: PATHOPHYSIOLOGY
SALT WATER FRESH WATER  Decreased lung
DROWNING DROWNING compliance
 Ventilation-
perfusion
Aspirated hypotonic fluid mismatching
Hypertonicity of salt water rapidly passing through the
caused plasma to be drawn  Intrapulmonary
into the pulmonary lungs and into the shunting
interstitium and alveoli intravascular 
leading to massive compartment, leading to
Hypoxemia
volume overload and
pulmonary edema and dilutional effects on serum 
hypertonic serum. electrolytes. Diffuse organ
dysfunction

>11 mL/kg of body weight  Blood volume changes

> 22mL/kg  Electrolyte changes take place

Source: Drowning (submersion injuries). UpToDate

 DROWNING: END ORGAN EFFECTS
PULMONARY
• Fluid aspiration results in varying degrees of hypoxemia
• Both salt water and freshwater wash out surfactant, often producing
noncardiogenic pulmonary edema and the acute respiratory distress syndrome
(ARDS)
• Pulmonary insufficiency can develop insidiously or rapidly; signs and symptoms
include shortness of breath, crackles, and wheezing.
• The chest radiograph or computed tomography at presentation can vary from
normal to localized, perihilar, or diffuse pulmonary edema

NEUROLOGIC
• Hypoxemia and ischemia cause neuronal damage, which can produce cerebral
edema and elevations in intracranial pressure

Source: Drowning (submersion injuries). UpToDate

 DROWNING: END ORGAN EFFECTS
CARDIOVASCULAR
• Arrhythmias secondary to hypothermia and hypoxemia are often observed: Sinus
tachycardia, sinus bradycardia, and atrial fibrillation

ACID-BASE AND ELECTROLYTES

• A metabolic and/or respiratory acidosis is often observed.
• Significant electrolyte imbalances generally do not occur in nonfatal drowning
survivors except those submerged in unusual media (Dead Sea)

RENAL
• Renal failure due to acute tubular necrosis resulting from hypoxemia, shock,
hemoglobinuria, or myoglobinuria

COAGULATION
• Hemolysis and coagulopathy are rare
Source: Drowning (submersion injuries). UpToDate
 DROWNING: MANAGEMENT

PREHOSPITAL CARE AND ACUTE INTERVENTIONS

• Rescue and immediate resuscitation by bystanders improves the outcome of
drowning victims
• The need for CPR is determined as soon as possible without compromising the
safety of the rescuer or delaying the removal of the victim from the water.
• Ventilation is generally considered the most important initial treatment for victims
of submersion injury and rescue breathing should begin as soon as the rescuer
reaches shallow water or astable surface.
• If the patient does not respond to the delivery of two rescue breaths that make the
chest rise, the rescuer should immediately begin performing cardiopulmonary
resuscitation(CPR).
• The Heimlich maneuver or other postural drainage techniques to remove water
from the lungs are of no proven value, and rescue breathing should not be delayed
in order to perform these maneuvers.

Source: Drowning (submersion injuries). UpToDate

 DROWNING: MANAGEMENT

EMERGENCY DEPARTMENT MANAGEMENT

• In the symptomatic patient, indications for intubation include the
following:
 Signs of neurologic deterioration or inability to protect the airway
 Inability to maintain a PaO2 above 60 mmHg or oxygen saturation
(SpO2) above 90 percent despite use of a high-flow oxygen-delivery
system or noninvasive ventilation
• In symptomatic patients who do not require immediate intubation,
supplemental oxygen should be provided to maintain the SpO2 above 94
percent.

Source: Drowning (submersion injuries). UpToDate

 DROWNING: MANAGEMENT

INPATIENT MANAGEMENT
• Symptomatic patients require hospitalization for supportive care and treatment of
organ-specific complications.

Source: Drowning (submersion injuries). UpToDate