Drowning Incidents

Key Points

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Drowning is defined as the process of experiencing respiratory impairment from submersion/immersion in liquid.
Consider that drowning may have resulted from a primary medical or traumatic insult.
Treatment is largely supportive and stabilizing.
Patients who present and remain asymptomatic for 6 hours may be discharged from the emergency department.

Introduction

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The term “drowning incident” encompasses a variety of clinical entities. A 2005 report from the World Health Organization recommends that the term “near-drowning” be abandoned and instead to use the term “drowning incident” with a description of the outcome (death, morbidity, no morbidity). Drowning itself should be described as “the process of experiencing respiratory impairment from submersion/immersion in liquid.”

Nonfatal incidents are more common than fatal incidents; in 2009, 6,519 nonfatal drowning incidents were reported, whereas 4,211 incidents resulted in death. One estimate states that there is 1 death per 13 drowning incidents, suggesting that underreporting likely occurs. Children make up the majority of fatal incidents, with peak ages of 1–4 years and seasonal variability. Freshwater drowning is more common than saltwater, with bathtubs and pool as the most common locations. Accomplished swimmers make up 35% of deaths.

Clinical Presentation

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Wide variability exists in the presentation of drowning-related injury, both in terms of time of submersion/immersion as well as how the patient is found. Children are often found face-down in small depths of water (bathtub, 5-gallon bucket, toilet). Patients may fall or jump into a body of water and their distress is immediately noted or alternatively may be found floating or at the bottom of a lake or pool after a period of time without being seen.

Symptoms also vary. Patients may be asymptomatic or may present with severe illness. Clinical effects of the submersion/immersion event itself most often manifest as respiratory abnormalities including hypoxia, tachypnea, or abnormal lung sounds. Depending on the season, patients may be hypothermic. At severe levels of illness, cardiac dysrhythmias may occur, and mental status can change. Most, if not all, drownings involve aspiration. “Dry drowning” (hypoxia from laryngospasm without aspiration) is thought to be extremely rare and physiologically difficult to explain.

History

Drowned patients should be initially evaluated like major trauma patients, with attention to the airway, breathing, and circulation (ABCs) and rapid assessment of an AMPLE history. When evaluating a patient who has experienced a drowning incident, the following information must be obtained:

Events surrounding the incident (How did they end up in the water? Did they sustain any trauma?)
Temperature of the water and air
Length of time in the water, length of time underwater
Status on retrieval from the water (respiratory, mental status, cardiovascular, color)
Was any immediate treatment needed?
Current symptoms?

It will also be important to consider the potential of suicide; the medical status of the patient will dictate how urgently this assessment is needed.