Drowning Prevention

• According to the World Health Organization, drowning is defined as "...the process of experiencing respiratory impairment from submersion/immersion in liquid. "While there may be dry, wet, or "near" drowning, depending upon whether some water is inhaled into the lungs, there is no clinical difference in how the victim is treated or whether the final outcome is good or bad. (The term "near" drowning used to refer to a victim who did not die, however, this term is no longer widely used.)
• The causes of drowning are accidental and usually preventable. The accident often occurs within a short distance of safety like in a bathtub or close to shore.
• Other factors that contribute to drowning include
  • alcohol
  • trauma (injuries from diving into shallow water)
  • medical emergencies (seizures, heart attacks, hypoglycemic or diabetic coma, stroke)
• Symptoms of drowning may not be easily seen by bystanders. The victim may be expending all their energy keeping their head above water and may not be able to shout for help. If they breathe in water (aspirate), their vocal cords may go into spasm; this prevents the person from shouting for help. There is usually very little thrashing and the victim is often found floating or at the bottom of the pool, tub, or body of water.
• Treatment for the drowning victim begins by deciding if the victim is awake, and if not, if they are breathing. This is one of times when rescue breathing is required to help revive the victim. (Basic life support otherwise recommends hands only CPR). If there has been trauma, like diving into shallow water, there is risk of spinal cord injury and it is also important to protect the neck from moving. All drowning victims should be transported to a hospital for care. Activating emergency services by calling 911 is appropriate.
• Tips to prevent drowning are
  • Infants should never be left in the bathtub alone, even for a few seconds, and the caregiver should not be distracted by other tasks or chores.
  • Toddlers and small children should not be unattended near backyard or neighborhood pools.
  • Everybody should learn how to swim and the buddy system is important for every age. Never swim alone.
  • When in natural water, like rivers and lakes, it is important to know the depth of the water, its temperature, and whether any dangerous currents exist.
  • While enjoying watercraft, boats, kayaks, SUPs, etc. on lakes, rivers, or in the ocean; floatation devices should be available to every person on the vessel. Check the "A Boater's Guide to the Federal Requirements for Recreational Boats."
  • Boating while intoxicated (BWI) is against the federal law. Alcohol should not be used in excess when swimming or boating and its use is commonly associated with teenage drowning deaths.
• Tips for recognizing a person who is drowning are
  • It may be difficult to recognize a person having trouble in the water.
  • Often there is no thrashing, and the event may appear very quiet.
  • The victim may bob in the water in an uncoordinated way, with their head back and mouth open.
  • There may be weak and ineffective attempts at swimming.
• The outlook for a drowning victim is excellent if they arrive in the hospital alert and breathing on their own. For patients in a coma, the prognosis depends upon how long they were underwater and how long it took to start artificial respiration and breathing. The prognosis also depends upon the cleanliness and temperature of the water.

Who is likely to drown, when, and where?

• The World Health Organization estimates that there are 359,000 drowning deaths worldwide each year. In the Unites States, the latest yearly statistics from the CDC reported more than 38,000 people had died from drowning.
• Statistics are unreliable in regard to those who survive a drowning episode. Many countries do not keep records of non-fatal drownings ("near" drowning)
• Drowning is the third leading cause of accidental death in the United States. It is the second leading cause of accidental death in school-age children, and the number one cause of death in preschoolers.
• More than half of drowning deaths occur in swimming pools.
• One-quarter to one-third of drowning victims have had swimming lessons.
• Infants younger one year of age usually drown in bathtubs because they are not coordinated or strong enough to lift themselves or their heads out of the water.
• Children aged 1-4 most often drown in swimming pools.
• As children age, the percentage that drown in natural water such as rivers, lakes, ponds, and oceans begins to increase. For those older than age 15, 65% of drownings occur in natural water.
• Alcohol is a factor in up to half of adolescent and adult drowning deaths.

Mammalian Dive Reflex

Drowning suffocation causes a lack of oxygen, resulting in death in only a few minutes. An exception to this rule appears in victims who have been suddenly and rapidly submerged into ice-cold water. Some of these victims have been reported to survive up to an hour underwater without any physical damage. This phenomenon is known as the mammalian dive reflex, which is activated when the face and body plunge into ice-cold water. The acute cooling results in the very quick slowing of body metabolism and diverts blood to the essential organs of the body, the heart, lungs, and brain. With very slow metabolism, the amount of residual oxygen in the blood stream may be enough to maintain basic organ function for many minutes.

The mammalian diving reflex is most well developed in children, and gradually decreases with age. The drowning victim may appear deceased since the heart may be beating so slowly that rescuers cannot count a heartbeat, and blood pressure may drop so low it cannot be detected. It is very important to begin resuscitation attempts in this situation and not presume that the victim is deceased.

The mammalian dive reflex situation does not apply to victims who have gradually cooled and have developed hypothermia or low body temperature.

Drowning is a silent killer. Victims may not be able to call for help because they are expending all of their energy trying to breathe or keep their head above water. When water is inhaled, the upper airway or larynx (voice box) may go into a spasm, making it difficult to cry for help.

Victims of drowning usually do not thrash in the water as often depicted on television or in the movies. Most victims are found floating or submerged in the water.

The drowning sequence

• The victim struggles to keep his or her head above the water
• After the head submerges or drops below the water surface, breath holding occurs
• When water enters the upper airways, it causes the larynx to go into spasm
• Most often the spasm relaxes, allowing water through the larynx into the bronchial tree and the lungs. Approximately 10% to 20% of drowning victims have persistent laryngeal spasm and no fluid is found in their lungs on autopsy.
• The brain stops functioning within just a few minutes without oxygen, and permanent damage occurs if there is no oxygen for more than six minutes.
• The heart muscle needs oxygen to function and deadly, irregular heart rhythms may occur with oxygen deprivation.
• Young victims in cold water drowning may be spared this sequence because of the mammalian diving reflex.

Signs of drowning

In real life, drowning doesn't look at all like it is depicted on television or in the movies. The victim does not flail and thrash in the water. Instead, drowning tends to be a deceptive quieter act, and victims tend to appear lethargic or are found unresponsive floating on the water, or submerged beneath it.

The drowning victim often is bobbing with their head tilted back just at the waterline and the mouth wide open. There are attempts to keep rolling on to the back. The respiratory effort may be rapid but is often shallow. The eyes tend to be wide open and may hold a sense of panic. If there is a swimming effort, it is weak and uncoordinated.

• In the drowning sequence, laryngeal spasm occurs by water entering the upper airways. In most drowning cases, the spasm relaxes and water enters the lungs. Historically, this was known as a wet drowning.
• In 10% to 20% of drowning cases, the laryngeal spasm does not relax and no water enters. This was known as dry drowning.
• It is now felt that there is no clinical difference between wet and dry drowning and the distinction does not affect patient treatment or outcome.

The following are drowning risks in infants and children:

• Lack of supervision in the bathtub or other body of water
• A swimming pool is a risk factor in itself. Children, who have drowned, usually have been out of sight for less than 5 minutes.
• Lack of life jackets (personal floatation devices) on boats. Pool toys are not a substitute for a "real" life jacket.
• Child abuse or neglect

The following are drowning risks in teenagers and adults:

• Alcohol consumption. Alcohol use is a factor in half of all teenage and adult drowning deaths.
• Inability to swim
• Medical emergency in the water. This includes victims who experience a heart attack, stroke or seizure in the water. It also includes open water drowning victims who sustain an animal bite or sting.
• Fatigue or exhaustion when swimming. The buddy system is meant to prevent drowning associated with unsupervised swimming or failing to follow water safety rules.
• Not appreciating the environment. This includes diving into shallow water and sustaining a head or neck injury, or falling into the water when walking on thin ice.
• Boating accidents
• Lack of life jackets (personal floatation devices or PFDs)
• Scuba diving accidents
• Suicide attempts

All drowning victims require an emergency 911 call.

Even though the majority of drowning victims are revived with first aid, all these victims require activation of the emergency medical services and evaluation by a health care professional. Complications of the drowning event may take time to develop; it may be hours before signs and symptoms to develop.

There are two main issues involved with the care of a drowning victim. The first is to stabilize the ABCs of resuscitation (airway, breathing, circulation) that might be compromised because of the drowning. The second is to look for a potential underlying medical condition that could have caused the drowning to occur.

The initial care is directed to stabilizing the victim's breathing, heartbeat, and blood pressure. Once this has occurred, the health care professional will look for common complications of drowning. These include decreased mental function because of lack of oxygen supply to the brain. Lack of oxygen also can damage heart muscle. Lung irritation and infection may occur from water aspirated or inhaled into the lungs. Kidney damage is a common complication in drowning, and may result in electrolyte abnormalities and acid-base disturbances in the body.

If there was an associated trauma, for example a diving injury or a boating accident, evaluation of the head and neck and other parts of the body may be required. Testing that may be ordered depends upon the situation that led to the drowning, the patient's status and any other underlying medical conditions.

The treatment for a possible drowning is a first aid emergency. Often, once the victim has been removed from the water, CPR may be necessary and emergency medical services should be activated (call 911).

In a drowning emergency, the sooner the victim is removed from the water and first aid is administered, the greater opportunity the victim has for surviving.

First aid for a drowning victim

The focus of the first aid for a drowning victim in the water is to get oxygen into the lungs. Depending upon the circumstances, if there is concern that a neck injury is a possibility (for example, a diving accident) care should be taken to minimize movement of the neck.

When assessing a drowning victim, the first steps for care follow the initial American Heart Association guidelines.

• Is the victim awake?
• Are they breathing on their own?
• Do they have a heartbeat?

Rescue breathing can begin in the water, but all other care requires that the victim be safely out of the water. If other people are available, send person to get help and call 911. Send another person to get an automated external defibrillator (AED).

If the victim is breathing, he or she should be placed on their side in the recovery position to prevent potential aspiration should vomiting occur (inhaling vomit into the lung).

If the victim is not breathing and has no pulse, begin cardiopulmonary resuscitation (CPR). This is one of the exceptions to the hands-only CPR guidelines. If possible, rescue breathing needs to be initiated in a possible drowning victim.

There are some controversies in medical research that potentially might confuse bystanders who are willing to help. It is important to remember that a drowning victim who is not breathing and does not have a pulse is effectively dead, and any attempts at helping are appropriate.

Recently, chest compression only resuscitation has been endorsed by the American Heart Association and the American College of Cardiology, and rescue breathing is not recommended. This is not the case with drowning, since the initial insult to the body is lack of oxygen. This requires providing oxygen to the victim as soon as possible. This is a different situation than a patient who collapses on dry land, usually has a heart rhythm disturbance and adequate oxygen levels are present in the blood for a few minutes.

It usually is recommended to start rewarming drowning victims by removing wet clothing and covering them in warm blankets. This is appropriate if the patient who has not lost their pulse, or has been resuscitated and is awake.

For a potential drowning victim who was administered CPR, and the pulse has returned, but is still not awake, keeping the patient cool may be appropriate.

More research is required to determine what new approaches might be applicable to effectively treat drowning victims.

Care for the drowning patient will depend upon the situation surrounding the event, and how they have responded to pre-hospital care. The initial approach will be to stabilize vital signs by addressing the ABCs (airway, breathing, and circulation) to make certain the patient is breathing, has a good heart beat and adequate blood pressure to circulate blood to the organs of the body.

If the drowning occurred because of an injury, those injuries need to be assessed at the same time the patient is being evaluated for the consequences and complications of drowning (injury to the brain, head, heart, and lungs).

If a medical illness caused the drowning (for example, a seizure or heart attack), then the underlying illness will need assessment and treatment.

Supportive care is often required for the lungs because they can become inflamed due to aspiration (inhalation) of water during the drowning process. Pneumonia and acute respiratory distress syndrome (ARDS) are potential complications.

Scuba diving events may require hyperbaric oxygen therapy should there be a potential risk of decompression illness.

Many drowning victims are awake and stable by the time they arrive in the emergency department. Depending upon the circumstances, these patients may be observed for a period of time and discharged home.

The need for follow up will depend upon the events leading up to the drowning, the resuscitation of the victim, the complications that arise from the drowning event, and other underlying medical conditions.

As with any accident, prevention is the key.

• Learning how to swim should be a priority for all children and for people of all ages.
• A home swimming pool should always be fenced and secure. Motion detectors may be helpful should the fence fail to keep out unsupervised children.
• When participating in water sports, the use of a personal floatation device (life jacket) is mandatory. Pool toys are not a substitute.
• Alcohol is a major contributor to drowning accidents. Water and alcohol don't mix.
• Never leave an infant unattended in a bath tub or near water.
• Never leave a child unattended near water, whether that is a swimming pool or natural water.

Know where you are swimming:

• Make certain the depth is at least 10 feet if you decide to dive into the water
• Know about the dangerous undercurrents and waves that occur in fresh or sea water
• Avoid dangerous marine animals such as jellyfish and fire coral
• Know the depth of ice before walking on it
• Never swim alone.
• Learn CPR

• Drowning victims who are alert and oriented when they arrive in the emergency department usually have an excellent chance for full recovery.
• If the patient is confused and unconscious, recovery depends on the length of time under water. With early rescue and treatment, full recovery is possible.
• The mammalian diving reflex is more commonly found in infants and children with slowing of body functions from icy water, increases the opportunity for recovery even after a long immersion. There is no guarantee that the mammalian reflex will occur. The patient who is comatose after a cold water drowning is unlikely to return to completely normal function.
• The younger and healthier the patient, the better the prognosis. The colder and cleaner the water, the better the prognosis.