General: The process of experiencing respiratory impairment from submersion/immersion in liquid. There are three outcomes:
- Drowning without morbidity.
- Drowning with morbidity.
- Drowning with death.
- Terms like near-drowning, dry-drowning, etc. are no longer used.
Epidemiology: #1 cause of death in 1-4 year olds.
Pathophysiology: breathholding followed by involuntary gasps > aspiration and laryngospasm > loss of consciousness > active aspiration leading to loss of surfactant, atelectasis, V/Q mismatch and ARDS. Generally, there is respiratory arrest and tachycardia followed by bradycardia, PEA and asystole.
Clinical: Think about what caused the drowning; Trauma v. intoxication v. seizure v. cardiac arrhythmia/ syncope.
- if unconscious but breathing, place in lateral decubitus position.
- if unconscious and not breathing, administer rescue breaths.
- if unconscious, not breathing and without pulses use usual BLS and ACLS with a emphasis and "ABC's" instead of "CAB's".
- Heimlich Maneuver is not indicated.
- HPI and Exam + CXR + observation x 8 hours and repeat CXR prior to discharge; consider EKG to evaluate for long QTc or other cardiac etiology as source.
- Mild - asymptomatic patient with a normal exam, normal SaO2 and normal CXR can be discharged.
- Moderate - symptomatic patient or abnormal SaO2; admit for observation.
- Severe - requiring BiPAP or intubation; lung protective strategy, ARDS management, ECMO; ICU.
- Manage hypothermia and consider C-Collar if evidence of trauma or traumatic mechanism.
- No prophylactic antibiotics are indicated unless drowning occured in very dirty water.
- Provide infectious return to ER precautions.
- No steroids are indicated
Szpilman, D., Bierens, J. J., Handley, A. J., & Orlowski, J. P. (2012). Drowning. N Engl J Med, 366(22), 2102-2110. doi: 10.1056/NEJMra1013317