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(Fatal Drowning; Nonfatal Drowning)
Drowning is respiratory impairment resulting from submersion in a liquid medium. It can be nonfatal (previously called near drowning) or fatal. Drowning results in hypoxia, which can damage multiple organs, including the lungs and brain. Treatment is supportive, including reversal of respiratory arrest and cardiac arrest, hypoxia, hypoventilation, and hypothermia.
Drowning is among the top 10 causes of mortality for children and young people worldwide. In the United States, drowning is the 10th most common cause of unintentional death. In 2013 in the US, drowning was the leading cause of injury mortality in children ages 1 to 4 yr and was second only to motor vehicle collisions for children ages 5 to 14 yr (1). Other groups at higher risk of drowning death include the following:
Children from African American, Native American, immigrant, or impoverished families (2)
Males (80% of victims over age 1 yr)
People who have used alcohol or sedatives
People with conditions that cause temporary incapacitation (eg, epilepsy (3), with a twenty times increased chance of drowning among children and adolescents)
People with a long QT syndrome (swimming can trigger arrhythmias that cause unexplained drowning in people with a long QT syndrome, particularly LQT1)
People who engage in dangerous underwater breath-holding behaviors (DUBBs)
Drowning is common in pools, hot tubs, and natural water settings, and, among infants and toddlers, in toilets, bathtubs, and buckets of water or cleaning fluids. About 4 times as many people are hospitalized for nonfatal drowning as die as a result of drowning.
Hypoxia is the major insult in drowning, affecting the brain, heart, and other tissues; respiratory arrest followed by cardiac arrest may occur. Brain hypoxia may cause cerebral edema and, occasionally, permanent neurologic sequelae. Generalized tissue hypoxia may cause metabolic acidosis. Immediate hypoxia results from aspiration of fluid or gastric contents, acute reflex laryngospasm (previously called dry drowning), or both. Lung injury due to aspiration or hypoxia itself may cause delayed hypoxia (previously called secondary drowning). Aspiration, especially with particulate matter or chemicals, may cause chemical pneumonitis or secondary bacterial pneumonia and may impair alveolar secretion of surfactant, resulting in patchy atelectasis. Extensive atelectasis may make the affected areas of the lungs stiff, noncompliant, and poorly ventilated, potentially causing respiratory failure with hypercapnia and respiratory acidosis. Perfusion of poorly ventilated areas of the lungs (V/Q mismatch) worsens hypoxia. Alveolar hypoxia may cause noncardiogenic pulmonary edema.
Exposure to cold water induces systemic hypothermia, which can be a significant problem. However, hypothermia can be protective by stimulating the mammalian diving reflex, slowing the heart rate, and constricting the peripheral arteries, shunting oxygenated blood away from the extremities and the gut to the heart and brain. Also, hypothermia decreases the oxygen needs of tissues, possibly prolonging survival and delaying the onset of hypoxic tissue damage. The diving reflex and overall clinically protective effects of cold water are usually greatest in young children.
Laryngospasm often limits the volume of fluid aspirated. Distinction between freshwater and seawater drowning was once considered important due to the potential electrolyte shifts, hemolysis, and fluid compartment shifting that possibly could occur. However, studies have shown that in most patients, too little liquid is aspirated to have these effects. Aspiration can lead to pneumonia, sometimes with anaerobic or fungal pathogens, and pulmonary edema.
Dangerous underwater breath-holding behaviors (DUBBs) are practiced mostly by healthy young men (often good swimmers) trying to prolong their capacity to remain submerged. There are 3 described types of DUBB:
Intentional hyperventilation—blowing off carbon dioxide before submerged swimming, thereby delaying central hypercarbic ventilatory responses
Hypoxic training—extending capacity for underwater distance swimming or breath-holding
Static apnea—breath-holding for as long as possible while submerged and motionless, including as a game
In DUBB, while submerged, hypoxia occurs first, followed by loss of consciousness (hypoxic blackout, breath-hold blackout) and then drowning.
Centers for Disease Control and Prevention. National Center for Injury Prevention and Control: WISQARS (Web-based Injury Statistics Query and Reporting System) [database]. The cost on injury in the U.S. Accessed September 6, 2017.
Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Racial/Ethnic disparities in fatal unintentional drowning among persons aged <=29 years – United States 1999-2010. MMWR 63:421-426, 2014.
Sillanpää M, Shinnar S. SUDEP and other causes of mortality in childhood-onset epilepsy. Epilepsy Behav 28(2):249-255, 2013. doi: 10.1016/j.yebeh.2013.04.016.
During drowning, panic and air hunger occur. Children who are unable to swim may become submerged in < 1 min, more rapidly than adults. After rescue, anxiety, vomiting, wheezing, and altered consciousness are common. Patients may have respiratory failure with tachypnea, intercostal retractions, or cyanosis. Respiratory symptoms are sometimes delayed for up to 6 hours after submersion. Patients may have symptoms due to injuries or exacerbations of underlying disorders.
For concomitant injuries, imaging studies as indicated
Pulse oximetry and, if results are abnormal or if respiratory symptoms and signs are present, ABG and chest x-ray
Core temperature measurement to rule out hypothermia
Evaluation for causative or contributing disorders (eg, seizure, hypoglycemia, MI, intoxication, injury)
Ongoing monitoring as indicated for delayed respiratory complications
Most people are found in or near water, making the diagnosis obvious clinically. Resuscitation, if indicated, should precede completion of the diagnostic assessment. Cervical spine injury is considered, and the spine is immobilized in patients who have altered consciousness or whose mechanism of injury involves diving or trauma. Secondary head injury and conditions that may have contributed to drowning (eg, hypoglycemia, MI, stroke, intoxication, arrhythmia) are considered.
All patients undergo assessment of oxygenation by oximetry or, if results are abnormal or if there are respiratory symptoms or signs, ABG and chest x-ray. Because respiratory symptoms may be delayed, even asymptomatic patients are transported to the hospital and observed for several hours.
In patients with symptoms or a history of prolonged submersion, core body temperature is measured, ECG and serum electrolytes are obtained, and continuous oximetry and cardiac monitoring are done. Patients with possible cervical spine injury undergo cervical spine imaging.
Patients with altered consciousness undergo head CT. Any other suspected predisposing or secondary conditions are evaluated with appropriate testing (eg, fingerstick glucose for hypoglycemia, ECG for MI, cardiac monitoring for arrhythmia, evaluation for intoxication). Patients who drown without apparent risk factors are evaluated for long QT syndrome and torsades de points ventricular tachycardia. In patients with pulmonary infiltrates, bacterial or fungal pneumonia is differentiated from chemical pneumonitis and pulmonary edema using blood cultures and sputum Gram stain and culture. If indicated (eg, bacterial or fungal pneumonia is suspected but the pathogen cannot be otherwise identified), bronchial washings are obtained for testing, including culture.
Factors that increase the chance of surviving submersion without permanent injury include the following:
Survival may be possible in cold water submersion that lasts > 1 h, especially among children; thus, even patients with prolonged submersion are vigorously resuscitated.
Treatment aims to correct cardiac arrest, hypoxia, hypoventilation, hypothermia, and other physiologic insults.
In apneic patients, rescue breathing is started immediately—in the water, if necessary. If spinal immobilization is necessary, it is done in a neutral position, and rescue breathing is done using a jaw thrust without head tilt or chin lift. Emergency medical services are called. If the patient does not respond to rescue breathing, cardiac compression is started, followed by advanced cardiac life support. Although the 2015 American Heart Association Guidelines for CPR recommend chest compressions as the first step in resuscitation of patients in cardiac arrest, drowning is an exception to this recommendation. Attempts to remove water from the lungs are avoided because they delay ventilation and increase the risk of vomiting. Oxygenation, endotracheal intubation, or both should proceed as soon as possible. Hypothermic patients are warmed as soon as possible. Immediate treatment measures may include removing clothing, drying, and insulation.
All hypoxic or moderately symptomatic patients are hospitalized. In the hospital, supportive treatment continues, aimed primarily at achieving acceptable arterial oxygen and carbon dioxide levels. Mechanical ventilation may be necessary. Patients are initially given 100% oxygen; the concentration is titrated lower based on ABG results. Positive end-expiratory pressure ventilation is usually necessary to help expand or maintain patency of alveoli to maintain adequate oxygenation. Pulmonary support may be necessary for hours or days. If adequate oxygenation is impossible despite maximizing ventilator settings, extracorporeal membrane oxygenation may be considered. Nebulized β2-agonists may help reduce bronchospasm and wheezing. Surfactant administration may be helpful in critically ill patients with significant lung compliance issues after drowning, although no clinical trials have addressed this. Patients with pneumonia are treated with antibiotics targeting organisms identified or suspected based on results of sputum testing and/or blood cultures. Corticosteroids are not used. Core body temperature is monitored, and hypothermia is treated.
Fluids or electrolytes are rarely required to correct significant electrolyte imbalances. Fluid restriction is rarely indicated, unless pulmonary or cerebral edema occurs. Concomitant injuries and disorders (eg, head or cervical injury, seizure, arrhythmia) may also require treatment.
Patients with mild symptoms, clear lungs, and normal oxygenation should be observed in the emergency department for at least 6 hours. If symptoms resolve and the examination and oxygenation remain normal, patients can be discharged with instructions to return if symptoms recur. Reports in social media and other sources of patients dying after such evaluations (sometimes called "dry drowning" or "secondary drowning") are unfounded.
Swimmers should use common sense and be aware of weather and water conditions. Swimmers should be accompanied by an experienced swimmer or swim only in guarded areas. Swimming should stop if the swimmer looks or feels very cold, because hypothermia may impair judgment. Ocean swimmers should learn to escape rip currents by swimming parallel to the beach rather than toward the beach. Swimmers should be discouraged from DUBBs. If they practice them, they should be supervised and should know their dangers. Swimmers should avoid swimming near a boat exhaust port, which can cause carbon monoxide poisoning.
Public swimming areas should be supervised by lifeguards trained in water safety and resuscitation as well as rescue techniques. Life preservers, life jackets, and a shepherd's crook should be available close to poolside. Emergency airway equipment, automated external defibrillators (AEDs), and immediate telephone access to emergency medical services should be available. Comprehensive community prevention programs should target high-risk groups, teach children to swim as early as possible, and teach CPR to as many adolescents and adults as possible. Owners of private pools should also have immediate telephone access to emergency medical services and know about resuscitation after drowning.
Children should wear US Coast Guard–approved flotation devices when in or around water. Air-filled swimming aids and foam toys (water wings, noodles, etc) are not designed to keep swimmers from drowning and should not be used as a substitute for US Coast Guard–approved equipment. Children must be constantly supervised by an adult when around water, including beaches, pools, and ponds. Infants and toddlers should also be supervised, ideally within arm’s length, when near toilets, bathtubs, or any collection of water. Studies in the US and China have shown that formal swimming lessons reduce the risk of fatal drowning among children ages 1 to 4; however, even children who have been taught how to swim require constant supervision when in or around water. Adults should remove water from containers such as pails and buckets immediately after use. Swimming pools should be surrounded with a locked fence ≥ 1.5 m in height.
Before embarking, boaters should wear US Coast Guard–approved life jackets and should check weather and water conditions. Nonswimmers and small children in a boat should wear US Coast Guard–approved life jackets at all times. Because consuming any quantity of alcohol increases the risk of drowning, operators and passengers on recreational boats should generally avoid consuming alcohol.
People who are debilitated or elderly or have seizure disorders or other medical conditions that can alter consciousness require constant supervision when they are boating or swimming and when in bathtubs.
People with a personal or family history of unexplained drowning not attributable to alcohol use, drug use, or a seizure disorder merit evaluation for long QT syndrome.
Evaluate patients for suspected or feasible causes of drowning (eg, cervical spine injury, head injury, seizure arrhythmias, hypoglycemia) as well as injuries or consequences of drowning (eg, head or cervical spine injury, aspiration).
Vigorously resuscitate cold water drowning victims even if submersion was prolonged; survival is possible even after 1 h of submersion, particularly in young children.
Resuscitation begins with rescue breathing, not chest compressions.
Preventive measures (eg, swimming lessons, child supervision, use of US Coast Guard–approved flotation devices or life jackets, avoiding alcohol, access to trained lifeguards and emergency medical services) can have significant public health benefits.