Notes – Drowning

Drowning

Patient Safety Considerations

  1. Avoidance of hyperoxygenation of the drowning victim
  2. Rescuer safety considerations

Notes/Educational Pearls

Key Considerations

  1. The World Health Organization definition of drowning is “the process of experiencing respiratory impairment from submersion/immersion in liquid”
  2. Drowning is further defined in the following categories:
    1. Non-fatal drowning – patients rescued from drowning
    2. Fatal drowning – any death, acutely or subacutely, resultant from drowning
  3. Submersion refers to situations in which the patient’s airway is underwater. Immersion refers to situations in which the patient’s body is in water but the patient’s airway remains out of the water
  4. Pediatric Considerations:
    1. Drowning is a common cause of death in children
    2. Risk factors for drowning include male gender, age less than 14 yo, alcohol use, lack of supervision, and risky behavior
  5. Rescue efforts should be coordinated between all responding agencies to ensure patient is rapidly accessed and removed from the water
  6. Initiation of in-water ventilations may increase survival – In-water chest compressions are futile
  7. The European Resuscitation Council recommends 5 initial breaths be provided to the drowning victim
    1. The initial ventilations may be more difficult to achieve as water in the airways may impede alveolar expansion
    2. After the initial 5 breaths and 30 compressions, the standard ratio of 2 breaths to 30 compressions may be resumed
  8. Active efforts to expel water from the airway (by abdominal thrusts or other means) should be avoided as they delay resuscitative efforts and increase the potential for vomiting and aspiration
  9. Long-standing teaching has suggested that rescuers should always assume c-spine injury in victims of drowning
    1. The 2010 American Heart Association update on special circumstances in cardiac arrest notes that routine c-spine precautions in all victims of drowning is likely unnecessary unless the mechanism or injury, history, or physical exam suggests a cervical spine injury
    2. Mechanisms of injury highly suggestive of cervical spine injury include diving, water skiing, surfing or watercraft accidents
  10. Uncertainty exists regarding survival in cold water drowning, however, recent literature suggests the following:
    1. If water temperature is less than 43°F (6°C) and the patient is submerged with evidence of cardiac arrest:
      1. Survival is possible for submersion time less than 90 minutes and resuscitative efforts should be initiated
      2. Survival is not likely for submersion time greater than 90 minutes and providers may consider not initiating resuscitation or termination of resuscitation on scene
    2. If water temperature is greater than 43°F (6°C) and the patient is submerged with evidence of cardiac arrest:
      1. Survival is possible for submersion time less than 30 minutes and resuscitative efforts should be initiated
      2. Survival is not likely for submersion time greater than 30 minutes and providers may consider not initiating resuscitation or termination of resuscitation on scene
  11. Patients may develop subacute respiratory difficulty after drowning and therefore all victims of drowning should be transported for observation

Quality Improvement

Associated NEMSIS Protocol(s) (eProtocol.01)

  • 9914093 – Injury-Drowning/Near Drowning
  • 9914091 – Injury-Diving Emergencies

Key Documentation Elements

  • Mechanism of injury or history suggesting cervical spine injury
  • Submersion time
  • Water temperature
  • Activities leading to drowning
  • Consider a standardized data collection metrics such as the Utstein drowning data reporting elements

Performance Measures

  • Recognition and appropriate care of pulmonary/respiratory complaints
  • Cervical spine management when appropriate
  • Adherence to Cardiac Arrest guideline

References

  1. Harris M. ABC of resuscitation, near drowning. BMJ. 2003;327(7427):1336-8.
  2. Idris AH, Berg RA, Bierens J, et al. Recommended guidelines for uniform reporting of data from drowning: The “Utstein Style.” Circulation. 2003;108(20):2565-74.
  3. Layon J, Modell JH. Drowning, update 2009. Anesthesiology. 2009;110(6):1390-401.
  4. Olshaker J. Submersion. Emerg Med Clin N Am. 2004;22(2):357-67.
  5. Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012;366(22):2102-10.
  6. Vanden Hoek T, Morrison LJ, Shuster M, et al. Part 12: Cardiac arrest in special situations. 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010;122(18 Suppl 3):S829-61.