#113: In Too Deep – Water Safety and Drowning

July 3, 2024 | By Sam Masur

Audio

Summary:

Grab your goggles and U.S. Coast Guard approved life jacket as we plunge deep into another great episode! Our special guest, Dr. Mercedes Blackstone, a pediatric emergency medicine physician, makes a SPLASH in this episode on water safety, prevention of drowning, and management of the child who drowned. We learn who’s at risk for drowning, what happens when children drown, and DIVE into the management of children who drown. With all of these great pearls, you’re sure to not FLOP.

Water Safety and Drowning Pearls

1. Use the terms “drowning” or “submersion event;” don’t use “near-drowning,” as it is a non-specific term that doesn’t imply outcome.
2. Direct supervision by caregivers who are an arm’s length away from children is key to preventing drowning. 
3. Drowning has a bimodal distribution; young children drown due to inability to swim, curiosity, and lack of supervision whereas older adolescents drown due to overestimating their swimming ability and increased risk-taking around water. 
4. Rapid recognition of drowning with quality bystander CPR and rescue breaths are essential for survival and good neurologic outcomes in patients who drown.
5. Key goals in management of patients who have drowned are reversing hypoxemia and addressing airway, breathing and circulation; while bronchodilators can be helpful, prophylactic antibiotics and steroids are generally not recommended.

Water Safety and Drowning Notes

Definitions, Epidemiology, & Pathophysiology 

• Drowning is a leading cause of accidental death in the United States, with about 1000 deaths per year and many more emergency department visits.
  • The term drowning does not imply outcome – it spans the spectrum from survival with intact neurologic function to death 
  • Terms such as “near drowning” or “secondary drowning”  are not used; instead use “submersion injury” for small water-related events 
• Most drowning is silent – children rarely exhibit signs of distress.
• Drowning exhibits a bimodal distribution by age – it peaks in young children and then again in adolescence. 
  • Babies often drown in bathtubs or are victims of nonaccidental trauma. 
  • Children aged 1-5 are at the highest risk of drowning due to inability to swim, curiosity, or lack of supervision. 
  • Adolescents typically demonstrate overestimation of swimming ability, increased risk taking, and, sometimes, alcohol/substance use. 
• There are disparities in patients who are affected by drowning. Certain populations are more likely to drown including:
  • Males
  • Children of lower socioeconomic status, perhaps due to less exposure and access to swim lessons 
  • Black children. Between 10-14 years old, black children drown at rates almost 8 times higher than white children, in part due to SES and lack of access to swim lesson
• Certain conditions can put patients at increased risk for drowning including epilepsy, channelopathies, and long QT syndrome. 

Prevention of Drowning

• Multiple layers of prevention are key to preventing drowning.
• Advise parents to provide direct supervision! Those supervising children in water should be at arm’s length, focused on the child, and not using substances or alcohol.
• Flotation devices may provide a false sense of security. They are an adjunct and should not be a replacement for direct supervision. 
  • Properly fitted U.S. Coast Guard approved life-jackets are recommended above other flotation devices, especially for boating.
• The AAP now recommends swim lessons after age 1
  • Editor’s note: Swimming lessons are associated with an 88% decreased risk of drowning in 1- to 4- year-olds (Brenner et al. Arch Pediatr Adolesc Med. 2014.)
  • Baby swim lessons are not-evidenced based
  • High-quality swim lessons should include “swimming in clothes, in life jackets, falling in, and practicing self-rescue,” and requires multiple lessons over time per the AAP 
• Pools should be completely surrounded (i.e. not attached to the house) by a self-latching, self-closing fence that cannot be scaled or climbed.
  • Pool fencing has been shown to be superior to alarms or pool covers
• Editor’s note: There are underwater breath-holding behaviors such as breath holding games, hyperventilation prior to submersion, underwater distance swimming and freediving that are dangerous as they decrease CO2 levels and delay the cerebral response to breathe resulting in hypoxia, loss of consciousness underwater, and sometimes death (Boyd et al 2015).

Management of Drowning

• Rapid recognition of drowning and quality bystander CPR with rescue breaths are essential to achieving good outcomes for patients who drown

• • • Drowning victims have a primary respiratory insult as water gets into the airway and causes hypoxemia, so rescue breaths are key
    • Compression only CPR is not appropriate – drowning victims need rescue breaths 
    • The Heimlich maneuver to remove swallowed water is NOT recommended

• It is ideal to have an automated external defibrillator (AED) at public pools

• • • Children who drown may go into a shockable arrhythmia, especially ones with an underlying arrhythmia 
    • Be sure to dry the chest before delivering a shock so the AED pads will stick

• The initial assessment of drowning includes: 

• Place on the monitor & obtain vital signs

• ABCDE assessment: airway, breathing, circulation, disability (neurologic status), and exposure (remove wet clothes, re-warm if needed)

• Airway management:
  • Bronchospasm is common, consider beta agonists
  • Can use non-invasive ventilation such as HFNC or positive pressure 
  • Consider intubation for patients with inadequate oxygenation, inadequate ventilation, low GCS without intact airway reflexes, or those who present in cardiac arrest 
  • In symptomatic patients, watch out for acute respiratory distress syndrome due to aspiration and surfactant washout in the setting of reflex inspiratory effort during drowning 
  • Prophylactic antibiotics and steroids are generally not recommended, as they have not been shown to be beneficial for drowning victims
• Most patients do not need a cervical collar, but a collar should be used in patients with a concerning mechanism of injury, such as motor vehicle collision into water, a diving accident, or when you are unsure of the history/mechanism
  • A cervical collar can be counterproductive in good airway management and reversal of hypoxia.
  • Can initially place a collar, then remove when more history is obtained and there is low concern for cervical injury given mechanism 
• Patients who drown can present in a multisystem organ failure due to hypoxia and acidosis
• Anoxic brain injury from drowning can result in significant neurologic impairment
  • There are no good therapies to reverse this insult, so management focuses on minimizing secondary insults by maintaining euglycemia, normothermia, normal ICP, and minimizing metabolic demand. 
• There are no significant differences in the management of saltwater vs freshwater drowning; however drowning in very cold temperatures can trigger the “mammalian diving reflex” (which shunts blood to vital organs) and can result in intact neurological survival 
• Better outcomes are associated with:
  • Shorter submersion time, shorter time to CPR and EMS, shorter pre-hospital time, higher GCS on arrival, better initial blood gas, cold water drowning

Work-up and Disposition 

• Work-up
  • Consider a CXR in patients who drown, noting that CXR does not always correlate with symptoms 
  • Routine testing of electrolytes is not indicated in well appearing patients who have drowned
  • In critically ill patients who have drowned, obtaining electrolytes, creatine, LFTs, coags, blood gas, and an EKG can be helpful 
  • Consider toxicology screens and antiepileptic drug levels based on patient history 
• Disposition
  • Consider discharge home in patients with a minor submersion event who appear well with normal respiratory rate, oxygen saturations, and mental status after a 6-8 observation period in the ED, as most patients with a drowning event will have signs/symptoms within 6-8 hours
  • Patients with mild symptoms such as tachypnea or cough should be admitted to the floor after a period of observation in the ED to ensure stability
  • Patients with a worsening course, significant respiratory support, or neurologic compromise should be admitted to the ICU

Other Stuff

Resources

• AAP Policy Statement on Prevention of Drowning: Prevention of Drowning | Pediatrics (Pediatrics, 2019)
• UpToDate: Drowning (submersion injuries) – UpToDate 
• Association Between Swimming Lessons and Drowning in Childhood
• How to Choose the Safest Life Jacket

Goal

Listeners will understand the epidemiology of who drowns, risk factors for drowning, management of patients who have drowned, and long-term outcomes in patients who have drowned.

Learning Objectives

After listening to this episode listeners will…  

1. Understand the epidemiology of drowning and which populations are most at risk
2. Feel comfortable counseling patients on water safety and drowning prevention
3. Describe the pathophysiology of drowning 
4. Identify factors that may predict outcomes in children who drown
5. Feel comfortable in the initial management of patients who have drowned

Disclosures

Dr. Blackstone reports no relevant financial disclosures. The Cribsiders report no relevant financial disclosures. 

Citation

Rago AR, Blackstone M, Kelly JM, Masur S, Chiu C, Berk J. “113: In Too Deep – Water Safety and Drowning”. The Cribsiders Pediatric Podcast. https:/www.thecribsiders.com/ July 3, 2024