near-drowning


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Related to near-drowning: Secondary drowning

Near-Drowning

 

Definition

Near-drowning is the term for survival after suffocation caused by submersion in water or another fluid. Some experts exclude from this definition cases of temporary survival that end in death within 24 hours, which they prefer to classify as drownings.

Description

An estimated 15,000-70,000 near-drownings occur in the United States each year (insufficient reporting prevents a better estimate). The typical victim is young and male. Nearly half of all drownings and near-drownings involve children less than four years old. Home swimming pools pose the greatest risk for children, being the site of 60-90% of drownings in the 0-4 age group. Teenage boys also face a heightened risk of drowning and near-drowning, largely because of their tendency to behave recklessly and use drugs and alcohol (drugs and alcohol are implicated in 40-50% of teenage drownings). Males, however, predominate even in the earliest age-groups, possibly because young boys are often granted more freedom from supervision than young girls enjoy, making it more likely that they will stumble into danger and less likely that they will attract an adult's attention in time for a quick rescue. Roughly four out of five drowning victims are males.

Causes and symptoms

The circumstances leading to near-drownings (and drownings also) cannot be reduced to a single scenario involving nonswimmers accidentally entering deep water. On many occasions, near-drownings are secondary to an event such as a heart attack that causes unconsciousness or a head or spinal injury that prevents a diver from resurfacing. Near-drownings, moreover, can occur in shallow as well as deep water. Small children have drowned or almost drowned in bathtubs, toilets, industrial-size cleaning buckets, and washing machines. Bathtubs are especially dangerous for infants six months to one year old, who can sit up straight in a bathtub but may lack the ability to pull themselves out of the water if they slip under the surface.
A reduced concentration of oxygen in the blood (hypoxemia) is common to all near-drownings. Human life, of course, depends on a constant supply of oxygen-laden air reaching the blood by way of the lungs. When drowning begins, the larynx (an air passage) closes involuntarily, preventing both air and water from entering the lungs. In 10-15% of cases, hypoxemia results because the larynx stays closed. This is called "dry drowning." Hypoxemia also occurs in "wet drowning," the 85-90% of cases where the larynx relaxes and water enters the lungs. The physiological mechanisms that produce hypoxemia in wet drowning are different for freshwater and saltwater, but only a small amount of either kind of water is needed to damage the lungs and interfere with the body's oxygen intake. All of this happens very quickly: within three minutes of submersion most people are unconscious, and within five minutes the brain begins to suffer from lack of oxygen. Abnormal heart rhythms (cardiac dysrhythmias) often occur in near-drowning cases, and the heart may stop pumping (cardiac arrest). An increase in blood acidity (acidosis) is another consequence of near-drowning, and under some circumstances near-drowning can cause a substantial increase or decrease in the volume of circulating blood. Many victims experience a severe drop in body temperature (hypothermia).
The signs and symptoms of near-drowning can differ widely from person to person. Some victims are alert but agitated, while others are comatose. Breathing may have stopped, or the victim may be gasping for breath. Bluish skin (cyanosis), coughing, and frothy pink sputum (material expelled from the respiratory tract by coughing) are often observed. Rapid breathing (tachypnea), a rapid heart rate (tachycardia), and a low-grade fever are common during the first few hours after rescue. Conscious victims may appear confused, lethargic, or irritable.

Diagnosis

Diagnosis relies on a physical examination of the victim and on a wide range of tests and other procedures. Blood is taken to measure oxygen levels and for many other purposes. Pulse oximetry, another way of assessing oxygen levels, involves attaching a device called a pulse oximeter to the patient's finger. An electrocardiograph is used to monitor heart activity. X rays can detect head and neck injuries and excess tissue fluid (edema) in the lungs.

Treatment

Treatment begins with removing the victim from the water and performing cardiopulmonary resuscitation (CPR). One purpose of CPR—which, of course, should be attempted only by people trained in its use—is to bring oxygen to the lungs, heart, brain, and other organs by breathing into the victim's mouth. When the victim's heart has stopped, CPR also attempts to get the heart pumping again by pressing down on the victim's chest. After CPR has been performed and emergency medical help has arrived on the scene, oxygen is administered to the victim. If the victim's breathing has stopped or is otherwise impaired, a tube is inserted into the windpipe (trachea) to maintain the airway (this is called endotracheal intubation). The victim is also checked for head, neck, and other injuries, and fluids are given intravenously. Hypothermia cases require careful handling to protect the heart.
In the emergency department, victims continue receiving oxygen until blood tests show a return to normal. About one-third are intubated and initially need mechanical support to breathe. Rewarming is undertaken when hypothermia is present. Victims may arrive needing treatment for cardiac arrest or cardiac dysrhythmias. Comatose patients present a special problem: although various treatment approaches have been tried, none have proved beneficial. Patients can be discharged from the emergency department after four to six hours if their blood oxygen level is normal and no signs or symptoms of near-drowning are present. But because lung problems can arise 12 or more hours after submersion, the medical staff must first be satisfied that the patients are willing and able to seek further medical help if necessary. Admission to a hospital for at least 24 hours for further observation and treatment is a must for patients who do not appear to recover fully in the emergency department.

Prognosis

Neurological damage is the major long-term concern in the treatment of near-drowning victims. Patients who arrive at an emergency department awake and alert usually survive with brain function intact, as do about 90% of those who arrive mentally impaired (lethargic, confused, and so forth) but not comatose. Death or permanent neurological damage is very likely when patients arrive comatose. Early rescue of near-drowning victims (within five minutes of submersion) and prompt CPR (within less than 10 minutes of submersion) seem to be the best guarantees of a complete recovery. An analysis of 715 patients admitted to emergency departments in 1971–81 revealed that 69% recovered completely, 25% died, and 6% survived but suffered permanent neurological damage.

Prevention

Prevention depends on educating parents, other adults, and teenagers about water safety. Parents must realize that young children who are left in or near water without adult supervision even for a short time can easily get into trouble, not just at the beach or next to a swimming pool, but in bathtubs and around toilets, buckets, washing machines, and other household articles where water can collect. Research on swimming pool drownings involving young children shows that the victims have usually been left unattended less than five minutes before the accident. Experts consider putting up a fence around a home swimming pool an essential precaution, and estimate that 50-90% of child drownings and near-drownings could be prevented if fences were widely adopted. The fence should be at least five feet high and unclimbable, have a self-closing and self-locking gate, and completely surround the pool.
Pool owners—and, indeed, all other adults—should consider learning CPR. Everyone, of course, should follow the rules for safe swimming and boating. Those who have a medical condition that can cause a seizure or otherwise threaten safety in the water are advised always to swim with a partner. And of course, people need to be aware that alcohol and drug use substantially increase the chances of an accident.
The danger of alcohol and drug use around water is a point that requires special emphasis where teenagers are concerned. Teenagers can also benefit from CPR training and safe swimming and boating classes.

Resources

Books

Modell, Jerome H. "Drowning and Near-Drowning." In Harrison's Principles of Internal Medicine, edited by Anthony S. Fauci, et al. New York:McGraw-Hill, 1997.

near-drowning

Survival after immersion in water. This term is being replaced with the term “submersion, ” which is more accurate and was agreed upon at the Utstein Guidelines Conference for uniform reporting of drowning and submersion incidents.

About 330,000 persons, most of whom are children, adolescents, or young adults, survive an immersion injury in the U.S. each year; of these, about 10% receive professional attention. Many who suffer near-drowning do so because of preventable or avoidable conditions, such as the use of alcohol or drugs in aquatic settings or the inadequate supervision of children by adults. Water sports (e.g., diving, swimming, surfing, or skiing) and boating or fishing accidents also are common causes of near-drowning. A small percentage of near-drowning episodes occur when patients with known seizure disorders convulse while swimming or boating. See: drowning

Etiology

The injuries suffered result from breath holding (“dry drowning”), the aspiration of water into the lungs (“wet drowning”), and/or hypothermia.

Symptoms

Common symptoms of near-drowning result from oxygen deprivation, retention of carbon dioxide, or direct damage to the lungs by water. These include cough, dyspnea, coma, and seizures. Additional complications of prolonged immersion may include aspiration pneumonitis, noncardiogenic pulmonary edema, electrolyte disorders, hemolysis, disseminated intravascular coagulation, and arrhythmias.

Treatment

In unconscious patients rescued from water, the airway is secured, ventilation is provided, and cardiopulmonary resuscitation is begun. Oxygen, cardiac, and blood pressure monitoring, rewarming techniques, and other forms of support are provided (e.g., anticonvulsants are given for seizures; electrolyte and acid-base disorders are corrected).

Prognosis

Most patients who are rapidly resuscitated from a dry drowning episode recover fully. The recovery of near-drowning victims who have inhaled water into the lungs depends on the underlying health of the victim, the duration of immersion, and the speed and efficiency with which oxygenation, ventilation, and perfusion are restored.

near-drowning

nonfatal water inhalation.
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