In this episode, host Jason Woods speaks with Emma Harding and Laura Bricklin about drowning in children. The discussion covers prevention (specifically parental and patient education) and management, as well as the current terminology and existing data.

This episode is produced in conjunction with Drs. Emma Harding and Laura Bricklin as part of their worth on an AAP CATCH grant.  

The following show notes were authored by Drs. Bricklin and Harding and provide a fantastic review.

Take-Home Points

1. Drowning is the #1 cause of preventable death in children age 1-4
2. You can’t drown-proof a child – multiple layers of protection help prevent drowning
3. Providers are a major source of water-safety education for most families

Major Data Points

Drowning claimed the lives of nearly 1,000 children (under 20 years old) in 2017, and an estimated 8,700 children visited a hospital emergency department for a drowning.

Two age groups have the highest risk of drowning – toddlers, and teens. Teens of color are at especially high risk. 

The highest rate of drowning is among children under age 4, with children 12 to 36 months of age being at the highest risk. 

• Most infants drown in bathtubs and buckets. 
• Most preschool-aged children drown in swimming pools. 
• CPSC found that 69% of children under 5 who drowned were not expected to be at or near a pool when the drowned. 

Teens ages 15-19 years have the second-highest fatal drowning rate. Every year, about 370 children ages 10-19 drown.

• Among teens, half of all drownings occur in natural water settings like lakes, rivers or oceans. 
• Among teens, drowning is due to a variety of factors, but alcohol is often involved. 

Layers of Protection

• All children and adults should learn to swim. If swim lessons are suspended in your area due to coronavirus, it is important to add other layers of protection until your child can access lessons.

• Close, constant, attentive supervision around water is important. Assign an adult ‘water watcher,’ who should not be distracted by work, socializing, or chores.

• Around the house, empty all buckets, bathtubs, and wading pools immediately after use. If you have young children, keep the bathroom door closed, and use toilet locks to prevent access.

• Pools should be surrounded by a four-sided fence, with a self-closing and self-latching gate. Research shows pool fencing can reduce drowning risk by 50%. Additional barriers can include door locks, window locks, pool covers, and pool alarms.

• Adults and older children should learn CPR. 

• Everyone, children and adults, should wear US Coast Guard-approved life jackets whenever they are in open water, or on watercraft.

• Parents and teens should understand how using alcohol and drugs increase the risk of drowning while swimming or boating.

Pathophysiology

• Fatal and nonfatal drowning typically begins with a period of panic, loss of the normal breathing pattern, breath-holding, air hunger, and a struggle by the victim to stay above the water. 

• Reflex inspiratory efforts eventually occur, leading to hypoxemia by means of either aspiration or reflex laryngospasm that occurs when water contacts the lower respiratory tract

• Results in decreased lung compliance, ventilation-perfusion mismatching, and intrapulmonary shunting, leading to hypoxemia that causes diffuse organ dysfunction

Management

• Prehospital
  • Rescue and immediate resuscitation by bystanders improves the outcome of drowning victims

• Ventilation is generally considered the most important initial treatment for victims of submersion injury. Rescue breathing should begin as soon as the rescuer reaches shallow water or a stable surface. Note that the priorities of CPR in the drowning victim differ from those in the typical adult cardiac arrest patient, which emphasizes immediate uninterrupted chest compressions. If the patient does not respond to the delivery of two rescue breaths that make the chest rise, the rescuer should immediately begin performing high-quality chest compressions.
  • In a large, population-based, observational study using a Japanese government registry, no significant difference in neurologic outcome at one month was found between drowning victims treated initially with compression-only CPR and conventional CPR with rescue breathing

• According to the AHA Guidelines for Advanced Cardiac Life Support (ACLS), routine cervical spine immobilization can interfere with essential airway management and is not recommended
  • unless there are clinical signs of injury or a concerning mechanism (eg, dive into shallow water)

• Pulses may be very weak and difficult to palpate in the hypothermic patient with sinus bradycardia or atrial fibrillation; a careful search for pulses should be performed for at least one minute before initiating chest compressions in the hypothermic patient because these arrhythmias require no immediate treatment.

• Attempts at rewarming hypothermic patients with a core temperature <33ºC should be initiated, either by passive or active means as available. 
• ED
  • If tracheal intubation is performed, an orogastric tube should be placed to relieve gastric distension, which occurs from passive passage of fluid and is common in nonfatal drowning patients.

• A bedside glucose measurement should be obtained soon upon arrival.

• Wet clothing should be removed and rewarming initiated in hypothermic patients. 
  • Methods include passive and active external rewarming (eg, application of warm blankets, plumbed garments, heating pads, radiant heat, forced warm air), and active internal core rewarming (eg, warmed humidified oxygen via tracheal tube, heated irrigation of peritoneal and pleural cavities). 
  • In addition, endovascular and several extracorporeal rewarming options are available in some centers.

• Possibly because of the neuroprotective effects of hypothermia, complete recovery of some patients with accidental hypothermia and cardiac arrest, despite prolonged resuscitation, has been well documented 
  • Therefore, prolonged resuscitative efforts may be effective (in rare instances, even if continued for several hours) and should be continued until the patient’s core temperature reaches 32 to 35ºC (90 to 95ºF)

• Most non-fatal drowning victims are hospitalized because of the severity of illness or concern for clinical deterioration. 
  • However, a review of 75 pediatric patients found that all who ultimately developed symptoms did so within seven hours of immersion

• Asymptomatic patients should be closely observed for approximately eight hours and admitted if any deterioration occurs. 
  • If vital signs, pulse oximetry, and all studies, including a chest radiograph obtained close to the end of the observation period, are normal and no clinical deterioration develops during this period, the patient may be discharged with appropriate follow-up. 
  • Clear verbal and written instructions to return to the emergency department immediately for any respiratory or other problems must be given, and the patient must be accompanied by a responsible adult.

References:

Brenner, R. A., Taneja, G. S., Haynie, D. L., Trumble, A. C., Qian, C., Klinger, R. M., & Klebanoff, M. A. (2009). Association Between Swimming Lessons and Drowning in Childhood. Archives of Pediatrics & Adolescent Medicine, 163(3), 203. doi:10.1001/archpediatrics.2008.563

Causey, A. L., Tilelli, J. A., & Swanson, M. E. (2000). Predicting discharge in uncomplicated near-drowning. The American Journal of Emergency Medicine, 18(1), 9-11. doi:10.1016/s0735-6757(00)90039-1

Chandy, D., MD, & Weinhouse, G. L., MD. (2020). Drowning (submersion injuries). Retrieved August 01, 2020, from https://www.uptodate.com/contents/drowning-submersion-injuries

Denny, S. A., Quan, L., Gilchrist, J., Mccallin, T., Shenoi, R., Yusuf, S., . . . Weiss, J. (2019). Prevention of Drowning. Pediatrics, 143(5). doi:10.1542/peds.2019-0850

Hoek, T. L., Morrison, L. J., Shuster, M., Donnino, M., Sinz, E., Lavonas, E. J., . . . Gabrielli, A. (2010). Part 12: Cardiac Arrest in Special Situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 122(18_suppl_3). doi:10.1161/circulationaha.110.971069

Lavonas, E. J., Drennan, I. R., Gabrielli, A., Heffner, A. C., Hoyte, C. O., Orkin, A. M., . . . Donnino, M. W. (2015). Part 10: Special Circumstances of Resuscitation. Circulation, 132(18 suppl 2). doi:10.1161/cir.0000000000000264

Pratt, F. D., & Haynes, B. E. (1986). Incidence of “Secondary Drowning” after saltwater submersion. Annals of Emergency Medicine, 15(9), 1084-1087. doi:10.1016/s0196-0644(86)80133-0

Schmidt, A. C., Sempsrott, J. R., Hawkins, S. C., Arastu, A. S., Cushing, T. A., & Auerbach, P. S. (2016). Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning. Wilderness & Environmental Medicine, 27(2), 236-251. doi:10.1016/j.wem.2015.12.019

Tobin, J. M., Ramos, W. D., Pu, Y., Wernicki, P. G., Quan, L., & Rossano, J. W. (2017). Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning. Resuscitation, 115, 39-43. doi:10.1016/j.resuscitation.2017.04.004

Venema, A. M., Groothoff, J. W., & Bierens, J. J. (2010). The role of bystanders during rescue and resuscitation of drowning victims. Resuscitation, 81(4), 434-439. doi:10.1016/j.resuscitation.2010.01.005

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