ED registrar: “Hi there. You’re on for ICU outside reviews, are you?… Great. Look, we’re expecting in a near drowning to the resus bay in the next few minutes. Sounds like he needed a bit of work at the pool-side and they’ll be here fairly soon. Can you start coming down here to give us a hand? Thanks.” *Click*
Does a person drown by immersion or submersion?
If the patient isn’t dead as a result, was it a drowning or a near-drowning?
WHO 2002 definition of drowning: “Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid.” i.e. Drowning is a process that starts on exposure of the airway to a liquid and results in some degree of respiratory impairment.
Therefore, a patient can drown due to either submersion (the airway goes below the level of the surface of the liquid) or immersion (a liquid is splashed across a person’s face – think of water-boarding).
In the absence of respiratory impairment, it cannot be called a drowning.
If the drowning process is interrupted and the person survives, it is termed a non-fatal drowning.
If the person dies during any part of the drowning process, it is a fatal drowning.
The WHO advises that all other terminology, such as near-drowning, should no longer be used.
Remember that drowning is often associated with hypothermia, so that in the event of cardiac arrest following drowning it may be warranted to continue resuscitative efforts for longer than usual and efforts should be made to normalised the person’s core temperature as rapidly as possible before ceasing resuscitative efforts (See this EM Crit podcast for more details)
From the NEJM review article: “in-water resuscitation is possible only when attempted by a highly trained rescuer, and it consists of ventilation alone. Attempts at chest compression are futile as long as the rescuer and drowning person are in deep water, so assessment for a pulse does not serve any purpose. Drowning persons with only respiratory arrest usually respond after a few rescue breaths. If there is no response, the person should be assumed to be in cardiac arrest and be taken as quickly as possible to dry land, where effective CPR can be initiated .” The authors of the NEJM article recommend that once on land, initial CPR be performed following the traditional A-B-C approach, while the ARC guidelines (Guideline 9.3.2, updated Feb 2005) advocate using the current standard BLS approach – commence chest compressions with expired air resuscitation optional.
Key prognostic information:
estimated duration that the person was missing for (highly variable, and frequently unreliable)
absence of respiratory effort upon rescue
absence of pulse upon rescue
time to initiation of CPR efforts
time to first breath
level of conciousness on arrival to ED
water temperature may influence the outcome, with temperatures < 10degrees Celcius potentially providing some neuro-protective effect
identifiable precipitants; e.g. did the person have a cardiac arrest secondary to an AMI while in the swimming pool?
David Szpilman, M.D., Joost J.L.M. Bierens, M.D., Ph.D., Anthony J. Handley, M.D., and James P. Orlowski, M.D. Drowning [Review article]. N Engl J Med 2012; 366:2102-2110 – Very useful review, covering pathophysiology, initial resuscitation, emergency department and ICU care.