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What is drowning?
What happens during drowning?
What are the complications of drowning?
Does the type of drowning matter?
What are the risk factors of drowning?
What are the symptoms of drowning?
When should one seek medical care for drowning?
How is drowning diagnosed?
How is drowning treated?
How can drowning be prevented?
What is the prognosis for a drowning victim?
Health questions?

As children, most of us heard lots of health advice. Unfortunately, some of it, however well-intentioned, was medically incorrect. See if you've ever heard - or believed - any of these common summer health myths.

1."Wait a half hour after eating before you can safely go swimming." This one seemed almost universally accepted when I was a child and is still believed today. The myth involves the possibility of suffering severe muscle cramping and drowning from swimming on a full stomach. While it's true that the digestive process does divert the circulation of the blood toward the gut and to a certain extent, away from the muscles, the fact is that an episode of drowning caused by swimming on a full stomach has never been documented. Neither the American Academy of Pediatricsnor the American Red Cross makes any specific recommendations about waiting any amount of time after eating before taking a swim. There's a theoretical possibility that one could develop a cramp while swimming with a full stomach, but a person swimming in a pool or controlled swimming area could easily exit the water if this happens. As with any exercise after eating, swimming right after a big meal might be uncomfortable, but it won't cause you to drown.

What is drowning?

According to the World Health Organization, "Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid." The possible outcomes of drowning are classified as death, morbidity (the development of disability or injury), and no morbidity.

This relatively simple definition was agreed upon at the 2002 World Congress of Drowning held in Amsterdam. Prior to that meeting, some definitions and classifications of drowning were not necessarily well defined, and their meanings were subject to a variety of interpretations by different countries and health organizations. While some people still try to sort drowning events into categories (for example wet vs. dry, primary vs. secondary, fatal vs. non-fatal), these terms may or may not adequately describe a patient's situation, the effects of drowning on their body, or the potential outcome.

Drowning is a common cause of death and disability. In 2002 over 400,000 (worldwide) people died from drowning; of the 400,000 deaths, 129,000 were in China. In the US it is the third most common cause of accidental death, with 3,500 deaths per year, or 10 per day. Twenty-five percent of the victims are children aged 14 and younger.

The death rate from drowning does not reflect the potential morbidity (disability) due to brain injury for those who survive a drowning episode.

What happens during drowning?

Drowning occurs when water comes into contact with the larynx (voice box).

After an initial gasp, there is an initial voluntary breath holding.

This is followed by spasm of the larynx and the development of hypoxemia (hypo=low + ox=oxygen + emia=blood), or decreased levels of oxygen in the bloodstream.

Lack of oxygen causes aerobic metabolism to stop, and the body becomes acidotic. If not corrected quickly, the lack of oxygen in combination with too much acid may lead to problems with the electrical conduction system of the heart (cardiac arrest) and lack of blood supply to the brain.

As body function declines, the larynx may relax and allow water to enter the lungs. However, up to 20% of drowning victims have persistent spasm of the larynx, and no water is aspirated (this was formerly known as "dry" drowning).

What are the complications of drowning?

Hypoxemia causing brain damage is the major complication in drowning victims who do not die.

Direct lung tissue damage because of water aspirated into the lung can also occur and lead to pneumonia and acute respiratory distress syndrome (ARDS).

If the drowning occurs in colder water risks include hypothermia or a drop in body temperature. (If the body temperature drops below 95F (35C) get medical attention immediately.)

Cervical spine fractures may occur in diving injuries associated with drowning.

Does the type of drowning matter?

There have been a variety of theories reported regarding the potential responses of the body to different drowning situations. Most discuss dry vs. wet drowning and salt vs. fresh water drowning.

Wet vs. Dry Drowning

Most drownings are unwitnessed, and the victim is found floating. While only a small amount of aspirated water is required to cause significant problems with lung function, it is the prolonged submersion time and lack of breathing that causes morbidity due to hypoxemia.

Approximately 10%-20% of drowning victims have dry drowning, but even most wet drowning victims have less than 4cc/kg of water found in their lungs. For a 50 pound child, this amounts to less than 3 ounces.

Salt vs. Fresh Water Drowning

In the lung, the breathing tubes (trachea, bronchi, bronchioles) branch into smaller and smaller segments until they end in an air pocket called an alveolus (plural alveoli). This is the part of the lung where air and red blood cells in capillary blood vessels come near enough to allow the transfer of oxygen and carbon dioxide between the two. Alveoli are covered with a chemical called surfactant that allows the air pocket to open and close easily when breathing occurs.

When fresh water enters an alveolus, it destroys the surfactant and causes the alveoli to collapse, unable to open with breathing. A ventilation-perfusion mismatch occurs in which the body sends blood to parts of the lung that lack oxygen, resulting in a decrease in the concentration of oxygen in the blood.

Salt water doesn't destroy surfactant, rather it washes it away and damages the membrane between the alveolus and the capillary blood vessel. One again, the body sends blood flow to areas of the lung that aren't able to provide it oxygen, and hypoxemia occurs.

Regardless of the type of water, lung function is compromised, and hypoxemia occurs. In some circumstances, electrolyte abnormalities may occur with fresh water drowning.

What are the risk factors of drowning?

There are two peak ages for drowning: children aged younger than 4 and young adults aged 15 to 25.

Children less than one year old most often drown in bathtubs.

Children younger than age 5 most commonly drown in residential swimming pools.

Young adults tend to drown in larger bodies of water (for example, rivers and lakes). Neck fractures caused by diving into shallow water are associated with drowning in this age group. Alcohol is also implicated in up to 50% of drownings in this age group.

Medical emergencies that occur in the water can lead to drowning. These may include, among others, seizures, heart attack (myocardial infarction), sudden cardiac death, and hypoglycemia (low blood sugar in a person with diabetes).

What are the symptoms of drowning?

The appearance of drowning can vary widely. A drowning victim may show no symptoms or complaints, or may be found deceased.

It is the rare person who is found thrashing in water. Instead, most drownings are unwitnessed and the person is found floating or submerged in the water.

For those who are alive, they may be anxious, confused, and short of breath. Again, it is the function of the brain and lungs that are the main concerns in drowning victims.

Special Situations

Young children may have a mammalian diving reflex. When they are suddenly immersed in cold water less than 68F (20C), they can stop breathing, slow their heart rate dramatically, and shunt all the blood flow to the heart and brain. Though not common, these children may be resuscitated and return to normal function. Cases have been reported of survival, even after being underwater for an hour.

When should one seek medical care for drowning?

All patients who are victims of drowning, even if they have no symptoms, should seek medical care. Sometimes, subtle information will be revealed that may help prevent future complications when the healthcare provider takes a history or conducts a physical examination.

How is drowning diagnosed?

The initial evaluation of any drowning victim will begin with a history of the events.

How old is the patient?

Are there any underlying medical problems?

Does the patient take any prescription or non-prescription medications? Is there a history of drug or alcohol use?

How long was the person unattended prior to being found?

Was there any potential trauma associated with the drowning (diving/falling into the water/falling out of a boat)?

Was there loss of consciousness before, during, or after the drowning episode?

Has there been any change in behavior?

Has the person had vomiting or diarrhea?

Physical examination will begin with taking and monitoring the vital signs (the ABCs will be evaluated - airway, breathing, and circulation). Careful examination of the whole body will be required, especially focusing on the neurological examination to assess brain function and examination of the heart and lungs.

If trauma or a diving injury is a consideration, the neck and spine may be immobilized to protect against potential spinal cord damage.

Laboratory and x-ray testing will be utilized depending upon the situation and potential injuries.

How is drowning treated?

Treatment begins at the water's edge. The American Heart Association recommends that if possible, one person is sent to activate Emergency Medical Services and call 911. Another should be sent for an automatic external defibrillator (AED).

If no pulse can be identified and the patient is not breathing, CPR should be started. If there is a potential for a neck injury, special care needs to be taken to prevent further injury to the victim.

If the patient is breathing but not awake, they should be placed on their side in the rescue position to prevent aspiration if vomiting should occur.

Further treatment by EMTs, paramedics, and staff at the hospital will depend upon the severity of the symptoms. Those patients who have no symptoms may require nothing more than observation.

Those who are in cardiopulmonary arrest will likely undergo CPR with attempts to restore a regular heart rhythm and heart beat.

Those patients who have symptoms related to the function of their heart, lung, or brain will need further evaluation and treatment tailored to their specific circumstances and situation.

And unfortunately, for those who are found dead, no further treatment or evaluation may be indicated.

How can drowning be prevented?

Most drownings are preventable, and simple steps can be taken to help with water safety.

Learn how to swim.

When in the water, use the buddy system.

Do not use alcohol or drugs when swimming or boating.

Supervise children closely around water and make certain they are the focus of your attention. Even bathtubs and buckets full of water can be dangerous.

Swimming pools should have barriers (fences, gates, alarms) to prevent children from entering unattended.

Learn CPR.

What is the prognosis for a drowning victim?

The prognosis for many drowning victims is poor. The brain does not tolerate lack of oxygen well and the amount of potential damage is dependent upon the time the patient spends hypoxemic in the water.

Even if the brain survives, acute respiratory distress syndrome (ARDS) may cause significant short and long-term problems as the lungs try to recover from their injuries.

The key to the treatment of drowning is prevention.

Drowning is a common cause of death and disability worldwide. In the _________, it is the third most common cause of accidental death. Brain damage, pneumonia, ARDS, hypothermia, and spine fractures are complications of drowning. At times, there are discussions of wet vs. dry, or salt vs. fresh water drownings. Children and young adults are at most risk for drowning accidents. Medical emergencies in the water may lead to drowning (such as seizures, hypoglycemia, sudden cardiac death, or heart attack). Treatment of a drowning victim depends up on the severity of the injury. Prevention is the key to prevent drowning.