eMedicine Specialties > Emergency Medicine > Environmental

Near Drowning
Author: Michael J Verive, MD, Director, Pediatric Intensive Care, Department of Pediatric Critical Care,
Mount Sinai Hospital; Program Director, Pediatric Intensive Care, Hope Children's Hospital
Contributor Information and Disclosures

Updated: Apr 29, 2009

Introduction
Background

Submersion injuries are a significant cause of death and disability in children, second only to unintentional
trauma. At least one third of survivors sustain moderate to severe neurologic sequelae. Although no uniform
classification for submersion injuries is noted, drowning is usually defined as death from asphyxia within 24
hours of submersion in water. Near drowning refers to survival (even if temporary) beyond 24 hours after a
submersion episode.

Submersion injuries may be further classified as cold-water or warm-water injuries. Warm-water drowning
occurs at water temperatures of 20°C or higher, and cold-water drowning occurs at water temperatures of less
than 20°C. Some references include very-cold-water drowning, which refers to submersion in water at
temperatures of 5°C or less.

Additional classification may include the type of water in which the submersion occurred, such as freshwater
and salt-water submersion injury. However, the distinction between freshwater and salt-water submersion
injury is primarily academic because initial treatment is not affected by water type.

Pathophysiology

Submersion injury occurs when a person is submerged in water, attempts to breathe, and either aspirates water
(wet drowning) or has laryngospasm without aspiration (dry drowning). Although most patients with
submersion injury have aspirated a small amount of water or gastric contents into their lungs, approximately
10-15% of patients have become asphyxiated without evidence of aspiration. The most important contributory
factors to morbidity and mortality from near drowning are hypoxemia and a decrease in oxygen delivery to
vital tissues. The pathophysiology of near drowning is intimately related to the multiorgan effects of
hypoxemia. CNS damage may occur because of hypoxemia sustained during the drowning episode (primary
injury) or may result from ongoing pulmonary injury, reperfusion injury, or multiorgan dysfunction
(secondary injury), particularly with prolonged tissue hypoxia.

Although differences observed between freshwater and salt-water aspirations in electrolyte and fluid
imbalances are frequently discussed, they are rarely of any clinical significance for people who have
experienced near drowning. Most patients have fluid aspiration of less than 4 mL/kg. Fluid aspiration of at
least 11 mL/kg is required for alterations in blood volume to occur, and aspiration of more than 22 mL/kg is
required before significant electrolyte changes develop. Ingestion, rather than aspiration, is more likely to
cause clinically significant electrolyte imbalances, including hyponatremia from ingestion of large volumes of
fresh water (especially in children).
CNS effects

CNS injury remains the major determinant of subsequent survival and long-term morbidity in cases of near
drowning. Primary CNS injury is initially associated with tissue hypoxia and ischemia. If the period of
hypoxia and ischemia is brief or if the person is a very young child who rapidly develops core hypothermia,
primary injury may be limited, and the patient may recover with minimal neurologic sequelae. However,
submersion injuries that are associated with prolonged hypoxia or ischemia are likely to lead to both
significant primary injury and secondary injury from reperfusion, sustained acidosis, cerebral edema,
hyperglycemia, release of excitatory neurotransmitters, seizures, hypotension, and impaired cerebral
autoregulation, especially in older patients who cannot rapidly achieve core hypothermia.

Although cerebral edema is a common consequence of prolonged submersion (or submersion followed by
prolonged circulatory insufficiency), retrospective reviews and animal studies have not demonstrated any
benefit from the use of intracranial pressure monitoring with diffuse axonal injury. However, as submersion
injuries may be associated with trauma (especially to the head, neck, and trunk), focal or persistent neurologic
deficit may indicate mass lesions or other injury amenable to surgical intervention.

Autonomic instability (diencephalic/hypothalamic storm) is common following severe traumatic, hypoxic, or

ischemic brain injury, often presenting with signs and symptoms of hyperstimulation of the sympathetic
nervous system (including tachycardia, hypertension, tachypnea, diaphoresis, agitation, muscle rigidity).

CNS infection, an uncommon but serious complication of near drowning, may result from unusual soil and
waterborne bacteria and fungi, including Pseudallescheria boydii and Scedosporium apiospermum. These
infections are usually insidious in onset, typically occurring more than 30 days after the initial submersion
injury.

Pulmonary effects

Fluid aspiration of as little as 1-3 mL/kg can result in significantly impaired gas exchange, primarily
secondary to altered surfactant function. Freshwater is considerably hypotonic relative to plasma and causes
disruption of alveolar surfactant. Salt water, which is hyperosmolar, increases the osmotic gradient and
therefore draws fluid into the alveoli, diluting surfactant (surfactant washout).

Altered surfactant volume, function, or both result in atelectasis and pronounced injury to the alveoli-capillary
unit, resulting in lower functional residual capacity and pulmonary edema. Acute respiratory distress
syndrome (ARDS) from altered surfactant function and neurogenic pulmonary edema is a common
complication in survivors of submersion injury. Increased airway resistance secondary to plugging of the
patient's airway with debris, as well as release of inflammatory mediators that result in vasoconstriction, may
impair gas exchange.

Ventilator-associated lung injury (VALI) can further compromise noncompliant, edematous lung tissue.
Newer modes of ventilation, including high-frequency oscillatory ventilation and airway pressure release
ventilation, or an open-lung approach that limits tidal volumes to 6-8 cc/kg while using positive end-
expiratory pressure (PEEP) to support optimal respiratory compliance, can help support oxygenation and
ventilation with less risk of VALI than is associated with older methods of ventilation.

Pneumonia is a rare consequence of submersion injury and is more common with submersion in stagnant,
warm, and fresh water. As with CNS infections, uncommon pathogens, including Aeromonas, Burkholderia,
and Pseudallescheria, cause a disproportionate percentage of cases of pneumonia. Because pneumonia is
uncommon early in the course of treatment of submersion injuries, the use of prophylactic antimicrobial
therapy has not proven to be of any benefit.

Cardiovascular effects
Hypovolemia is primarily due to fluid losses from increased capillary permeability. Profound hypotension
may occur during and after the initial resuscitation period, especially when rewarming is accompanied by
vasodilatation. Myocardial dysfunction may result from ventricular dysrhythmias, pulseless electrical activity
(PEA), and asystole due to hypoxemia, hypothermia, acidosis, or electrolyte abnormalities (less common). In
addition, hypoxemia may directly damage the myocardium, decreasing cardiac output. Pulmonary
hypertension may result from the release of pulmonary inflammatory mediators, increasing right ventricular
afterload and thus decreasing both pulmonary perfusion and left ventricular preload. However, although
cardiovascular effects may be severe, they are usually transient, unlike severe CNS injury.

Other effects

The clinical course may be complicated by multiorgan system failure resulting from prolonged hypoxia,
acidosis, rhabdomyolysis, acute tubular necrosis, or infection or from the treatment modalities. Disseminated
intravascular coagulation (DIC), hepatic and renal insufficiency, metabolic acidosis, and GI injuries must be
considered and appropriately managed.

Clinical
History

All aspects leading to the near-drowning episode should be determined. Rarely does a patient present with the
classic "Hollywood scenario" of a novice swimmer stranded in water, frantically struggling and flapping his or
her arms in desperation. Experienced snorkelers, for example, may experience syncope secondary to hypoxia
after hyperventilating to drive off carbon dioxide, and deep-water divers may succumb to "shallow-water
blackout" as they ascend.

Most persons are found after having been submerged in water for an unobserved period. Witnessed events
may include experienced swimmers not resurfacing after a dive. Relevant factors include submersion time,
associated trauma, drug or alcohol ingestion, type of water, amount of water contamination, water
temperature, and attempted rescue maneuvers.

Medical history must be obtained to look for a secondary cause or causes of drowning, including one or more
of the following:

• Trauma (unintentional and intentional)

• Seizures
• Cardiac disease, dysrhythmias, and syncope
• Exhaustion and hypothermia
• Hypoglycemia
• Alcohol and drug use

Physical

The clinical presentations of people who experience submersion injuries widely vary.

• Asymptomatic, especially if brief, witnessed submersions with immediate resuscitation

• Symptomatic
o Cough
o Dyspnea
o Wheezing
o Hypothermia
o Bradycardia or tachycardia
o Vomiting, diarrhea, or both
 o Anxiety
o Altered mental status
• Cardiopulmonary arrest
o Cardiac arrhythmias (ventricular tachycardia, ventricular fibrillation, bradycardia)
o Apnea
• Death

Causes

Drowning and near-drowning events must be thought of as primary or secondary events. Secondary causes of
drowning include seizures, head or spine trauma, cardiac arrhythmias, hypothermia, alcohol and drug
ingestion, syncope, apnea, hyperventilation, suicide, and hypoglycemia. Causes grouped by age of persons
follows:

• In infants younger than 1 year

o Bathtubs and buckets of water are the most common means of drowning.
o Child abuse should be considered in all such cases.
• In children aged 1-5 years: Residential swimming pools are the most common venue.
• In young adults aged 15-19 years
o Submersion injuries occur in ponds, lakes, rivers, oceans, and other natural bodies
of water.
o Injuries are frequently associated with boating, alcohol, or both.

Workup
Laboratory Studies

The following studies are indicated in near drowning:

• Blood gas analysis with co-oximetry to detect methemoglobinemia and

carboxyhemoglobinemia
• CBC count, prothrombin time with international normalized ratio (INR), partial
thromboplastin time, fibrinogen, D-dimer, fibrin split products
• Serum electrolytes (with glucose)
• Liver enzymes, especially aspartate aminotransferase and alanine aminotransferase
• Renal function tests (BUN, creatinine)
• Drug screen and ethanol level (consider)
• Continuous pulse oximetry and cardiorespiratory monitoring (may be needed)
• Cardiac troponin I testing (may be useful as a marker to predict children who have an
elevated risk of not surviving to hospital discharge)

Imaging Studies

• Chest radiography
• Head CT and cervical spine imaging if trauma suspected
• Extremity, abdominal, pelvic imaging if clinically indicated
• Echocardiography if myocardial dysfunction present

Other Tests

• Consider electrocardiography if the patient has arrhythmias. Monitor the patient if

rewarming is necessary, because dysrhythmias are common when rewarming patients
who suffer cold-water immersion injuries.
 • Swan-Ganz catheter for monitoring cardiac output and related hemodynamic parameters
may be useful in patients with unstable cardiovascular status or in those who require
multiple inotropic and vasoactive medication requirements.

Procedures

• Endotracheal intubation with mechanical ventilation for respiratory failure, persistent

hypotension, or impaired airway protective reflexes.
• Nasogastric tube placement for removal of swallowed water and debris (Use orogastric
route if head or facial trauma is suggested.)
• Urinary catheter placement for assessment of urine output
• Central venous catheter placement for use in measurement of central venous pressure,
infusions, and blood sampling
• Arterial catheter for arterial blood pressure and blood gas analysis
• Extracorporeal membrane oxygenation (ECMO) - May be considered in the following
circumstances:
o Respiratory compromise resulting from lack of response to conventional
mechanical ventilation or high-frequency ventilation
o A reasonable probability of the patient recovering neurologic function
o Persistent hypothermia from cold-water drowning
• Bronchoscopy if needed for removal of foreign bodies, such as aspirated debris or
vomitus
• Intracranial pressure monitoring in patients with traumatic brain injury or mass lesions
(eg, hematomas)

Treatment
Medical Care

• Prehospital care in patients who experienced near drowning

o Success or failure of initial basic life support provided at the scene of the event is
the most important determinant of outcome.
o As in any rescue initiative, initial treatment should be geared toward ensuring
adequacy of the airway, breathing, and circulation, with attention given to cervical
spine stabilization if the scenario suggests spinal trauma or if the event is
unwitnessed.
o The patient should be removed from water as soon as possible.
o Initiate rescue breathing immediately, even while the patient is still in the water, if
necessary and feasible.
o Chest compressions are not effective in the water and waste valuable time.
o The Heimlich maneuver has not been shown to be effective in removing aspirated
water.
o Debris visible in the oropharynx should be removed with a finger-sweep maneuver.
o Higher pressures may be required for ventilation because of the poor compliance
resulting from pulmonary edema.
o Supplemental oxygen, 100%, should be administered as soon as available. The
degree of hypoxemia may be difficult to determine on clinical observation.
• ED care
o Associated injuries must be considered, as in any other form of injury. Consider
potential spinal injuries, especially if diving is part of the history.
o The need for hospitalization is determined on clinical evaluation.
o Noninvasive continuous pulse oximetry is valuable.
o Patients with completely normal findings on examination and trivial history may be
discharged after a 6-hour observation period.
 o Admit any patient with respiratory symptoms, altered oxygenation by pulse
oximetry or blood gas analysis, or altered mental status or any patient in whom
child abuse is suggested.
o The most critical role in management is prompt correction of hypoxemia and
acidosis.
o Ventricular dysrhythmias (typically, ventricular tachycardia or ventricular
fibrillation), bradycardia, and asystole may occur as a result of acidosis and
hypoxemia rather than electrolyte imbalance.
o Consider intubation and mechanical ventilation in any patient with poor respiratory
effort, altered sensorium, severe hypoxemia, severe acidosis, or significant
respiratory distress.
o Intravascular volume depletion is common, secondary to pulmonary edema and
intracompartmental fluid shifts, regardless of the type of fluid aspirated.
o Rapid volume expansion may be indicated using isotonic crystalloid (20 mL/kg) or
colloid.
o Inotropic support may be required using dopamine and/or dobutamine.
o Most acidosis is restored after correction of volume depletion and oxygenation.
o Hypothermia may also be present and exacerbate bradycardia, acidosis, and
hypoxemia.
o Ascertaining whether the drowning occurred in warm or cold water is essential.
This depends on the temperature of the water, not of the patient.
• Guidelines for treating cold-water drowning
o Patients with severe hypothermia may appear dead because of profound
bradycardia and vasoconstriction.
o Resuscitation should continue while aggressive attempts are made to restore
normal body temperature.
• Guidelines for treating warm-water drowning: Patients arriving at the emergency
department in cardiopulmonary arrest after a warm-water submersion have a dismal
prognosis. The benefits of resuscitative efforts should be continuously reassessed in such
situations.
• The Conn classification system: For other patients, the Conn classification system may be
used as a guideline to quantify the extent of cerebral hypoxia.
o Category A - Alert
o Category B - Blunted consciousness; admit and observe for pulmonary
compromise, which may result in hypoxemia and worsen CNS injury
o Category C - Comatose (C1 - decorticate, C2 - decerebrate, and C3 - flaccid [worse
prognosis than C1])

Consultations

• Consider neurology consultation for seizures or persistent neurologic deficit.

• Consider neurosurgery consultation if associated head or spine trauma, hematoma,
aneurysm, or CNS abscess is present.
• Consider cardiology consultation for dysrhythmias or myocardial dysfunction.
• Physical therapy, occupational therapy, rehabilitation therapy consultation is needed to
help prevent disuse injury and provide early rehabilitation.
• Consider pulmonology consultation for severe or persistent respiratory compromise.
• Consider infectious disease consultation for pneumonia or CNS infection.

Medication
• Corticosteroids have been shown to be of no benefit in the management of submersion
injuries.
• Routine antibiotic prophylaxis is not indicated unless the patient was submerged in
grossly contaminated water or sewage.
Follow-up
Further Inpatient Care

• The primary goal in the management of a submersion injury is preservation of CNS

perfusion and function. Cerebral edema and intracranial hypertension secondary to
hypoxic neuronal injury are frequently observed, but studies have shown that invasive
monitoring of intracranial pressure is neither useful nor necessary in near-drowning
incidents.
• Maintain adequate oxygenation and ventilation. Prophylactic hyperventilation has no
role.
• Avoid hypotension, hypoglycemia, and hyperthermia.
• Monitor and maintain intravascular volume and blood pressure. Arterial and central
venous pressure (CVP) monitoring is useful in patients requiring intensive care.
• The early use of supplemental oxygen with high levels of positive end-expiratory
pressure (PEEP) is helpful in reversing hypoxemia. High-frequency ventilation or
extracorporeal membrane oxygenation may be needed for patients who are refractory to
conventional ventilation.
• Monitor closely for bacterial and fungal infection. Evidence is insufficient to support the
use of prophylactic antibiotics.
• Begin aggressive rehabilitation early (as soon as tolerated) to prevent disuse injury and
promote functional improvement.

Further Outpatient Care

• Outpatient care dictated by nature and degree of residual functional impairment at

discharge.

Transfer

• Patients with severe neurologic impairment may benefit from transfer to inpatient
rehabilitation institutions.

Deterrence/Prevention

• In most instances, drowning and near drowning can be prevented with simple safety
measures and common sense. Most children younger than 5 years enter a swimming
pool directly adjacent to their home or one with inadequate fencing or unlatched gates or
doors. Most children are found silently floating with no screaming or splashing noted,
were last seen in the home, and were out of sight for only moments.
• Adult supervision is essential in the prevention of drowning. Because lapses of
supervision are inevitable, other safety precautions must be in place.
• The use of adequate fencing around swimming pools has decreased the number of
immersion injuries significantly (to less than one half). The enclosure may be a wall or
fence that completely surrounds a pool on all 4 sides, isolating the pool from the
remainder of the property. The enclosure must be at least 4 ft tall with no more than 4 in
between openings in the fence. A house or building wall may serve as part of the
enclosure only if it does not have any doors or windows through which a child may pass.
Doors and gates to the pool should be self-closing and self-latching.
• Pool alarms and covers have not been shown to prevent drowning.
• The use of personal flotation devices approved by the US Coast Guard may reduce the
incidence of drowning among children when playing in natural bodies of water or when
boating. However, these devices must not be used as a substitute for appropriate adult
supervision.
• Pool owners should be instructed on basic life support.
 • Children and adults should be instructed never to swim alone or unsupervised.
• Submersion injuries may occur in toilets and water buckets. Appropriate measures must
be taken to ensure that children are never unsupervised in bathrooms, and water
buckets must be emptied when not in use.
• Infant swimming or water-adjustment programs do not prevent submersion injuries and
are potentially hazardous, providing parents with a false sense of security if they
perceive their infant can swim.
• Refraining from alcohol use while boating.
• The American Academy of Pediatrics have established guidelines for the prevention of
drowning in infants, children, and adolescents.2

Complications

• Immediate complications are secondary to hypoxia and acidosis. The immediate threats
are the effects on the central nervous and cardiovascular systems. CNS effects depend
on the severity and duration of hypoxia. Posthypoxic cerebral hypoperfusion may occur.
Long-term effects of cerebral hypoxia, including vegetative survival, are the most
devastating.
• Hypoxia and acidosis may lead to cardiac dysrhythmias, including ventricular fibrillation
and asystole. Myocardial damage may lead to cardiogenic shock. Capillary leak and
neurologic injury can predispose submersion victims to hypovolemia and hypotension.
• Aspiration of freshwater or salt water alters the function of surfactant, causing injury to
the alveoli and pulmonary capillaries. Increased capillary permeability can worsen the
hypoxia and impair ventilation.
• Near-drowning patients may develop pneumonia, although it is less common than
chemical pneumonitis, especially if the submersion occurs in a chlorinated pool or in a
bucket containing a cleaning product.
• Nonpulmonary infections, including brain abscesses, osteomyelitis, and soft tissue
infections with unusual fungal, amebic, and bacterial pathogens, may present after initial
recovery.3,4,5,6 Because the causative organisms for these infections are rarely seen in
other clinical settings, a high index of suspicion must be maintained in patients after
acute or subacute injury. Surgical consultation may be required because many of these
infections do not respond to antimicrobial therapy alone.

Prognosis

• The prognosis is directly related to the duration and magnitude of hypoxia.

• The most significant impact on morbidity and mortality occurs before the patient arrives
at the hospital.
• Poor survival is associated with the need for continued cardiopulmonary resuscitation
efforts on arrival to the hospital.
o Of these patients, 35-60% die in the ED.
o Of the survivors, 60-100% have long-term neurologic sequelae.
• Of the patients who recover from the pulmonary effects of the submersion, those who
were fully awake on arrival to the hospital generally do very well.
• The neuroprotective effects of cold-water drowning are poorly understood.
o Hypothermia profoundly decreases the cerebral metabolic rate.
o Neuroprotective effects seem to occur only if the hypothermia occurs at the time
of submersion and only if very rapid cooling occurs in water with a temperature of
less than 5°C. Helpful general rule to consider is if the child broke through ice on
the surface, indicates potential for cold water event.
o Intact survival of comatose patients after cold-water submersion injuries is still
quite uncommon.
Patient Education

• Prevention is the best approach to minimize the risk of morbidity and mortality
associated with submersion injuries.
• Children should never swim alone or unsupervised.
• Toddlers should not be near bathrooms or buckets of water outside of immediate adult
supervision.
• Families with swimming pools should ensure that all safety concerns are addressed,
especially appropriate barriers.
• Families with swimming pools should learn basic life support.
• Alcohol and drugs should not be used when operating or riding in motorized watercraft.
• For excellent patient education resources, visit eMedicine's Public Health Center and
Environmental Exposures and Injuries Center. Also, see eMedicine's patient education
articles Cardiopulmonary Resuscitation (CPR) and Drowning (CPR).