Elsevier

Critical Care Clinics

Volume 13, Issue 3, 1 July 1997, Pages 477-502
Critical Care Clinics

SUBMERSION INJURIES IN CHILDREN AND ADULTS

https://doi.org/10.1016/S0749-0704(05)70325-0Get rights and content

An ounce of prevention is worth a pound of cure.

P.C. HALIBURTON

Drowning is defined as death by suffocation after submersion in a liquid medium. Near drowning is a term used when a patient recovers, at least temporarily, from the drowning episode. Most authors include loss of consciousness while submerged to complete the criteria of near drowning. Patients who are initially resuscitated following submersion, but who expire within 24 hours, are ultimately classified as drowning victims. Immersion injury is a generic term that refers to all patients who have experienced an episode in which submersion occurred.83 Secondary drowning refers to patients who have recovered uneventfully from a submersion injury and are asymptomatic for a protracted period of time but who later succumb from respiratory failure secondary to the episode. The existence of secondary drowning has been questioned in the literature, and the term should probably not be used. Patients with so-called secondary drowning have subtle but clearly manifest respiratory compromise immediately after submersion.99 As many as 15% to 20% of near-drowning victims who ultimately expire may do so with severe respiratory failure. Nonetheless, the term secondary drowning is misleading, because most of these patients have secondary pulmonary infections and concomitant severe neurologic dysfunction.19

Section snippets

EPIDEMIOLOGY

It is estimated that 6000 to 8000 patients a year die of drowning in the United States alone. Worldwide estimates of drowning are approximately 140,000 to 150,000 deaths yearly. Drowning is the third most common cause of all accidental deaths and is the second most common cause of death in victims less than or equal to 44 years old. Forty percent of all drowning deaths are of children less than 5 years of age, with another 15% to 20% of drowning victims being between the ages of 5 and 20 years.

Education

Liller et al61 conducted a telephone survey of pool owners. They found that families had some knowledge of drowning risks but they had a deficit in their knowledge of the importance of adult supervision and did not know the recommended age to begin swimming instruction (4 to 5 years of age). Forty percent said they did not know how to perform cardiopulmonary resuscitation (CPR) on an adult and most did not know how to perform CPR on an infant or child.61 The first efforts in education must be

PATHOPHYSIOLOGY

Drowning may be subdivided into wet drowning and dry drowning. As the victim becomes submerged, breathholding occurs and panic ensues. In approximately 15% of drowning victims, severe larynogospasm prevents the aspiration of the liquid medium. In the majority of cases, however, wet drowning occurs, and the patient aspirates the water in which he or she is submerged.50

In the 1970s, a large amount of literature made the distinction between fresh water and salt water wet drowning. It was believed

FUTURE AND SUGGESTIONS

The American Academy of Pediatrics Committee on Injury and Poison Prevention has produced a list of 23 recommendations to reduce the incidence of drowning to infants, children, and adolescents. They have also recommended the establishment of a national surveillance system for childhood drowning.21 This system could identify regional risk factors for a more focused public health initiative. Although this proposition is attractive, pediatric intensivists are likely to understand the issues in

ACKNOWLEDGMENT

We express our appreciation to Mary New and Pat Bunce for coordinating submission of our multiple authors and preparing the final manuscript.

References (126)

  • W.D. Graf et al.

    Predicting outcome in pediatric submersion victims

    Ann Emerg Med

    (1995)
  • H. Heimlich

    Subdiaphragmatic pressure to expel water from lungs of drowning persons

    Ann Emerg Med

    (1981)
  • R.L. Kriel et al.

    Outcome of severe anoxic/ischemic brain injury in children

    Pediatr Neurol

    (1994)
  • M. Kuisma et al.

    Pediatric out-of-hospital cardiac arrests: Epidemiology and outcome

    Resuscitation

    (1995)
  • D.L. Levin et al.

    Drowning and near drowning

    Pediatr Clin North Am

    (1993)
  • S. Linder

    Injury as a metaphor: Towards an integration of perspectives

    Accid Anal Prev

    (1987)
  • P.A. Maningas et al.

    Regional flow during hypothermic arrest

    Ann Emerg Med

    (1986)
  • M. McBrien et al.

    Artificial surfactant in the treatment of near-drowning

    Lancet

    (1993)
  • J.H. Modell et al.

    Clinical course of 91 consecutive near-drowning victims

    (1976)
  • J.P. Orlowski

    Drowning, near-drowning and ice-water submersions

    Pediatr Clin North Am

    (1987)
  • J.P. Orlowski

    Prognostic factors in pediatric cases of drowning and near-drowning

    J Am Coll Emerg Phys

    (1979)
  • T.E. Paulson et al.

    New concepts in the treatment of children with acute respiratory distress syndrome

    J Pediatr

    (1995)
  • F.D. Pratt et al.

    Incidence of secondary drowning after saltwater submersion

    Ann Emerg Med

    (1986)
  • F.D. Allman et al.

    Outcome following cardiopulmonary resuscitation in severe near-drowning

    Am J Dis Child

    (1986)
  • S. Ashwal et al.

    Prognostic implications of hyperglycemia and reduced cerebral blood flow in child of near-drowning

    Neurology

    (1990)
  • P.S. Auerbach

    Some people are dead when they're cold and dead

    JAMA

    (1990)
  • D.M. Bofetiado et al.

    Alkaloid delta agonist BW373U86 increases hypoxic tolerance

    Anesth Analg

    (1996)
  • D.J. Bohn et al.

    Influence of hypothermia, barbiturate therapy, and intracranial pressure monitoring on morbidity and mortality after near-drowning

    Crit Care Med

    (1986)
  • R.G. Bolte et al.

    The use of extracorporeal rewarming in a child submerged for 66 minutes

    JAMA

    (1988)
  • S.I. Bratton et al.

    Serial neurologic examinations after near drowning and outcome

    Arch Pediatr Adolesc Med

    (1994)
  • Briefing Package on Child Drownings in Residential Pools

    (1987)
  • M.H. Bross et al.

    Near-drowning

    Am Fam Physician

    (1995)
  • R.A. Calder et al.

    Drownings in Florida, 1977–1986

    J Fl Med Assoc

    (1990)
  • H.W. Calderwood et al.

    The ineffectiveness of steroid therapy for treatment of fresh water near-drowning

    Anesthesiology

    (1985)
  • Centers for Disease Control

    Fatal injuries to children - United States, 1986

    MMWR

    (1990)
  • D.S. Cohen et al.

    Pulmonary edema associated with salt water near-drowning

    Am Rev Respir Dis

    (1992)
  • Committee on Accident and Poison Prevention

    Injury Control for Children and Youth

    (1987)
  • Committee on Injury and Poison Prevention

    Drowning in infants, children and adolescents

    Pediatrics

    (1993)
  • A.W. Conn et al.

    Fresh water drowning and near-drowning—an update

    Can J Anaesth

    (1984)
  • A.W. Conn et al.

    Near-drowning in cold fresh water: Current treatment regimen

    Can J Anaesth

    (1978)
  • A. Conn et al.

    Cerebral salvage in near-drowning following neurologic classification by triage

    Can J Anaesth

    (1980)
  • A.F. Connors et al.

    The effectiveness of right heart catheterization in the initial care of critically ill patients

    JAMA

    (1996)
  • Consumer Product Safety Commission

    A Handbook for Public Playground Safety, vols 1 and 2

    (1981)
  • H.M. Cornell

    Accidental hypothermia

    J Pediatr

    (1992)
  • J.M. Dean et al.

    Prognostic indicators in pediatric near-drowning: The Glasgow coma scale

    Crit Care Med

    (1981)
  • P.B. Everett et al.

    Profile of drowning victims in a coastal community

    Journal of the Florida Medical Assoication

    (1989)
  • I. Fandel et al.

    Near-drowning in children: Clinical aspects

    Pediatrics

    (1976)
  • D. Fiser

    Near-drowning

    Pediatr Rev

    (1993)
  • B. Fisher et al.

    Use of brain stem auditory evoked response testing to assess neurological outcome following near-drowning in children

    Crit Care Med

    (1992)
  • Cited by (0)

    Address reprint requests to Lucian K. DeNicola, MD, FCCM, Division of Pediatric Critical Care, University of Florida Health Science Center/Jacksonville, 820 Prudential Drive, Suite 203, Jacksonville, FL 32207

    View full text