Understanding the Epidemiology & Pathophysiology of Drowning: Implications for Prevention and Resuscitation

• Drowning Definition:
  • Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid.
  • It can be fatal, nonfatal with complications, or nonfatal without complications.
• Epidemiology:
  • Drowning accounts for approximately 300,000 unintentional drowning deaths globally.
  • Over 90% of these deaths occur in low- and middle-income countries.
  • Drowning is in the top five causes of death for children 1-14 years old in many countries.
  • Low-income and minority groups have a higher burden from drowning.
• Other Causes and Data:
  • Other causes of drowning, such as transportation accidents and intentional drowning, are not included in the standard definition.
  • Nonfatal drowning data is limited and varies based on location.
  • Different drowning patterns can be observed based on local context.
• Pathophysiology:
  • The drowning process begins with respiratory impairment and can lead to fatal drowning if not interrupted.
  • Coughing and hypoxemia occur as water enters the airways.
  • Cerebral damage occurs after 5-10 minutes of submersion.
  • Water in the alveoli causes surfactant destruction and pulmonary edema.
• Drowning Chain of Survival:
  • The drowning chain of survival shows the steps to reduce drowning risk and severity.
  • Prevention is the most effective way to reduce drowning.
  • Recognizing distress and calling for help is crucial.
• Prevention:
  • 80-90% of drownings can be prevented with appropriate measures.
  • Multifactorial approaches to prevention are available from organizations like the WHO.
• Recognize Distress and Call for Help:
  • Recognizing a person in distress and activating help is an important step.
  • The instinctive drowning response (IDR) may not always be the only visible drowning behavior.
• Conclusion:
  • Drowning is a global public health issue that can be prevented.
  • Understanding the epidemiology and pathophysiology is essential for effective prevention strategies.
• Provide flotation to stop the process of drowning:
  • Flotation devices like ring buoys or improvised buoyancy aids can be used to provide flotation and reduce submersion risk.
  • Approaching a struggling person with an intermediary object is recommended to avoid becoming another drowning victim.
• In-water ventilation for unconscious persons:
  • In-water ventilation can increase neurologically intact survival for unconscious drowning victims.
  • If there is no response, the person should be moved to a boat or dry land for effective chest compressions.
• Remove from water: Rescue only if safe to do so:
  • Several strategies can be used to remove a person from the water, such as directing them to the closest exit or throwing a floating object.
  • Entering the water should be a personal decision based on various factors, and wearing a lifejacket is recommended.
  • Rapid transport to shore for unconscious persons is important to minimize the hypoxic period.
• Professional lifeguards and equipment:
  • The incidence of in-water cervical spine injury is low, so immobilization should not delay oxygenation and extrication.
  • Once on land, proper positioning and resuscitation techniques should be followed.
  • Cardiopulmonary resuscitation (CPR) should be performed by professional rescuers with breaths and compressions.
  • Compression-only CPR is less effective, and initial breaths are crucial for drowning victims.
• Early basic life support for better outcomes:
  • Ventilation should be started with 5 initial breaths followed by chest compressions until signs of life reappear.
  • Presence of noncardiogenic pulmonary edema fluid makes initial ventilation difficult.
  • Efforts to expel water from the airway should be avoided to prevent aspiration injury.
  • Compression-only CPR is not recommended for drowning victims.
  • Considerations for ventilation during the COVID-19 pandemic and the use of AED in drowning resuscitation.
• AED and prehospital advanced life support:
  • AED effectiveness in drowning resuscitation scenario is low, and optimization of oxygenation, ventilation, and compressions is important.
  • Medical equipment should be brought to the patient instead of delaying care.
  • Recommendations for when to initiate and discontinue CPR for drowning cases.
• Initial Resuscitation:
  • Effective ventilation is crucial in drowning resuscitation.
  • Positive end-expiratory pressure (PEEP) should be used for optimal oxygenation.
• Drug Administration:
  • Peripheral venous or intraosseous access is preferred for drug administration.
  • Endotracheal administration of drugs is not recommended.
• Transport to Hospital:
  • If initial resuscitation is not successful, transport to a hospital with neuroprotective therapies is necessary.
  • Consider transfer to ECMO-capable hospitals for further treatment.
• Oxygenation and Ventilation:
  • Continue oxygen administration until spontaneous breathing is restored.
  • Intubation and mechanical ventilation may be needed for inadequate oxygenation.
• Hypotension:
  • If hypotension persists, a rapid crystalloid infusion should be used.
  • Consider pneumothorax as a potential cause of hypotension.