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SUBMERSION INJURIES

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The World Health Organization (WHO) estimates the annual incidence of death by drowning to be approximately 500,000 a year worldwide; and in males aged 5-14 years, the leading cause of death worldwide. The pediatric population is most at risk for drowning events. Submersion injuries are the second leading cause of death from unintentional injuries in children aged 1-18 years, and leading cause of accidental death in children aged 1-4 years. For 2009, the Centers for Disease Control and Prevention (CDC) reported 983 fatal and 5,624 nonfatal injuries due to unintentional drowning or submersion injuries in the pediatric population.

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EPIDEMIOLOGY

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Age distribution of drowning incidents in the pediatric population follows a bimodal distribution. The first and larger peak occurs among children aged 1-4 years who are inadequately supervised in swimming pools, bathtubs, buckets, and other bodies of water. The second age peak occurs among adolescent males, which has been attributed to higher risk-taking behavior, overestimating of swimming abilities, use of alcohol and/or illicit drugs, and greater exposure to bodies of water. There exists a higher drowning rate in African American and Native American children. Drowning is much more common during the summer months when swimming pools, beaches, and other bodies of water are more frequented, particularly during daylight hours and on weekends. There are special populations at increased risk for drowning, specifically patients with epilepsy, children with developmental delay, and individuals with long QT syndrome or other cardiac arrhythmias.

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DEFINITION

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Historically, there has been considerable confusion due to the varied terminology used to describe drowning symptoms. In 2002, the World Congress on Drowning met and ­established the official Utstein style which standardized the medical discourse currently used. The following terms have been abandoned in medical discourse: dry versus wet drowning; active versus silent drowning; secondary drowning; near-drowned. The Utstein style defines drowning as “a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium.” Implicit in this definition is that a liquid/air interface is present at the entrance of the victim’s airway, preventing the victim from breathing air.

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PATHOPHYSIOLOGY

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The drowning process begins when the victim’s airway lies below the surface of liquid, usually water, at which time the victim voluntarily holds his or her breath. The breath-­holding period is followed by an involuntary period of laryngospasm secondary to the presence of liquid in the oropharynx or larynx. The lack of ventilation and oxygenation results in hypoxia and ultimately death if the process is not reversed. The majority of submersion injuries involve aspiration of liquid. The distinction between freshwater and saltwater drowning historically was significant due to concerns that the tonicity of water could cause major electrolyte ­disturbances, and influenced past treatment and management protocols. It is now recognized that this distinction has no bearing on the treatment of victims. Aspiration of more than 11 mL/kg of body weight ...

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