Home > Encyclopedia of Nursing & Allied Health > Near-Drowning

Definition

Near-drowning is the term used for survival after suffocation caused by submersion in water or other fluid or liquid.

Description

An estimated 15,000–70,000 near-drownings occur in the United States each year; insufficient reporting prevents a more precise estimate. A typical person experiencing near-drowning is young and male. Nearly half of all drownings and near-drownings involve children less than four years old. Because home swimming pools are the sites for 60–90% of drownings in the 0–4 age group, they pose the greatest risk for children. Teenage boys are also at heightened risk for drowning and near-drowning; drugs and alcohol are implicated in 40–50% of teenage drownings. Overall, roughly four out of five drowning victims are males.

Causes and symptoms

On many occasions, near-drownings are secondary to an event such as a heart attack that causes unconsciousness or a head or spinal injury that prevents a diver from resurfacing. Near-drownings, moreover, can occur in shallow as well as deep water. Small children have drowned or almost drowned in bathtubs, toilets, industrial-size cleaning buckets, and washing machines. Bathtubs are especially dangerous for infants between six months and one year of age, who can sit up straight in a bathtub but may lack the ability to pull themselves out of the water if they slip under the surface.

A reduced concentration of oxygen in the blood (hypoxemia) is common to all near-drownings. When drowning begins, the larynx (air passage) closes involuntarily, preventing both air and water from entering the lungs. In 10–15% of cases, hypoxemia results because the larynx stays closed; this is called dry drowning. Hypoxemia also occurs in wet drownings, the 85–90% of cases where the larynx relaxes and water enters the lungs. Only a small amount of either freshwater or saltwater is needed to damage the lungs and interfere with the body's oxygen intake. Within three minutes of submersion, most people are unconscious. Within five minutes, the brain begins to suffer from lack of oxygen. Abnormal heart rhythms (cardiac dysrhythmias) often occur in near-drowning cases, and the heart may stop pumping (cardiac arrest). An increase in blood acidity (acidosis) is another consequence of near-drowning and, under some circumstances,

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KEY TERMS

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Acidosis—An increase in acid content of the blood manifested by a decrease in blood pH below 7.40.

Cardiac arrest—Cessation of heartbeats.

Cardiac dysrhythmias—Abnormal heart rhythms.

Cyanosis—A blue color of the skin caused by inadequate oxygen in the blood.

Dry drowning—Hypoxemia due to closure of the larynx.

Endotracheal intubation—Inserting a tube in the trachea to maintain an open airway.

Hypothermia—A decrease in the internal temperature of the body to a core temperature below 96°F (35.6°C).

Hypoxemia—A reduced concentration of oxygen in the blood.

Tachycardia—Rapid heart rate.

Tachypnea—Rapid breathing.

Trachea—Windpipe.

Wet drowning—Water entering the lungs due to relaxation of the larynx.

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near-drowning can cause a substantial increase or decrease in the volume of circulating blood. Many individuals experience a severe drop in body temperature (hypothermia).

The signs and symptoms of near-drowning can differ widely from person to person. Some people are alert but agitated, while others are comatose. Breathing may have stopped in one person, while another may be gasping for breath. Bluish skin (cyanosis), coughing, and frothy pink sputum (material expelled from the respiratory tract by coughing) are often observed. Rapid breathing (tachypnea), a rapid heart rate (tachycardia), and a low-grade fever are common during the first few hours after rescue. People who have experienced near-drowning but remain conscious may appear confused, lethargic, or irritable.

Diagnosis

Diagnosis relies on a physical examination and on a wide range of tests and other procedures. Blood is taken to measure oxygen levels. Pulseoximetry is another way of assessing oxygen levels. An electrocardiograph is used to monitor heart activity. X rays, computed tomography (CT) scans, or magnetic resonance imaging (MRI) scans can detect head and neck injuries and excess tissue fluid (edema) in the lungs.

Treatment

Treatment begins with removing the victim from the water and performing cardiopulmonary resuscitation (CPR). One purpose of CPR is to bring oxygen to the lungs, heart, brain, and other organs by breathing into a person's mouth. When someone's heart has stopped, CPR also attempts to get the heart pumping again by pressing down on the chest. After CPR has been performed and emergency medical help has arrived on the scene, oxygen is administered. If the person's breathing has stopped or is otherwise impaired, a tube is inserted into the windpipe (trachea) to maintain the airway (endotracheal intubation). The person is also checked for head, neck, and other injuries, and intravenous fluids are given. Hypothermia cases require careful handling to protect the heart.

In the emergency department, victims who have experienced near-drowning continue receiving oxygen until blood tests show a return to normal. About one-third of the patients are intubated and initially need mechanical support to breathe. Re-warming is undertaken when hypothermia is present. People may arrive requiring treatment for cardiac arrest or cardiac dysrhythmias. Comatose patients present a special problem. Although various treatment approaches have been tried, none have proved beneficial. Many of these patients die.

People can be discharged from the emergency department after four to six hours if their blood oxygen level is normal, and no signs or symptoms of near-drowning are present. Because lung problems can arise 12 or more hours after submersion, the medical staff must emphasize that the individuals must seek further medical help, if necessary. Admission to a hospital for at least 24 hours for further observation and treatment is a must for people who do not appear to recover fully in the emergency department.

Prognosis

Neurological damage is the major long-term concern in the treatment of people experiencing near-drowning. Those who arrive at an emergency department awake and alert usually survive with brain function intact, as do about 90% of those who arrive mentally impaired (lethargic or confused) but not comatose. Death or permanent neurological damage is very likely when individuals arrive in a comatose condition. Early rescue of people experiencing near-drowning (within five minutes of submersion) and prompt application of CPR (within less than 10 minutes of submersion) seem to be the best predictors of a complete recovery.

Health care team roles

First aid can be administered by anyone with proper training. This may include CPR. Paramedics may provide support during transport to a hospital. Physicians commonly evaluate and provide treatment in an emergency department. Nurses provide emergency and supportive care. Therapists may be called upon to provide follow-up counseling.

Prevention

Prevention depends on educating parents, other adults, and teenagers about water safety.

Parents must realize that young children who are left in or near water without adult supervision, even for a short time, can easily get into trouble. Experts consider putting up a fence around a home swimming pool an essential precaution, and estimate that 50–90% of child drownings and near-drownings could be prevented if fences were widely adopted. The fence should be at least five feet (1.5 m) high, have a self-closing and self-locking gate, and completely surround the pool.

Pool owners and all other adults should consider learning CPR. Everyone should follow the rules for safe swimming and boating. Those who have a medical condition that can cause a seizure or otherwise threaten safety in the water are advised always to swim with a partner. People need to be aware that alcohol and drug use substantially increase the chances of an accident.

L. Fleming Fallon, Jr., M.D., Dr.P.H.