Drowning Clinical Presentation

  • Author: Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM; Chief Editor: Rick Kulkarni, MD   more...
 
Updated: Aug 23, 2011
 

History

All aspects of the drowning episode should be determined, including the circumstances around the actual submersion. 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.

Typical incidents involve a toddler left unattended temporarily or under the supervision of an older sibling, an adolescent found floating in the water, or a victim diving and not resurfacing. Less typically, drowning may be a deliberate form of child abuse and infant homicide, including Munchhausen syndrome by proxy.

Intentional newborn deaths

In an analysis of intentional newborn deaths (72 coroner cases < 1 year old), 2 of the major causes were asphyxiation by strangulation (41%) and drowning (27%).[48] Studies have identified the following as risk factors for such newborn deaths:

  • Young and unmarried mothers
  • Parental depression
  • Family financial problems
  • Residence of the mother and child in households with unrelated male adults

The infant often was found to be at home alone with the caretaker-perpetrator (93%) and was crying. The authors suggest that these incidents may be impulsive, largely unintended, and result from stress.[49] A study by Dias et al, suggested that targeted hospital-based education and social service involvement may be effective in reducing these cases.[50]

Drowning factors

Relevant factors in drowning cases include the following:

  • Age of the victim
  • Submersion time
  • Water temperature
  • Water tonicity
  • Degree of water contamination
  • Symptoms
  • Associated injuries (especially cervical spine and head)
  • Coincident alcohol or drug use
  • Underlying medical conditions
  • Type and timing of rescue and resuscitation efforts
  • Response to initial resuscitation

Thermal conduction of water is 25-30 times that of air. The temperature of thermally neutral water, in which a nude individual's heat production balances heat loss, is 33°C. Physical exertion increases heat loss secondary to convection/conduction up to 35-50% faster.

A significant risk of hypothermia usually develops in water temperatures less than 25°C, which is the temperature found in most US natural waters during the majority of the year.

During immersion in ice water, a person will become hypothermic in approximately 30 minutes. Cooling at this temperature becomes life-threatening in approximately 60 minutes.[51]

Other important historical factors include the following:

  • Shortness of breath, difficulty breathing, apnea
  • Persistent cough, wheezing
  • In stream, lake, or saltwater immersion, possible aspiration of foreign material or exposure to fungi, bacteria, and other microorganisms
  • level of consciousness at presentation, history of loss of consciousness, anxiety, fatigue, changes in usual behavior; Modell suggests that most individuals will have some period of unconsciousness after drowning secondary to cerebral hypoxia[52]
  • Vomiting, diarrhea
  • Coincident alcohol or drug use

Pertinent past medical history

Underlying medical conditions that are particularly more likely to lead to drowning include the following:

  • Seizure disorder
  • Diabetes mellitus
  • Psychiatric illness
  • Severe arthritis
  • Cardiac disease
  • Neuromuscular disorder

A United Kingdom study found a 15- to 19-fold increase in the risk of drowning in individuals with epilepsy.[53]

A number of studies worldwide have documented that drowning is a not infrequent method for suicide, especially among older individuals. Cultural attitudes toward death, water source availability and accessibility, social acceptability of this method, gender, and age may influence drowning as the method of choice.[54, 55, 56]

Cardiac history is important to obtain, especially that of dysrhythmias and syncope. Ion channelopathies and sudden arrhythmic death syndromes, including Brugada syndrome and prolonged QT syndrome, should be considered[28] ; however, this cause of drowning is probably uncommon. Lunetta et al looked for genetic mutations in 63 drowning victims and failed to document one case of long QT founder gene mutation.[7]

Next

Physical Examination

The clinical presentations of people who experience submersion injuries vary widely. A drowning victim may be classified initially into 1 of the following 4 groups:

  • Asymptomatic
  • Symptomatic
  • Cardiopulmonary arrest
  • Obviously dead

Patients are especially likely to be asymptomatic if they experienced brief, witnessed submersions with immediate resuscitation.

Symptomatic patients may exhibit the following:

  • Altered vital signs (eg, hypothermia, tachycardia or bradycardia)
  • Anxious appearance
  • Tachypnea, dyspnea, or hypoxia: If dyspnea occurs, no matter how slight, the patient is considered symptomatic
  • Metabolic acidosis (may exist in asymptomatic patients as well)
  • Altered level of consciousness, neurologic deficit
  • Cough
  • Wheezing
  • Hypothermia
  • Vomiting, diarrhea, or both

Patients in cardiopulmonary arrest exhibit the following:

  • Apnea
  • Asystole (55%), ventricular tachycardia/fibrillation (29%), bradycardia (16%)
  • Immersion syndrome

In cases of obvious death due to drowning, the following are present:

  • Normothermia with asystole
  • Apnea
  • Rigor mortis
  • Dependent lividity
  • No apparent CNS function
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Contributor Information and Disclosures
Author

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM  Associate Professor, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Michael J Verive, MD  Medical Director, Pediatric Intensive Care, Department of Pediatrics, St Mary's Hospital for Women and Children

Michael J Verive, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, Pediatric Sedation, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

G Patricia Cantwell, MD, FCCM  Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami, Leonard M Miller School of Medicine; Medical Director, Palliative Care Team, Director, Pediatric Critical Care Transport, Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Manager, FEMA, Urban Search and Rescue, South Florida, Task Force 2; Pediatric Medical Director, Tilli Kids – Pediatric Initiative, Division of Hospice Care Southeast Florida, Inc

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

William H Shoff, MD, DTM&H  Director, PENN Travel Medicine; Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine

William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Glaxo Smith Kline None None; Glaxo Smith Kline Honoraria Speaking and teaching

Specialty Editor Board

Robert L Norris, MD  Professor, Department of Surgery, Chief, Division of Emergency Medicine, Stanford University Medical Center

Robert L Norris, MD is a member of the following medical societies: American College of Emergency Physicians, American Medical Association, California Medical Association, International Society of Toxinology, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Eddy S Lang, MDCM, CCFP(EM), CSPQ  Associate Professor, Senior Researcher, Division of Emergency Medicine, Department of Family Medicine, University of Calgary Faculty of Medicine; Assistant Professor, Department of Family Medicine, McGill University Faculty of Medicine, Canada

Eddy S Lang, MDCM, CCFP(EM), CSPQ is a member of the following medical societies: American College of Emergency Physicians, Canadian Association of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Barry J Evans, MD  Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Chief Editor

Rick Kulkarni, MD  Attending Physician, Department of Emergency Medicine, Cambridge Health Alliance, Division of Emergency Medicine, Harvard Medical School

Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: WebMD Salary Employment

Additional Contributors

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous authors James Martin, MD, and Michael Fiore, MD, to the development and writing of the source articles.

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