Drownings

By: Alex Muller, Lauren Harnois, Anna Kuruc, and Urvinder Kaur

Accidents are just that, accidents. They are often times unavoidable and no one is to blame. In contrast to to what you might expect, drowning accidents are rarely the cause of neglectful parenting, and usually occur while children are under the supervision of adults. Drowning accidents strike families of all races, economic status, and education levels and is the third leading avertable cause of unintentional death worldwide. Children under the age of five account for the highest drowning mortality rate. ¹ Drowning occurs when someone experiences respiratory impairment while immersed in water. With a prolonged period of time submerged in water, both respiratory and cardiac arrest quickly follow. When a victim reaches this stage, it becomes important to start cardiopulmonary resuscitation and limit the length of time the body is without oxygen. As the knowledge of medicine advances and people begin to understand the significance of good compressions to improve blood circulation to the brain and other vital organs, the success rate of nonfatal drowning improves. For every pediatric drowning death, at least two survivors are hospitalized; however, if the child goes without oxygen for an extended period of time, multiorgan failure occurs and devastating disabilities may develop. ²

According to the literature on drowning, whether the child experienced respiratory or cardiac arrest, multiorgan system failure was almost always guaranteed to occur, with the respiratory system often being the first system to fail. When a child is brought to the hospital after experiencing a drowning or near-drowning episode, it is important for the medical staff to address or prevent hypoxic-ischemic brain injury, the most frequent cause of death in drowning victims. ³ When the brain is deprived of oxygen and blood flow for too long, it sustains significant damage and begins to shut down to prevent further harm. Hypoxic brain injury occurs secondary to lung injury, which is characterized by abnormal surfactant function and dysfunctional capillary endothelial permeability. This lung injury can progress to increased intrapulmonary shunting, ventilation and perfusion mismatching, atelectasis, poor lung compliance, acute respiratory distress syndrome, and ultimately respiratory failure. ³ The longer the respiratory system remains in this compromised state, the greater the risk for neurologic and cardiovascular impairments. Immediate CPR and supportive ventilator care have been shown to help improve outcomes and limit multiorgan function failure by preventing secondary organ insults in the post-resuscitation period. ³

Understandably, as the body fills with fluid, immediate impairment occurs, creating a trickle down effect on the rest of the organ systems. Pneumonia and other infections become apparent anytime an individual aspirates water into the lungs. In the process of drowning, a child might swallow a large amount of water; however, only a small quantity may actually make its way into the lungs. Unfortunately, any time aspiration into the lungs occurs, the risk of infection increases, even in previously healthy individuals. When a drowning victim is brought to the emergency room, antibiotics are quickly administered to prophylactically fight any potential infection, reducing the risk of multiorgan dysfunction. Depending on the type of water: fresh, salt, or muddy, the medical staff can determine the strength and dose of an antibiotic to be delivered. In the case of muddy water, which will have a larger amount of bacteria and fungi, both antibacterial (piperacillin) and antifungal (tazobactam) therapy will be initiated. ⁴ Once the medical team receives both microbiology and culture results, they can readjust the medications to direct treatment at the specific gram negative/positive bacteria or fungal infection. When the medical team delays the delivery of antibiotics and antifungal therapy, the infection can begin to spread, inhibiting the child from quickly recovering, and increases the risk of the child developing further complications such as respiratory failure. In addition to antimicrobial therapies, it is important to maintain intracranial pressures and temperatures to prevent further problems. Sadly, hypothermia below 27° C results in loss of deep tendon and capillary reflexes concluding death. With the realization that drowning occurrences can be prevented, taking proper precautions and understanding appropriate protocols will hopefully reduce the number of lives affected by drownings.

 

 

References:

1. Nitta M, Kitamura T, Iwami T, Nadkarni VM, Berg RA, Topjian AA, et al. Out-of-hospital cardiac arrest due to drowning among children and adults from the Utstein Osaka Project. Resuscitation 2013;84(11):1568-1573.
2. Ishaque M, Manning JH, Woolsey MD, Franklin CG, Tullis EW, Fox PT. Lenticulostriate arterial distribution pathology may underlie pediatric anoxic brain injury in drowning. Neuroimage Clin 2016;11:167-172.
3. Mtaweh H, Kochanek PM, Carcillo JA, Bell MJ, Fink EL. Patterns of multiorgan dysfunction after pediatric drowning. Resuscitation 2015;90:91-96.
4. Gerlach MM, Lippmann N, Kobelt L, Petzold-Quinque S, Ritter L, Kiess W, et al. Possible pulmonary Rhizopus oryzae infection in a previously healthy child after a near-drowning incident. Infection 2015.