AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Background

Submersion injuries are a significant cause of death and disability in children, second only to accidental trauma. At least one third of survivors sustain moderate to severe neurologic sequelae. Although no uniform classification for submersion injuries exists, drowning is usually defined as death from asphyxia within 24 hours of submersion in water. Near drowning refers to survival (even if temporary) beyond 24 hours after a submersion episode.

Submersion injuries may be further classified as cold-water or warm-water injuries. Warm-water drowning occurs at water temperatures of 20°C or higher, and cold-water drowning occurs at water temperatures of less than 20°C. Some references include very-cold-water drowning, which refers to submersion in water at temperatures of 5°C or less.

Additional classification may include the type of water in which the submersion occurred, such as fresh-water and salt-water submersion injury. The distinction between fresh-water and salt-water submersion injury, however, is primarily academic, as initial treatment is not affected by water type.

Pathophysiology

Submersion injury occurs when a person is submerged in water, attempts to breathe, and either aspirates water (wet drowning) or has laryngospasm without aspiration (dry drowning). Although most patients with submersion injury have aspirated a small amount of water or gastric contents into their lungs, approximately 10-15% of patients have become asphyxiated without evidence of aspiration. The most important contributory factors to morbidity and mortality from near drowning are hypoxemia and a decrease in oxygen delivery to vital tissues. The pathophysiology of near drowning is intimately related to the multiorgan effects of hypoxemia. CNS damage may occur because of hypoxemia sustained during the drowning episode (primary injury) or may result from ongoing pulmonary injury, reperfusion injury, or multiorgan dysfunction (secondary injury), particularly with prolonged tissue hypoxia.

Although differences observed between fresh-water and salt-water aspirations in electrolyte and fluid imbalances are frequently discussed, they are rarely of any clinical significance for people who have experienced near drowning. Most patients have fluid aspiration of less than 4 mL/kg. Fluid aspiration of at least 11 mL/kg is required for alterations in blood volume to occur, and aspiration of more than 22 mL/kg is required before significant electrolyte changes develop. Ingestion, rather than aspiration, is more likely to cause clinically significant electrolyte imbalances, including hyponatremia from ingestion of large volumes of fresh water (especially in children).

Central nervous system effects

CNS injury remains the major determinant of subsequent survival and long-term morbidity in cases of near drowning. Primary CNS injury is initially associated with tissue hypoxia and ischemia. If the period of hypoxia and ischemia is brief or if the person is a very young child who rapidly develops core hypothermia, primary injury may be limited, and the patient may recover with minimal neurologic sequelae. However, submersion injuries that are associated with prolonged hypoxia or ischemia, especially in older patients who cannot rapidly achieve core hypothermia, are likely to lead to both significant primary injury and secondary injury from reperfusion, sustained acidosis, cerebral edema, hyperglycemia, release of excitatory neurotransmitters, seizures, hypotension, and impaired cerebral autoregulation.

Although cerebral edema is a common consequence of prolonged submersion (or submersion followed by prolonged circulatory insufficiency), retrospective reviews and animal studies have not demonstrated any benefit from the use of intracranial pressure monitoring with diffuse axonal injury. However, as submersion injuries may be associated with trauma (especially to the head, neck, and trunk), focal or persistent neurologic deficit may indicate mass lesions or other injury amenable to surgical intervention.

Autonomic instability (diencephalic/hypothalamic storm) is common following severe traumatic, hypoxic, or ischemic brain injury, often presenting with signs and symptoms of hyperstimulation of the sympathetic nervous system (including tachycardia, hypertension, tachypnea, diaphoresis, agitation, muscle rigidity).

CNS infection, an uncommon but serious complication of near drowning, may result from unusual soil and waterborne bacteria and fungi, including Pseudallescheria boydii and Scedosporium apiospermum. These infections are usually insidious in onset, typically occurring more than 30 days after the initial submersion injury.

Pulmonary effects

Fluid aspiration of as little as 1-3 mL/kg can result in significantly impaired gas exchange, primarily secondary to altered surfactant function. Fresh water is considerably hypotonic relative to plasma and causes disruption of alveolar surfactant. Salt water, which is hyperosmolar, increases the osmotic gradient and therefore draws fluid into the alveoli, diluting surfactant (surfactant washout).

Altered surfactant volume, function, or both result in atelectasis and pronounced injury to the alveoli-capillary unit, resulting in lower functional residual capacity and pulmonary edema. Acute respiratory distress syndrome (ARDS) from altered surfactant function and neurogenic pulmonary edema is a common complication in survivors of submersion injury. Increased airway resistance secondary to plugging of the patient's airway with debris, as well as release of inflammatory mediators that result in vasoconstriction, may impair gas exchange. Ventilator-associated lung injury (VALI) can further compromise noncompliant, edematous lung tissue. Newer modes of ventilation, including high-frequency oscillatory ventilation and airway pressure release ventilation, can help support ventilation and oxygenation with less risk of VALI than that associated with older methods of ventilation.

Pneumonia is a rare consequence of submersion injury and is more common with submersion in stagnant, warm, and fresh water. As with CNS infections, uncommon pathogens, including Aeromonas, Burkholderia, and Pseudallescheria, cause a disproportionate percentage of cases of pneumonia. Because pneumonia is uncommon early in the course of treatment of submersion injuries, the use of prophylactic antimicrobial therapy has not proven to be of any benefit.

Cardiovascular effects

Hypovolemia is primarily secondary to fluid losses from increased capillary permeability. Profound hypotension may occur during and after the initial resuscitation period, especially when rewarming is accompanied by vasodilatation. Myocardial dysfunction may result from ventricular dysrhythmias, pulseless electrical activity (PEA), and asystole due to hypoxemia, hypothermia, acidosis, or electrolyte abnormalities (less common). In addition, hypoxemia may directly damage the myocardium, decreasing cardiac output. Pulmonary hypertension may result from the release of pulmonary inflammatory mediators, increasing right ventricular afterload and thus decreasing both pulmonary perfusion and left ventricular preload. However, although cardiovascular effects may be severe, they are usually transient, unlike severe CNS injury.

Other effects

The clinical course may be complicated by multiorgan system failure resulting from prolonged hypoxia, acidosis, rhabdomyolysis, acute tubular necrosis, or infection or from the treatment modalities. Disseminated intravascular coagulation (DIC), hepatic and renal insufficiency, metabolic acidosis, and gastrointestinal injuries must be considered and appropriately managed.

Frequency

United States

According to data from the 1997 National Center for Health Statistics, drowning is the second leading cause of injury-related deaths in children aged 1-14 years. (In California, Arizona, and Florida, it is the number one cause of injury-related death.) The US Consumer Product Safety Commission reports that a swimming pool is 14 times more likely than a motor vehicle to be involved in the death of a child younger than 5 years. The overall drowning and submersion injury death rate was 1.93/100,000 people for all age groups in 1995. Peak incidence of 3.22/100,000 injury deaths occurred in children younger than 4 years.

Mortality/Morbidity

More than 1500 children die in the United States each year from submersion injuries. For every drowning death in this country, an estimated 4 additional hospitalizations and 14 emergency department visits are due to submersion injuries. It is also estimated that approximately 1 in 8 males and 1 in 23 females experience some form of water-associated accident but never seek medical attention.

Boating and related water sports, combined with alcohol consumption, increase both the likelihood and severity of submersion injuries. Risk-taking behaviors, especially in males, are similarly associated with increased morbidity and mortality.

As early resuscitation is associated with improved outcomes, many studies have attempted to determine clinical, laboratory, or other variables to identify which patients would benefit from resuscitative efforts. Although no individual characteristics have been found to predict survivability, the Orlowski score has been found to identify the likelihood of neurologically intact survival. In using the Orlowski score, 1 point is given for each item; scores of 2 or less are associated with a 90% likelihood of complete recovery, and submersion-injury patients with scores of 3 or more have only a 5% chance of survival. The items in the Orlowski score are as follows:

1. Age 3 years or older
2. Submersion time of more than 5 minutes
3. No resuscitative efforts for more than 10 minutes after rescue
4. Comatose on admission to the emergency department
5. Arterial pH of less than 7.10

Anecdotal reports of survival exist for children with moderate hypothermic submersion (core temperature <32°C), but most persons experiencing cold-water submersion do not develop hypothermia rapidly enough to decrease cerebral metabolism before severe, irreversible hypoxia and ischemia occur.

Sex

Males are approximately 4 times more likely than females to have submersion injuries. This rate is consistent with increased risk-taking behavior in boys, especially in adolescence. Males are also 12 times more likely than females to be involved in a boat-related drowning.

Age

A bimodal age distribution exists for persons with a submersion injury. Children younger than 4 years and adolescents aged 15-19 years are at highest risk. This bimodal distribution exists predominantly in males, who have a much higher incidence of submersion injuries during adolescence than females do. Most toddlers drown in swimming pools and bathtubs, whereas most adolescents drown in natural bodies of water.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

History

All aspects leading to the submersion episode should be determined. 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. Witnessed events may include experienced swimmers not resurfacing after a dive. Relevant factors include submersion time, associated trauma, drug or alcohol ingestion, type of water, amount of water contamination, water temperature, and attempted rescue maneuvers.

• Medical history must be obtained to look for a secondary cause or causes of drowning, including one or more of the following:
• • Trauma (accidental and intentional)
  • Seizures
  • Cardiac disease, dysrhythmias, and syncope
  • Exhaustion and hypothermia
  • Hypoglycemia
  • Alcohol and drug use

Physical

The clinical presentations of people who experience submersion injuries vary greatly.

• Asymptomatic, especially in brief, witnessed submersions with immediate resuscitation
• Symptomatic
• • Cough
  • Dyspnea
  • Wheezing
  • Hypothermia
  • Bradycardia or tachycardia
  • Vomiting, diarrhea, or both
  • Anxiety
  • Altered mental status
• Cardiopulmonary arrest
• • Cardiac arrhythmias (ventricular tachycardia, ventricular fibrillation, bradycardia)
  • Apnea
• Death

Causes

Drowning and near-drowning events must be thought of as primary or secondary events. Secondary causes of drowning include seizures, head or spine trauma, cardiac arrhythmias, hypothermia, alcohol and drug ingestion, syncope, apnea, hyperventilation, suicide, and hypoglycemia. Causes grouped by age of persons follows:

• In infants younger than 1 year
• • Bathtubs and buckets of water are the most common means of drowning.
  • Child abuse should be considered in all such cases.
• In children aged 1-5 years: Residential swimming pools are the most common venue.
• In young adults aged 15-19 years
• • Submersion injuries occur in ponds, lakes, rivers, oceans, and other natural bodies of water.
  • Injuries are frequently associated with boating, alcohol, or both.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Other Problems to be Considered

Suicide
Hazing
Gang initiation

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Lab Studies

• Blood gas analysis with co-oximetry to detect methemoglobinemia and carboxyhemoglobinemia
• Complete blood cell count, prothrombin time with international normalized ratio (INR), partial thromboplastin time, fibrinogen, D-dimer, fibrin split products
• Serum electrolytes (with glucose)
• Liver enzymes, especially aspartate aminotransferase and alanine aminotransferase
• Renal function tests (BUN, creatinine)
• Drug screen and ethanol level (consider)
• Continuous pulse oximetry and cardiorespiratory monitoring (may be needed)
• Cardiac troponin I testing (May be useful as a marker to predict children who have an elevated risk of not surviving to hospital discharge)

Imaging Studies

• Chest radiography
• Head CT and cervical spine imaging if suspected trauma
• Extremity, abdominal, pelvic imaging if clinically indicated
• Echocardiography if myocardial dysfunction

Other Tests

• Consider electrocardiography if the patient has arrhythmias. Monitor the patient if rewarming is necessary, because dysrhythmias are common when rewarming patients who suffer cold-water immersion injuries.
• Swan-Ganz catheter for monitoring cardiac output and related hemodynamic parameters may be useful in patients with unstable cardiovascular status or in those who require multiple inotropic and vasoactive medication requirements.

Procedures

• Endotracheal intubation with mechanical ventilation for respiratory failure, persistent hypotension, or impaired airway protective reflexes.
• Nasogastric tube placement for removal of swallowed water and debris (Use orogastric route if head or facial trauma is suggested.)
• Urinary catheter placement for assessment of urine output
• Central venous catheter placement for use in measurement of central venous pressure, infusions, and blood sampling
• Arterial catheter for arterial blood pressure and blood gas analysis
• Extracorporeal membrane oxygenation (ECMO) - May be considered in the following circumstances:
• • Respiratory compromise resulting from lack of response to conventional mechanical ventilation or high-frequency ventilation
  • A reasonable probability of the patient recovering neurologic function
  • Persistent hypothermia from cold-water drowning
• Bronchoscopy if needed for removal of foreign bodies, such as aspirated debris or vomitus
• Intracranial pressure monitoring in patients with traumatic brain injury or mass lesions (eg, hematomas)

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical Care

• Prehospital care
  • Success or failure of initial basic life support provided at the scene of the accident is the most important determinant of outcome.
  • As in any rescue initiative, initial treatment should be geared toward ensuring adequacy of the airway, breathing, and circulation, with attention given to cervical spine stabilization if the scenario suggests spinal trauma.
  • The patient should be removed from water as soon as possible.
  • Initiate rescue breathing immediately, even while the patient is still in the water, if necessary and feasible.
  • Chest compressions are not effective in the water and waste valuable time.
  • The Heimlich maneuver has not been shown to be effective in removing aspirated water.
  • Debris visible in the oropharynx should be removed with a finger-sweep maneuver.
  • Higher pressures may be required for ventilation because of the poor compliance resulting from pulmonary edema.
  • Supplemental oxygen, 100%, should be administered as soon as available. The degree of hypoxemia may be difficult to determine on clinical observation.
• Emergency department care
  • Associated injuries must be considered, as in any other form of accidental injury. Consider potential spinal injuries, especially in diving accidents.
  • The need for hospitalization is determined on clinical evaluation.
  • Noninvasive continuous pulse oximetry is valuable.
  • Patients with completely normal findings on examination and trivial history may be discharged after a 6-hour observation period.
  • Admit any patient with respiratory symptoms, altered oxygenation by pulse oximetry or blood gas analysis, or altered mental status or any patient in whom child abuse is suggested.
  • The most critical role in management is prompt correction of hypoxemia and acidosis.
  • Ventricular dysrhythmias (typically, ventricular tachycardia or ventricular fibrillation), bradycardia, and asystole may occur as a result of acidosis and hypoxemia rather than electrolyte imbalance.
  • Consider intubation and mechanical ventilation in any patient with poor respiratory effort, altered sensorium, severe hypoxemia, severe acidosis, or significant respiratory distress.
  • Intravascular volume depletion is common, secondary to pulmonary edema and intracompartmental fluid shifts, regardless of the type of fluid aspirated.
  • Rapid volume expansion may be indicated using isotonic crystalloid (20 mL/kg) or colloid.
  • Inotropic support may be required using dopamine and/or dobutamine.
  • Most acidosis is restored after correction of volume depletion and oxygenation. Sodium bicarbonate may be administered in cases of severe acidosis that do not correct themselves using the above measures, but only administer it after adequate ventilation has been established.
  • Hypothermia may also exist and exacerbate bradycardia, acidosis, and hypoxemia.
  • Ascertaining whether the drowning occurred in warm or cold water is essential. This depends on the temperature of the water, not of the patient.
• Guidelines for treating cold-water drowning
  • Patients with severe hypothermia may appear dead because of profound bradycardia and vasoconstriction.
  • Resuscitation should continue while aggressive attempts are made to restore normal body temperature.
• Guidelines for treating warm-water drowning: Patients arriving at the emergency department in cardiopulmonary arrest after a warm-water submersion have a dismal prognosis. The benefits of resuscitative efforts should be continuously reassessed in such situations.
• The Conn classification system: For other patients, the Conn classification system may be used as a guideline to quantify the extent of cerebral hypoxia.
• • Category A - Alert
  • Category B - Blunted consciousness; admit and observe for pulmonary compromise, which may result in hypoxemia and worsen CNS injury
  • Category C - Comatose (C1 - decorticate, C2 - decerebrate, and C3 - flaccid [worse prognosis than C1])

Consultations

• Neurology consultation for seizures or persistent neurologic deficit.
• Neurosurgery consultation if there is associated head/spine trauma, hematoma, aneurysm, CNS abscess.
• Cardiology consultation for dysrhythmias/myocardial dysfunction.
• Physical therapy, occupational therapy, rehabilitation therapy consultation to help prevent disuse injury and provide early rehabilitation.
• Pulmonology consultation for severe/persistent respiratory compromise.
• Infectious disease consultation for pneumonia, CNS infection.

MEDICATION

Section 7 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Corticosteroids have been shown to be of no benefit in the management of submersion injuries.

Routine antibiotic prophylaxis is not indicated unless the patient was submerged in grossly contaminated water or sewage.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Further Inpatient Care

• The primary goal in the management of a submersion injury is preservation of CNS perfusion and function. Cerebral edema and intracranial hypertension secondary to hypoxic neuronal injury are frequently observed, but studies have shown that invasive monitoring of intracranial pressure is neither useful nor necessary in near-drowning incidents.
• Maintain adequate oxygenation and ventilation. There is no role for prophylactic hyperventilation.
• Avoid hypotension, hypoglycemia, and hyperthermia.
• Monitor and maintain intravascular volume and blood pressure. Arterial and central venous pressure (CVP) monitoring is useful in patients requiring intensive care.
• The early use of supplemental oxygen with high levels of positive end-expiratory pressure (PEEP) is helpful in reversing hypoxemia. High-frequency ventilation or extracorporeal membrane oxygenation may be needed for patients who are refractory to conventional ventilation.
• Monitor closely for bacterial and fungal infection. Evidence is insufficient to support the use of prophylactic antibiotics.
• Begin aggressive rehabilitation early (as soon as tolerated) to prevent disuse injury and promote functional improvement.

Further Outpatient Care

• Outpatient care dictated by nature and degree of residual functional impairment at discharge.

Transfer

• Patients with severe neurologic impairment may benefit from transfer to inpatient rehabilitation institutions.

Deterrence/Prevention

• In most instances, drowning and near drowning can be prevented with simple safety measures and common sense. Most children younger than 5 years enter a swimming pool directly adjacent to their home or one with inadequate fencing or unlatched gates or doors. Most children are found silently floating with no screaming or splashing noted, were last seen in the home, and were out of sight for only moments.
• Adult supervision is essential in the prevention of drowning. Because lapses of supervision are inevitable, other safety precautions must be in place.
• The use of adequate fencing around swimming pools has decreased the number of immersion injuries significantly (to less than one half). The enclosure may be a wall or fence that completely surrounds a pool on all 4 sides, isolating the pool from the remainder of the property. The enclosure must be at least 4 ft tall with no more than 4 in between openings in the fence. A house or building wall may serve as part of the enclosure only if it does not have any doors or windows through which a child may pass. Doors and gates to the pool should be self-closing and self-latching.
• Pool alarms and covers have not been shown to prevent drowning.
• The use of personal flotation devices approved by the US Coast Guard may reduce the incidence of drowning among children when playing in natural bodies of water or when boating. However, these devices must not be used as a substitute for appropriate adult supervision.
• Pool owners should be instructed on basic life support.
• Children and adults should be instructed never to swim alone or unsupervised.
• Submersion injuries may occur in toilets and water buckets. Appropriate measures must be taken to ensure that children are never unsupervised in bathrooms, and water buckets must be emptied when not in use.
• Infant swimming or water-adjustment programs do not prevent submersion injuries and are potentially hazardous, providing parents with a false sense of security if they perceive their infant can swim.

Complications

• Immediate complications are secondary to hypoxia and acidosis. The immediate threats are the effects on the central nervous and cardiovascular systems. CNS effects depend on the severity and duration of hypoxia. Posthypoxic cerebral hypoperfusion may occur. Long-term effects of cerebral hypoxia, including vegetative survival, are the most devastating.
• Hypoxia and acidosis may lead to cardiac dysrhythmias, including ventricular fibrillation and asystole. Myocardial damage may lead to cardiogenic shock. Capillary leak and neurologic injury can predispose submersion victims to hypovolemia and hypotension.
• Aspiration of fresh or salt water alters the function of surfactant, causing injury to the alveoli and pulmonary capillaries. Increased capillary permeability can worsen the hypoxia and impair ventilation.
• Near-drowning patients may develop pneumonia, although it is less common than chemical pneumonitis, especially if the submersion occurs in a chlorinated pool or in a bucket containing a cleaning product.

Prognosis

• The prognosis is related directly to the duration and magnitude of hypoxia.
• The most significant impact on morbidity and mortality occurs before the patient arrives at the hospital.
• Poor survival is associated with the need for continued cardiopulmonary resuscitation efforts on arrival to the hospital.
• • Of these patients, 35-60% die in the emergency department.
  • Of the survivors, 60-100% have long-term neurologic sequelae.
• Of the patients who recover from the pulmonary effects of the submersion, those who were fully awake on arrival to the hospital generally do very well.
• The neuroprotective effects of cold-water drowning are poorly understood.
• • Hypothermia profoundly decreases the cerebral metabolic rate.
  • Neuroprotective effects seem to occur only if the hypothermia occurs at the time of submersion and only if very rapid cooling occurs in water with a temperature of less than 5°C.
  • Intact survival of comatose patients after cold-water submersion injuries still is quite uncommon.

Patient Education

• Prevention is the best approach to minimize the risk of morbidity and mortality associated with submersion injuries.
• Children should never swim alone or unsupervised.
• Toddlers should not be near bathrooms or buckets of water outside of immediate adult supervision.
• Families with swimming pools should ensure that all safety concerns are addressed, especially appropriate barriers.
• Families with swimming pools should learn basic life support.
• Alcohol and drugs should not be used when operating or riding in motorized watercraft.
• For excellent patient education resources, visit eMedicine's Public Health Center and Environmental Exposures and Injuries Center. Also, see eMedicine's patient education articles Cardiopulmonary Resuscitation (CPR) and Drowning (CPR).

MISCELLANEOUS

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

Medical/Legal Pitfalls

• The degree of hypoxemia is often underrecognized. Administer 100% oxygen. Oxygenation should be monitored closely via pulse oximetry, blood gas analysis, or both. Patients who remain hypoxic warrant endotracheal intubation with an appropriate level of PEEP.
• Secondary causes of drowning should always be considered. Child neglect and abuse, including sexual abuse and Munchausen syndrome by proxy, may result in submersion injury.
• Cervical spine injuries may be present in any near-drowning episode. Unless a clear history rules out the possibility of such injuries, a cervical collar should be used until a proper evaluation is made.

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Miscellaneous
• References

• AAP. Drowning in infants, children, and adolescents. Pediatrics. Aug 1993;92(2):292-4. [Medline]. [Full Text].
• AAP. Infant Swimming Programs (RE5045). Pediatrics. April 1985;75 (2).
• AAP. Swimming Pool Safety Act. 1992 Dec. [Full Text].
• Blasco Alonso J, Moreno Perez D, Milano Manso G, et al. [Drowning in pediatric patients]. An Pediatr (Barc). Jan 2005;62(1):20-4. [Medline].
• Checchia PA, Moynihan JA, Brown L. Cardiac troponin I as a predictor of mortality for pediatric submersion injuries requiring out-of-hospital cardiopulmonary resuscitation. Pediatr Emerg Care. Apr 2006;22(4):222-5. [Medline].
• Gulliver P, Begg D. Usual water-related behaviour and 'near-drowning' incidents in young adults. Aust N Z J Public Health. Jun 2005;29(3):238-43. [Medline].
• Habib DM, Tecklenburg FW, Webb SA, et al. Prediction of childhood drowning and near-drowning morbidity and mortality. Pediatr Emerg Care. Aug 1996;12(4):255-8. [Medline].
• Health, United States 1996-97 and Injury Chartbook. DHHS Publication No (PHS) 96-1232. US Department of Health and Human Services. Hyattsville, Md: National Center for Health Statistics;. 1997.
• Modell JH. Drowning. N Engl J Med. Jan 28 1993;328(4):253-6. [Medline].
• Papa L, Hoelle R, Idris A. Systematic review of definitions for drowning incidents. Resuscitation. Jun 2005;65(3):255-64. [Medline].
• Sarnaik AP, Preston G, Lieh-Lai M, Eisenbrey AB. Intracranial pressure and cerebral perfusion pressure in near-drowning. Crit Care Med. Apr 1985;13(4):224-7. [Medline].
• Sarnaik AP, Lieh-Lai MW. Near-Drowning. In: Fuhrman BP, Zimmerman JJ, eds. Pediatric Critical Care. St. Louis, Mo:. Mosby-Year Book;1998:1190-1197.
• Somers GR, Chiasson DA, Smith CR. Pediatric drowning: a 20-year review of autopsied cases: III. Bathtub drownings. Am J Forensic Med Pathol. Jun 2006;27(2):113-6. [Medline].
• Somers GR, Chiasson DA, Smith CR. Pediatric drowning: a 20-year review of autopsied cases: II. Pathologic features. Am J Forensic Med Pathol. Mar 2006;27(1):20-4. [Medline].
• Somers GR, Chiasson DA, Smith CR. Pediatric drowning: a 20-year review of autopsied cases: I. Demographic features. Am J Forensic Med Pathol. Dec 2005;26(4):316-9. [Medline].
• Spack L, Gedeit R, Splaingard M, Havens PL. Failure of aggressive therapy to alter outcome in pediatric near-drowning. Pediatr Emerg Care. Apr 1997;13(2):98-102. [Medline].
• Vernon DD, Banner W, Cantwell GP, et al. Streptococcus pneumoniae bacteremia associated with near-drowning. Crit Care Med. Oct 1990;18(10):1175-6. [Medline].
• Wintemute GJ. Childhood drowning and near-drowning in the United States. Am J Dis Child. Jun 1990;144(6):663-9. [Medline].

Article Last Updated: Feb 16, 2007