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Special Report: The Myth of Dry Drowning Remains at Large

Schmidt, Andrew, DO, MPH; Sempsrott, Justin, MD; Hawkins, Seth, Collings, MD

doi: 10.1097/01.EEM.0000535015.19364.32
Special Report

Dr. Schmidt, top, is an assistant professor with the University of Florida-Jacksonville Department of Emergency Medicine, where he also serves as deputy medical director for the TraumaOne Flight Program. Follow him on Twitter @904Schmidt. Dr. Sempsrott, center, is an emergency physician and a founder of the nonprofit Lifeguards Without Borders, now serving as its executive director. He also serves as the medical director for the International Surf Lifesaving Association, Starfish Aquatics Institute, and Innovative Attraction Management Starguard Elite. Follow him on Twitter at @LifeguardsWB. Dr. Hawkins, bottom, is an emergency physician in active clinical practice, an assistant professor at Wake Forest University School of Medicine, and the medical director of Starfish Aquatics Institute, Landmark Learning, the Burke County EMS Special Operations Team, and the North Carolina State Parks system. Follow him on Twitter @hawkvox.

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Frankie Delgado was on vacation with his family a week before he died. The 4-year-old had been playing in shallow water when a wave crashed over him, and his parents reported that he seemed fine at the time. The next night, however, he developed diarrhea and started to vomit, and he later complained of shoulder pain. Then, a week later, he stopped breathing. (CNN. June 9, 2017; http://cnn.it/2rECrOV.)

Initial reports blamed his death on “dry drowning,” which started a media frenzy that sent panicked parents to EDs to have their children checked after inhaling water. As we suspected, Frankie Deglado did not die from drowning, dry or otherwise, but by that time, stopping the misinformation was like trying to dam a tidal wave.

We wrote about this case in EMN last year, trying to shed light on the common use of outdated and confusing drowning-related terminology. (2017;39[8]:1; http://bit.ly/EMN-Drowning.) Most news outlets called what happened to Frankie “dry drowning,” but we also saw reports using the terms “secondary drowning” and “near-drowning.” As we said then, and have said many times since, these are not accepted medical terms.

Even today, searching online for Frankie Delgado's name yields myriad news reports of his “dry drowning,” followed by articles about how to prevent it. As it turns out, and as we expected, the results of the autopsy revealed Frankie's cause of death was recurrent myocarditis. Few mainstream media outlets reported that, which stresses how important it is to continue the discussion and understand ED treatment and disposition for drowning. Some downplay the need for precise terminology, but words matter when describing something like drowning. Without a universal understanding of current terminology and nomenclature, we cannot work efficiently toward decreasing the global burden of drowning morbidity and mortality.

As expected with a disease like drowning where randomized controlled trials aren't ethically possible, the evidence surrounding much of these treatments is scarce and based on expert opinion.

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Systemic Hypoxia

Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid. The primary cause of morbidity and mortality, and the focus of treatment, is systemic hypoxia. No matter the factors involved in the drowning event or the current condition of the presenting patient, the primary goal in the physician's mind must be optimizing systemic oxygenation. As with most medical and traumatic derangements, this all starts with a rapid evaluation of the airway and breathing status of the patient.

One physiologic process that may be apparent and that should immediately alert the physician to an airway compromise is fluid coming from the patient's mouth. This can have numerous causes, including emesis from reflexive swallowing while underwater or air gulping and noncardiogenic pulmonary edema from direct airway and alveolar injury from water aspiration and surfactant disruption. Whatever the cause, this is common in severe drowning patients and can greatly complicate the patient's ability to breathe and the physician's ability to establish a definitive airway. During the initial resuscitation, this is not a process that will quickly cease, so spending time attempting to clear the airway without attempting oxygenation could be detrimental to the critical or crashing patient.

Recommended oxygenation strategies are:

  • Awake and alert, protecting airway, no fluid material from airway:
    • Oxygenation via nasal cannula or nonrebreather mask to maintain SaO2 > 95%
  • Awake and alert, respiratory distress, minimal fluid material from airway:
    • Oxygenation via nasal cannula or nonrebreather mask to maintain SaO2 > 95%
    • Noninvasive positive pressure ventilation (NIPPV) if the patient is a candidate based on mentation
    • Proceed to intubation if the patient does not improve on NIPPV within 10 minutes.
    • Endotracheal intubation (ETI) for refractory hypoxemia or worsening respiratory distress
  • Altered mental status, large amount of fluid material from airway, or respiratory failure:
    • Rapid setup for endotracheal intubation
    • If necessary, bag-valve-mask ventilation attempted though fluid material to pre-oxygenate

The disposition of drowning patients, primarily those who appear clinically well, is a poorly studied subject that tends to cause a great deal of anxiety among physicians. Only a few small, retrospective studies provide the basis for disposition recommendations:

  • Discharge home from the ED:
    • Normal mentation and oxygenation and no continued dyspnea or tachycardia when off supplemental oxygen for more than four to eight hours
    • Adequate social support or family structure to observe for worsening symptoms
  • Admit to inpatient floor bed
    • Continued dyspnea, tachycardia, altered mental status, hypothermia, or hypoxia that is improving or stabilized with ED treatment and mild-moderate in nature
    • Not requiring NIPPV, ETI, or vasoactive medication
  • Admit to Intensive Care Unit:
    • Continued dyspnea, tachycardia, altered mental status, hypothermia, or hypoxemia refractory to ED treatment or severe in nature
    • NIPPV, ETI, or vasoactive medication

Drowning continues to be a leading cause of injury death worldwide, especially among children. Hypoxemia and subsequent cerebral hypoxia are the primary causes of morbidity and mortality, and their immediate reversal should be the goal of any initial intervention. Following these recommendations will give your next patient the best chance of walking out of the hospital with minimal morbidity.

Read the original article, “‘Drowning’ in a Sea of Misinformation” at http://bit.ly/EMN-Drowning.

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