Near-drowning is the term for survival after suffocation caused by
submersion in water or other fluid. Some experts exclude from this
definition cases of temporary survival that end in death within 24 hours,
which they prefer to classify as drownings.
Drowning is always fatal, but near-drowning may result in survival with no
long-lasting effects; survival with permanent damage, usually to the
brain; or death after a 24-hour survival period. Near drowning sets into
motion a collection of reactions in the body that ultimately can damage
the lungs and lead to an absence of oxygen in tissues, even when
individuals have been removed from the water and begun breathing either on
their own or with mechanical help.
Near-drowning happens very quickly. Within three minutes of submersion,
most people are unconscious, and 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). The blood may increase in acidity (acidosis) and, under
some circumstances, near drowning can cause a substantial increase or
decrease in the volume of circulating blood. If not rapidly reversed,
these events cause permanent damage to the brain.
About 1,500 children drown every year in the United States. Drowning is
the second leading cause of injury-related deaths in children ages one
month to 14 years of age in the United States as a whole, and the first
leading cause of injury-related deaths in California, Arizona, and
Florida. The rate of near drowning is much higher, as not all near
drownings are reported. It is estimated that for every drowning, there are
four additional hospitalizations and 14 additional emergency room visits
due to near drowning.
Children under age four and between 15 and 19 years of age are at highest
risk of drowning or near drowning. Most young children drown in swimming
pools and bathtubs, while teens drown in natural bodies of water. Teen
drownings are often associated with boating accidents, alcohol
consumption, and illicit drug use. Boys are 12 times more likely to drown
than girls, especially during
, when risk-taking behavior is more pronounced in males. However, even in
younger age groups, except in bathtub drownings, substantially more boys
drown than girls.
Causes and symptoms
The circumstances leading to near-drownings and drownings are varied.
Rarely do they involve nonswimmers accidentally entering deep water. In
older children and adults, near-drownings are often secondary to an event
such as or a head or spinal injury or (in adults) a heart attack that
causes unconsciousness and prevents a diver from resurfacing.
Near-drownings 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 six months to 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. One 2004 study found that 88 percent of
children who drowned were under the supervision of another person, usually
member. Seventy-seven percent of these children were under age ten. The
most common occurrence was that the supervising adult knew the child was
in or near the water but was distracted long enough for the child to
A reduced concentration of oxygen in the blood (hypoxemia) is common to
all near-drownings. When drowning begins, the larynx (a part of the air
passage) closes involuntarily, preventing both air and water from entering
the lungs. In 10 to 20 percent of cases, hypoxemia results because the
larynx spasms and stays closed.
This is called "dry drowning," and no water is breathed
into the lungs. Hypoxemia also occurs in "wet drowning,"
when the larynx relaxes and water enters the lungs. Individuals who are
close to drowning can also regurgitate their stomach contents and breathe
these into the lungs.
The physiological mechanisms that produce hypoxemia in wet drowning are
different for freshwater and saltwater, but only a small amount of either
kind of water is needed to damage the lungs and interfere with
lung's ability to remove oxygen from the air.
The signs and symptoms of near-drowning can differ from person to person
depending in part on how long the individual has been submerged, the
person's age, and the temperature of the water. Upon rescue, some
victims are alert but agitated or disoriented, while others are comatose.
Breathing and heartbeat may have stopped, or the victim 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) and a rapid
heart rate (tachycardia) are common during the first few hours after
rescue. The victim may experience hypothermia (drop in core body
Emergency medical aid should be sought with any near drowning incident.
Even a child who appears to have recovered should be checked by a
physician, since some internal reactions to near drowning can be delayed.
Diagnosis relies on a physical examination of the victim, reports of
observers, and a wide range of tests and other procedures. Blood is taken
to measure oxygen levels and to determine electrolyte balances. Pulse
oximetry, another way of assessing oxygen levels, involves attaching a
device called a pulse oximeter to the patient's finger. An
electrocardiograph is used to monitor heart activity. X rays can detect
head and neck injuries and fluid in the lungs.
Treatment begins with removing the victim from the water and performing
(CPR) as needed to restore heartbeat and provide oxygen until the
individual is able to breath without assistance. When emergency medical
help arrives, 100 percent oxygen is administered to the victim. If the
victim's breathing has stopped or is otherwise impaired, a tube is
inserted into the windpipe (trachea) to maintain the airway (endotracheal
intubation). The victim is also checked for head, neck, and other
injuries, and intravenously fluids may be started. Hypothermia from
submersion in very cold water requires special handling to protect the
On arriving at the emergency room, the individual continues receiving
oxygen until blood tests show a return to normal. About one-third of
near-drowning victims are intubated and initially need mechanical support
to breathe. Treatment is administered as needed for cardiac arrest or
cardiac dysrhythmias. Slow rewarming is undertaken when hypothermia is
present. Individuals are observed for the development of acute
respiratory distress syndrome
(ARDS) or multi-organ failure, both of which can develop after near
drowning. Lung problems can develop 12 or more hours after submersion.
Based on symptoms, individuals may be admitted to the hospital or
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. Discharged individuals must understand that should complications
arise, they must immediately seek additional medical care. Admission to a
hospital for at least 24 hours for further observation and treatment is
necessary for patients who do not appear to fully recover in the emergency
Recovery is directly related to the amount of time the body was without
adequate oxygen (hypoxia). Brain damage is the major long-term concern in
the treatment of near-drowning victims. Patients who arrive at an
emergency department awake and alert usually survive with brain function
intact, although they may initially have respiratory complications.
is common following near drowning and often develops within the first 24
Death or permanent neurological damage is very likely when patients arrive
at the emergency room comatose or without a heartbeat. Of these patients,
35 to 60 percent die in the emergency department, while almost all of
those who survive have permanent disabilities. Early rescue of
near-drowning victims (within five minutes of submersion) and prompt CPR
(within less than ten minutes of submersion) seem to be the best
guarantees of a complete recovery. However, in a phenomenon that is not
well understood, extremely cold water (less than 41°F or 5°C)
seems to protect individuals from some of the neurological damage that
occurs with near drowning. Some hypothermic near-drowning victims
have been revived after they appeared dead and have experienced few
Drowning and near drowning are almost always preventable. Prevention
depends on educating adults and children about water
. Children cannot be left in or near water without adult supervision even
for a short time. Unsupervised young children are at risk around swimming
pools, bathtubs, toilets, buckets, and natural bodies of water. Pools and
spas need to be enclosed with a fence at least 5 ft (1.5 m) high and have
a self-closing and self-locking gate. Adults and teens should consider
learning CPR. No one should swim alone or
along flooded streams or streets. Teens and adults should be educated to
understand that alcohol and illicit drug use substantially increase the
chances of a drowning accident. Boat owners need to participate in boat
safety classes, and children should wear approved life preservers when
boating, water skiing, or riding on a jet ski.
—A bluish tinge to the skin that can occur when the blood oxygen
level drops too low.
—Salts and minerals that produce electrically charged particles
(ions) in body fluids. Common human electrolytes are sodium chloride,
potassium, calcium, and sodium bicarbonate. Electrolytes control the
fluid balance of the body and are important in muscle contraction,
energy generation, and almost all major biochemical reactions in the
—A serious condition in which body temperature falls below
95°F (35 °C). It is usually caused by prolonged exposure to
—A condition characterized by an abnormally low amount of oxygen
in the arterial blood. It is the major consequence of respiratory
failure, when the lungs no longer are able to perform their chief
function of gas exchange.
—A condition characterized by insufficient oxygen in the cells of
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Cecil Textbook of Medicine
, 21st ed. Edited by J. Claude Bennett and Fred Plum. Philadelphia:
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