Drowning

Drowning is death from asphyxia due to suffocation caused by a liquid entering the lungs and preventing the absorption of oxygen leading to cerebral hypoxia and myocardial infarction.

Near drowning is the survival of a drowning event involving unconsciousness or water inhalation and can lead to serious secondary complications, including death, after the event.

In many countries, drowning is one of the leading causes of death for children under 12 years old. For example, in the United States, it is the second leading cause of death (after motor vehicle crashes) in children 12 and younger. The rate of drowning in populations around the world varies widely according to their access to water, the climate and the national swimming culture. For example, typically the United Kingdom suffers 450 drownings per annum or 1 per 150,000 of population whereas the United States suffers 6,500 drownings or around 1 per 50,000 of population. In Asia, according to a study by The Alliance for Safe Children, suffocation and drowning were the most easily preventable causes of death for children under five years of age; a 2008 report by the organization found that in Bangladesh, for instance, 46 children drown each day.

Victims are more likely to be male, young or adolescent. Surveys indicate that 10% of children under 5 have experienced a situation with a high risk of drowning.

Signs and symptoms
A continued lack of oxygen in the brain, hypoxia, will quickly render a victim unconscious usually around a blood partial pressure of oxygen of 25-30mmHg. An unconscious victim rescued with an airway still sealed from laryngospasm stands a good chance of a full recovery. Artificial respiration is also much more effective without water in the lungs. At this point the victim stands a good chance of recovery if attended to within minutes. Latent hypoxia is a special condition leading to unconsciousness where the partial pressure of oxygen in the lungs under pressure at the bottom of a deep free-dive is adequate to support consciousness but drops below the blackout threshold as the water pressure decreases on the ascent, usually close to the surface as the pressure approaches normal atmospheric pressure. A blackout on ascent like this is called a deep water blackout.

Drowning is most often quick and unspectacular. Its media depictions as a loud, violent struggle have much more in common with distressed non-swimmers, a condition that may precede drowning. An aspyhxicating person seldom calls for help. Signs or behaviors associated with drowning or near-drowning:


 * Head low in the water, mouth at water level
 * Head tilted back with mouth open
 * Eyes glassy and empty, unable to focus
 * Eyes open, with fear evident on the face
 * Hyperventilating or gasping
 * Trying to swim in a particular direction but not making headway
 * Trying to roll over on the back to float
 * Uncontrollable movement of arms and legs, rarely out of the water.

Cardiac arrest and death
The brain cannot survive long without oxygen and the continued lack of oxygen in the blood combined with the cardiac arrest will lead to the deterioration of brain cells causing first brain damage and eventually brain death from which recovery is generally considered impossible. A lack of oxygen or chemical changes in the lungs may cause the heart to stop beating; this cardiac arrest stops the flow of blood and thus stops the transport of oxygen to the brain. Cardiac arrest used to be the traditional point of death but at this point there is still a chance of recovery. The brain will die after approximately six minutes without oxygen but special conditions may prolong this (see 'cold water drowning' below). Freshwater contains less salt than blood does and will therefore be absorbed into the blood stream by osmosis. In animal experiments this was shown to change the blood chemistry and led to cardiac arrest in 2 to 3 minutes. Sea water is much saltier than blood. Through osmosis water will leave the blood stream and enter the lungs thickening the blood. In animal experiments the thicker blood requires more work from the heart leading to cardiac arrest in 8 to 10 minutes. However, autopsies on human drowning victims show no indications of these effects and there appears to be little difference between drownings in salt water and fresh water. After death, rigor mortis will set in and remains for about two days, depending on many factors including water temperature.

Secondary drowning
Water, if inhaled into the lungs, may easily damage the alveoli—the tiny sacs surrounded by capillaries responsible for the gas exchange required for cellular respiration. The unnatural substance (being water) in the lungs will cause an irritation inside the lungs, triggering the lungs to attempt to purge the substance much like a sliver would fester—fluid gathers in/on the lungs creating what is known as pulmonary edema, reducing the ability to exchange air. Because of this, an asphyxiation is a very real possibility. Serious complications or death may occur up to 72 hours after a near drowning incident because of the time the body takes to sense the problem and attempt its own fix. Essentially, the person ends up drowning in their own bodily fluid. This is also known as secondary drowning, or "drowning after drowning". Inhaling certain poisonous vapors or gases (as for example in gas warfare), or vomit will have a similar effect.

Freshwater can be more dangerous than saltwater in secondary drowning. When fresh water enters the lungs it is pulled into the pulmonary circulation via the alveoli because of the low capillary hydrostatic pressure and high colloid osmotic pressure. Consequently, the plasma is diluted and the hypotonic environment causes red blood cells to burst (hemolysis). The resulting elevation of plasma K+ level and depression of Na+ level, due to the hemolysis, alter the electrical activity of the heart. Ventricular fibrillation often occurs as a result of these electrolyte changes. Additionally, if drowning occurs in very cold water (<10o C), the uptake of cold water into the vascular system can stop the heart. In open heart surgery, the technique of pouring cold saline solution over the heart is used to slow down enzymes in destroying the cells of the heart. If the victim is resuscitated death can occur hours later due to renal failure. During hemolysis, hemoglobin is also released into the plasma which can accumulate in the kidneys leading to acute renal failure. In contrast, salt-water drowning does not lead to uptake of inspired water into the vascular system because it is hypertonic to blood. Therefore, no hemolysis occurs and the cause of death is asphyxia.

Cause
Most drownings occur when the victim is in water (90% in freshwater (rivers, lakes and pools), 10% in seawater). Drownings in other fluids are rare, and are often related to industrial accidents.

People have drowned in as little as 30 mm of water lying face down, in one case in a wheel rut. Children have drowned in baths, buckets and toilets; inebriates or those under the influence of drugs have died in puddles. For a more detailed list of causes see swimming.

Body's reaction to submersion
Submerging the face in water colder than about 21 °C triggers the mammalian diving reflex, found in mammals, and especially in marine mammals such as whales and seals. This reflex protects the body by putting it into energy saving mode to maximize the time it can stay under water. The strength of this reflex is greater in colder water and has three principal effects:
 * Bradycardia, a slowing of the heart rate by up to 50% in humans.
 * Peripheral vasoconstriction, the restriction of the blood flow to the extremities to increase the blood and oxygen supply to the vital organs, especially the brain.
 * Blood Shift, the shifting of blood to the thoracic cavity, the region of the chest between the diaphragm and the neck, to avoid the collapse of the lungs under higher pressure during deeper dives.

The reflex action is automatic and allows both a conscious and an unconscious person to survive longer without oxygen under water than in a comparable situation on dry land. The exact mechanism for this effect has been debated and may be a result of brain cooling similar to the protective effects seen in patients treated with deep hypothermia.

Oxygen deprivation
A conscious victim will hold his or her breath (see Apnea) and will try to access air, often resulting in panic, including rapid body movement. This uses up more oxygen in the blood stream and reduces the time to unconsciousness. The victim can voluntarily hold his or her breath for some time, but the breathing reflex will increase until the victim will try to breathe, even when submerged.

The breathing reflex in the human body is weakly related to the amount of oxygen in the blood but strongly related to the amount of carbon dioxide (see Hypercapnia). During apnea, the oxygen in the body is used by the cells, and excreted as carbon dioxide. Thus, the level of oxygen in the blood decreases, and the level of carbon dioxide increases. Increasing carbon dioxide levels lead to a stronger and stronger breathing reflex, up to the breath-hold breakpoint, at which the victim can no longer voluntarily hold his or her breath. This typically occurs at an arterial partial pressure of carbon dioxide of 55 mm Hg, but may differ significantly from individual to individual and can be increased through training.

The breath-hold break point can be suppressed or delayed either intentionally or unintentionally. Hyperventilation before any dive, deep or shallow, flushes out carbon dioxide in the blood resulting in a dive commencing with an abnormally low carbon dioxide level; a potentially dangerous condition known as hypocapnia. The level of carbon dioxide in the blood after hyperventilation may then be insufficient to trigger the breathing reflex later in the dive and a blackout may occur without warning and before the diver feels any urgent need to breathe. This can occur at any depth and is common in distance breath-hold divers in swimming pools. Hyperventilation is often used by both deep and distance free-divers to flush out carbon dioxide from the lungs to suppress the breathing reflex for longer. It is important not to mistake this for an attempt to increase the body's oxygen store. The body at rest is fully oxygenated by normal breathing and cannot take on any more. Breath holding in water should always be supervised by a second person, as by hyperventilating, one increases the risk of shallow water blackout because insufficient carbon dioxide levels in the blood fail to trigger the breathing reflex.

Water inhalation
If water enters the airways of a conscious victim, the victim will try to cough up the water or swallow it, thus inhaling more water involuntarily. Upon water entering the airways, both conscious and unconscious victims experience laryngospasm, that is the larynx or the vocal cords in the throat constrict and seal the air tube. This prevents water from entering the lungs. Because of this laryngospasm, water enters the stomach in the initial phase of drowning and very little water enters the lungs. Unfortunately, this can interfere with air entering the lungs, too. In most victims, the laryngospasm relaxes some time after unconsciousness and water can enter the lungs causing a "wet drowning". However, about 10-15% of victims maintain this seal until cardiac arrest. This is called "dry drowning", as no water enters the lungs. In forensic pathology, water in the lungs indicates that the victim was still alive at the point of submersion. Absence of water in the lungs may be either a dry drowning or indicates a death before submersion.

Management
Many pools and designated bathing areas either have lifeguards, a pool safety camera system for local or remote monitoring, or computer aided drowning detection. However, bystanders play an important role in drowning detection and either intervention or the notification of authorities by phone or alarm. No person should attempt a rescue that is beyond his or her ability or level of training.

If a drowning occurs or a swimmer goes missing, bystanders should immediately call for help. The lifeguard should be called if present. If not, emergency medical services and paramedics should be contacted as soon as possible.

The first step in rescuing a drowning victim is to ensure your own safety. Then bring the victim's mouth and nose above the water surface. For further treatment it is advisable to remove the victim from the water. Conscious victims may panic and thus hinder rescue efforts. Often, a victim will cling to the rescuer and try to pull himself out of the water, submerging the rescuer in the process. To avoid this, it is recommended that the rescuer approach the panicking victim with a buoyant object, or from behind, twisting the victim's arm on the back to restrict movement. If the victim pushes the rescuer under water, the rescuer should dive downwards to escape the victim.

Actively drowning victims do not usually call out for help simply because they lack the air to do so. It is necessary to breathe to yell. Human physiology does not allow the body to waste any air when starving for it. They rarely raise their hands out of the water. They use the surface of the water to push themselves up in an attempt to get their mouths out of the water. Lifting arms out of the water always pushes the head down. Head low in the water, occasionally bobbing up and down is another common sign of active drowning.

There can be splashing involved during drowning, usually a butterfly like stroke where the hands barely clear the waters surface, and sometimes victims can look like they are climbing an invisible ladder in the water.

Extenuating factors such as increased levels of stress, secondary injuries, and environmental factors can increase the likelihood of distress and/or drowning in persons who end up overboard. It is important that you recognize the behaviors associated with aquatic distress and drowning, so you can make informed decisions during emergencies.

After successfully approaching the victim, negatively buoyant objects such as a weight belt are removed. The priority is then to transport the victim to the water's edge in preparation for removal from the water. The victim is turned on his or her back. A secure grip is used to tow panicking victims from behind, with both rescuer and victim lying on their backs, and the rescuer swimming a breaststroke kick. A cooperative victim may be towed in a similar fashion held at the armpits, and the victim may assist with a breaststroke kick. An unconscious victim may be pulled in a similar fashion held at the chin and cheeks, ensuring that the mouth and nose are well above the water.

There is also the option of pushing a cooperative victim lying on his or her back with the rescuer swimming on his or her belly and pushing the feet of the victim, or both victim and rescuer lying on the belly, with the victim hanging from the shoulders of the rescuers. This has the advantage that the rescuer can use both arms and legs to swim breaststroke, but if the victim pushes his or her head above the water, the rescuer may get pushed down. This method is often used to retrieve tired swimmers. If the victim wears lifejacket, buoyancy compensator, or other flotation device that stabilizes his or her position with the face up, only one hand of the rescuer is needed to pull the victim, and the other hand may provide forward movement or may help in rescue breathing while swimming, using for example a snorkel.

Special care has to be taken for victims with suspected spinal injuries, and a back board (spinal board) may be needed for the rescue. In water, CPR is ineffective, and the goal should be to bring the victim to a stable ground quickly and then to start CPR.

If the approach to a stable ground includes the edge of a pool without steps or the edge of a boat, special techniques have been developed for moving the victim over the obstacle. For pools, the rescuer stands outside, holds the victim by his or her hands, with the victim's back to the edge. The rescuer then dips the victim into the water quickly to achieve an upward speed of the body, aiding with the lifting of the body over the edge. Lifting a victim over the side of a boat may require more than one person. Special techniques are also used by the coast guard and military for helicopter rescues.

After reaching dry ground, all victims should be referred to medical assistance, especially if unconscious or if even small amounts of water have entered the lungs. An unconscious victim may need artificial respiration or CPR. If this is the case, it is recommended that the patient be positioned on their back with the head level to the body. The goal should be to perform chest compressions if the patient is pulseless, and if the patient isn't breathing to push air into the lungs even though the lungs may be filled with some amount of water.

The Heimlich maneuver is not recommended; the technique may have relevance in situations where airways are obstructed by solids but not fluids. Performing the manoeuver on drowning victims not only delays ventilation but may induce vomiting, which if aspirated will place the patient in a far worse situation. Moreover, the use of the Heimlich manoeuver in any choking situation involving solids or fluids has become controversial and is generally no longer taught. For more information on this debate refer to the article Henry Heimlich.

100% oxygen is neither recommended nor discouraged. Treatment for hypothermia may also be necessary. Water in the stomach need not be removed, except in the case of paediatric drownings, as a gastric distension can limit movement of the lungs. Other injuries should also be treated (see first aid). Victims that are alert, awake, and intact have a nearly 100% survival rate.

Drowning victims should be treated even if they have been submerged for a long time. The rule "no patient should be pronounced dead until warm and dead" applies. Children in particular have a good chance of survival in water up to 3 minutes, or 10 minutes in cold water (10 to 15 °C or 50 to 60 °F). Submersion in cold water can slow the metabolism drastically. There are rare but documented cases of survivable submersion for extreme lengths of time. In one case a child named Michelle Funk survived drowning after being submerged in cold water for 70 minutes. In another, an 18 year old man survived 38 minutes under water. This is known as cold water drowning.

Prevention


Training:
 * Learn how to swim.
 * Learn basic water rescue and basic life support.

Practices to be considered: Practices to be avoided:
 * Keep a watch out for others.
 * Keep children under full view.
 * Swim only in areas where adequate supervision is present (i.e. a trained and certified Lifeguard).
 * Have a locked fence around swimming pools.
 * Bring a cordless telephone to the pool, so children are not left unsupervised while answering a phone call.
 * Have cold-acclimatisation training prior to swimming in very cold waters.
 * Ensure that boats that are in use are reliable, properly loaded and that functional emergency equipment is onboard.
 * Wear a properly fitting lifejacket while enjoying water sports such as sailing, surfing or canoeing.
 * Pay attention to the weather, tides and water conditions, and especially currents. Currents are usually perceived from the outside as weaker than they actually are.
 * Be aware of your personal limits.
 * Stay Away From Deep Water.
 * Diving into water where the bottom cannot clearly be seen or the depth determined.
 * Swimming alone.
 * Swimming at night.
 * Swimming while under the influence of drugs or alcohol.
 * Using hyperventilation in an attempt to extend a breath-hold dive. See deep and shallow water blackout.
 * Relying wholly on swimming aids, as they may fail.
 * Playing games that will put your life, or others', at risk.
 * Walking on ice, unless it is known in absolute certainty that the ice is thick enough over the entire route.
 * Drunkenness while on any boat or ship
 * Horseplay on any boat or ship
 * Boating in any dangerous weather (storms, high winds)

Epidemiology


In the United States in 2006 1100 people under 20 years of age died from drowning.

People who drown are more likely to be male, young or adolescent. Surveys indicate that 10% of children under 5 have experienced a situation with a high risk of drowning. About 175,000 children die through drowning every year. The causes of drowning cases in the US from 1999 to 2006 are as follows :

31.0% 	Drowning and submersion while in natural water

27.9% 	Unspecified drowning and submersion

14.5% 	Drowning and submersion while in swimming pool

9.4% 	Drowning and submersion while in bathtub

7.2% 	Drowning and submersion following fall into natural water

6.3% 	Other specified drowning and submersion

2.9% 	Drowning and submersion following fall into swimming pool

0.9% 	Drowning and submersion following fall into bathtub

As a method of execution
In Europe, drowning was used as capital punishment. In fact, during the Middle Ages, a sentence of death was read using the words "cum fossa et furca," or "with drowning-pit and gallows." Furthermore, drowning was used as a way to determine if a woman was a witch. The idea was that witches would float and innocent women would drown. For more details, see trial by drowning. It is understood that drowning was used as the least brutal form of execution, and was therefore reserved primarily for women, although favorable men were executed in this way as well.

Drowning survived as a method of execution in Europe until the 17th and 18th centuries. England had abolished the practice by 1623, Scotland by 1685, Switzerland in 1652, Austria in 1776, Iceland in 1777, and Russia by the beginning of the 1800s. France revived the practice during the French Revolution (1789–1799) and was carried out by Jean-Baptiste Carrier at Nantes.