From the EM Model
6.0 Environmental Disorders
6.5 Submersion Incidents

It is estimated that there are between 8,000 and 9,000 deaths per year from drowning in the United States, and the incidence worldwide is believed to be in the range of 140,000 deaths per year.¹

More than one in four fatal submersion incident victims are children 14 years old or younger.²

Male victims predominate in all age groups and are four times as likely to die from submersion incidents as are females.2 The use of intoxicants, particularly alcohol, is frequently associated with submersion incidents. The ability to swim, interestingly, does not appear to be consistently related to drowning rates.³

On emergency department presentation, victims of submersion incidents may be anywhere in the spectrum of illness from asymptomatic to comatose or in cardiac arrest.

Emergency physicians must be able to recognize the sometimes subtle signs of a significant submersion injury and understand the treatment principles for submersion incidents.

Case Presentation

A 9-year-old boy presents with his mother complaining of a bump and abrasion on his head. The family was at a family picnic, and the children were swimming in a quarry. The child was playing with some older cousins jumping from the dock onto inner tubes. The mother reports that the boys were “roughhousing” on the inner tube, and her son got pushed off the tube. When he tried to surface he was under the dock and hit the top of his head. One of the older boys pulled him out from under the dock and brought him to his mother. The patient was upset and crying, stating that the bump on his head hurt. While she was trying to calm him down, he coughed several times and then vomited a small amount of clear liquid, but she says he has been fine ever since. She was concerned that the abrasion on his head might need stitches. She brought him straight from the quarry, which was about 30 minutes away.

Vital signs are blood pressure 105/58, pulse rate 92, respiratory rate 18, temperature 36.8°C (98.2°F), and oxygen saturation 97% on room air.

On examination, the child is well appearing and in no acute distress. Head examination reveals a small 2-cm by 2-cm cephalohematoma on his scalp with a small abrasion. Pupils are equal, round, and reactive, and the oropharynx is without abnormality. Lung examination reveals a faint expiratory wheeze, and the child is noted to have an occasional dry cough, but his mother says he has had a “spring cold.” Heart examination reveals a normal rate and regular rhythm, with no appreciable murmurs. The abdomen is nontender, and the neurologic examination is nonfocal.

Pathophysiology of Submersion

The typical timeline of events in drowning begins with panic and struggling, accompanied by uncontrolled hyperventilation that can lead to aspiration of large amounts of water. As the victim becomes submerged, breath-holding occurs and panic continues, resulting in the rapid development of hypoxia, hypercapnia, and acidosis.