Resuscitating drowned children

BMJ 2015; 350 doi: https://doi.org/10.1136/bmj.h535 (Published 10 February 2015) Cite this as: BMJ 2015;350:h535
  1. Ian Maconochie, consultant in paediatric emergency medicine and NIHR BRC funded researcher1,
  2. Charles D Deakin, honorary professor of resuscitation and prehospital medicine2, divisional medical director3
  1. 1St Mary’s Hospital, Imperial College NHS Healthcare Trust, London W2 1NY, UK
  2. 2NIHR Southampton Respiratory Biomedical Research Unit, Southampton University Hospital, Southampton, UK
  3. 3South Central Ambulance Service, Otterbourne, UK
  1. Correspondence to: I Maconochie i.maconochie{at}imperial.ac.uk

Outcomes are poor, we must focus on prevention

The World Health Organization published its global report on drowning in November 2014, reporting a staggering 372 000 deaths a year from all types of water immersion. Worldwide, drowning is in the top 10 causes of death in children and young people, particularly in males and those aged under 5. An estimated 21 children and young adults are drowned every hour.1 Other public health matters have had disproportionately greater attention, despite the numbers of deaths from drowning being equivalent to two thirds of global deaths from malnutrition and over one half of deaths from malaria.

The linked paper by Kieboom and colleagues (doi:10.1136/bmj.h418) looked at the outcomes of 160 Dutch children after cardiac arrest from drowning who were hypothermic at presentation to the emergency department.2 The authors analysed records from 1993 to 2012. Children who had been involved in traffic or boating incidents were excluded as injuries could have contributed to their arrest independently of drowning and also because air pockets could not be excluded. The duration of bystander cardiopulmonary resuscitation was not included in this study as emergency medical services reached patients within 15 minutes of being dispatched.

Of the children receiving prolonged resuscitation (>30 minutes), most (n=87, 89%) died and 11 survived but with severe neurological impairment, whereas 17 children who required briefer resuscitation survived with Paediatric Cerebral Perfusion Category scores of ≤3—that is, from normal to moderate disability status. The authors question whether we should continue resuscitating children beyond 30 minutes. This was a relatively small study, however, and included just 17 children who drowned in the colder winter months. The results should therefore be interpreted with caution.

The total duration of submersion was unclear in most children as only three episodes were witnessed. The duration of submersion, however, is an important factor influencing outcome. Although survival is unlikely after 30 minutes of submersion, proposed recommendations by the joint emergency services UK that rescue attempts in these children should continue for 60 minutes are still appropriate. Survival has been documented in children submerged for close to 30 minutes, and we still have no clear idea of the absolute limits of survival.

The physiological mechanisms for drowning begin with the person initially breath holding, progressing to involuntary gasping, which is associated with swallowing large quantities of water. Concomitant aspiration of water, together with varying degrees of laryngospasm, results in progressive hypoxia and hypercapnia. Aspiration of freshwater results in breakdown of pulmonary surfactant and subsequent atelectasis, whereas saltwater causes an intrapulmonary osmotic gradient that causes intravascular and interstitial water to be drawn into the alveoli. Both mechanisms act to worsen hypoxia. Initial tachycardia progresses to bradycardia (more marked in icy cold water) then asystole.

The study by Kieboom and colleagues identifies cooling as an important protective mechanism.2 As the authors discuss, hypothermia might be no more than a marker of prolonged submersion, but children were more likely to have a better outcome if the event occurred in winter, when water temperatures were 0-8°C. This is contrary to studies in adults in which no association has been found, perhaps because of the differences in surface area:volume ratio that enhances cold water cooling in children.3 Paradoxically, icy cold water clearly does have neuroprotective effects in adults.4

These authors have shown that the chances of neurologically intact survival diminish as the duration of resuscitation lengthens; a feature common to all cardiac arrests. Cardiac arrest from drowning, however, occurs as a consequence of hypoxia, and rapid correction of hypoxaemia during resuscitation is critical to successful return of spontaneous circulation. Correction of hypoxaemia cannot wait for the arrival of trained staff, and bystander resuscitation involving rescue breaths and oxygen, when available, is perhaps the biggest single determinant of survival in these unfortunate children once they are rescued. The authors appropriately question the therapeutic value of resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia, but it is important to remember that the parents are also victims. Parents need the reassurance that every effort has been made to resuscitate their child, particularly if a few more minutes of resuscitation might allow the parents to sit with their child before he or she is declared dead.

As outcomes from these hypoxic cardiac arrests are so poor, and most incidents occur well away from trained medical help, the most effective way to reduce mortality is through prevention programmes. Recent recommendations from WHO1 include teaching school aged children swimming and safe rescue skills, increasing public awareness, developing national safety water plans, and training bystanders in resuscitation.

Community and policy recommendations from WHO report on drowning, November 20141

Community based action
  • Install barriers controlling access to water

  • Provide safe places (for example, a crèche) away from water for preschool children, with capable child care

  • Teach school age children basic swimming, water safety, and safe rescue skills

  • Train bystanders in safe rescue and resuscitation

  • Strengthen public awareness of drowning and highlight the vulnerability of children

Effective policies and legislation
  • Set and enforce safe boating, shipping, and ferry regulations

  • Build resilience and manage flood risks and other hazards locally and nationally

  • Coordinate drowning prevention efforts with those of other sectors and agendas

  • Develop a national water safety plan

The report by Kieboom and colleagues is the largest series to date,2 but it is a fraction of the total number of drownings worldwide. National registries of cardiac arrests could and should be used more productively for further research in adults and children, including comparative studies to evaluate interventions and compare outcomes. The Utstein templates, comprising a core set of standardised variables for recording resuscitation, could be used for cardiac arrests in and outside hospital. Results from these studies will shape development of guidelines at national and international levels, through bodies such as the International Liaison Committee on Resuscitation. The data collected can then be used to evaluate whether community based actions and policy recommendations, such as those by WHO, really can help reduce the high burden of disability and death associated with near drowning and drowning.


Cite this as: BMJ 2015;350:h535


  • Research, doi:10.1136/bmj.h418
  • Competing interests: We have read and understood the BMJ policy on declaration of interests and declare the following interests: None.

  • Provenance: Commissioned; not externally peer reviewed.


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