Saturday, June 24, 2017

Water safety/Secondary and Dry Drowning

When frightening stories make the news, I know that I can anticipate some calls about whatever the issue is. There were some recent stories in the media about secondary drowning. Several parents have reached out and asked me to address the topic in a blog post. Next week I will continue the swimming theme. I had it all rolled into one but it was way too long. You would be surprised how many different body parts we get calls about that are swimming related. You can read all about those next week.

Let’s get the scary stuff out of the way first. Drowning is the second most common cause of death in children in the United States. Prevention is key. A person who is drowning may not thrash about and call attention to the fact that they are having trouble. They can slip silently under the water without being noticed until it is too late. Even if your child has proven themselves to be solid swimmers, you need to stay actively focused and engaged on watching them like a hawk while they are in the water.
If you are staying anywhere with a pool, make certain that your child has absolutely no access to the pool area when there is no adult present. If you do have pool access, there are lots of pool alarms and safety monitors on the market. Hotels or apartments with fountains need to be treated with caution as well.

We had a scare with one of our families a few summers ago. Several adults and children were enjoying a day at a friend's pool in the East Bay. They got out of the pool to have some lunch. Some of the oldest kids started to bicker. While the adults turned their attention to the squabble, a one year old got back into the pool unnoticed and submerged. Thank goodness another of the adults looked up, noticed and was able to get her out and perform CPR. The little girl is perfectly fine, but this was terrifying for everyone. Dr. Karen Makely, one of the wonderful urgent care physicians over at St. Lukes, says that sometimes having a lot of adults around lends a false sense of security. Consider having each adult take turns being on a shift as the designated lifeguard.
Drowning is horrible, but the recent stories that scared the bejesus out of my families were about delayed drowning. You may have heard of dry drowning as well. They are not the same thing.
The primary difference between dry drowning and secondary (or delayed) drowning is the presence or absence of water in the victim’s lungs.

Dry drowning is something that can be brought on in several different ways. The first theory is that a sudden rush of water into the throat causes the airway to go into spasm. During this event, although no water enters the lungs, no air enters either, so the victim dies of asphyxiation. Another explanation is that  the shock of a swimmer’s suddenly entering extremely cold water causes the heart to stop.

Distinct from “Dry Drowning” is secondary or delayed drowning. This is also very rare, but  is something that parents need to know about. Symptoms usually develop within 6-24 after an incident. If someone had a near drowning or accidentally swallowed a lot of water, they are at risk for pulmonary edema from the fluid imbalance to the lungs. They may seem fine initially but then present with cough and increased labored breathing. This usually shows up within 24 hours of the event.

Caregivers of young swimmers should try to head off some of these issues by training their kids to keep their mouths closed when jumping into water and to enter very cold water slowly.  This should help avoid aspirating large amounts of water. There is a big difference between water in the lungs and water in the belly. If your child swallows a lot of water they may end up with a tummy ache but it is rarely dangerous. The recent tragic news story about a child who died in Texas with this diagnosis is a bit of a puzzle. He had days of vomiting and diarrhea. Every physician that I spoke to says that it is respiratory, NOT tummy symptoms, that they would be on the lookout for. There is likely more to that story than is getting reported. It is the outliers that make the news.

Here is the takeaway message. It is important to closely monitor any child who has come out of the water coughing and sputtering. Especially keep an eye out for any further difficulties in breathing, extreme tiredness, or marked changes in behavior, all of which are signs that a swimmer may have inhaled a dangerous amount of fluid. If there is any concern, an emergency room or immediate medical intervention is needed. The first 24 hours are probably the most critical period. It is important to know what to look for, but to reiterate, in over 30 years with a practice full of swimmers, I am not aware of any of our patients having any serious complications from a mouthful of water. 

I spoke to Dr. Tamariz from the CPMC ER. He reiterates how extremely rare this is, but stresses that if any CPR or resuscitation was needed, a follow up emergency room visit is essential regardless of how well they may appear. For the majority of swimmers that accidentally get a mouthful of water, observation at home is fine unless they are showing the obvious symptoms that are listed above. If you are concerned, go the the emergency room. They will check the oxygen level, listen to the lungs, and keep an eye on things until everyone feels comfortable. If clinically indicated they might do an x-ray but it is not automatic.

I am going to close with a little tidbit of common sense. Labored respirations should ALWAYS prompt you to seek medical attention, even if there is no concern about recent swimming.

Next week I will continue the swimming theme, sharing all the possible swimming related call that the advice nurse team receives!

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