Correspondence
Drowning
N Engl J Med 1993; 329:64-65July 1, 1993
- Article
To the Editor:
Dr. Modell's discussion of drowning (Jan. 28 issue)1 was extremely informative. In the article he concluded that prevention is the best solution to the problem of drowning among children. Unfortunately, there is no evidence that early swimming lessons prevent young children from drowning2. If an adult caretaker thought that a young child had been “drown-proofed” by swimming lessons, the risk of drowning might actually increase, since the adult's vigilance when the child was around water might be less. There still seems to be no substitute for careful adult supervision of children around water (from buckets and bathtubs to pools and oceans), for barriers such as fences between children and bodies of water, and for the use of approved flotation devices by children.
2 ReferencesSara M. Naureckas, M.D.
Children's Memorial Hospital, Chicago, IL 606141
Modell JH . Drowning. N Engl J Med 1993;328:253-256
Full Text | Web of Science | Medline2
Drowning and other water-related injuries. In: Wilson MH, Baker SP, Teret SP, Shock S, Garbarino J. Saving children: a guide to injury prevention. New York: Oxford University Press, 1991:219.
To the Editor:
Modell did not mention an important potential cause of drowning -- namely, cold-induced anaphylaxis in people who have cold urticaria syndromes1,2. These are people in whom exposure to cold can cause hives, either local or diffuse, and in severe cases anaphylaxis.
Many cases of drowning or near-drowning have uncertain causes. When the cause is in doubt, a history of previous cold-induced urticaria should be sought. An elevated serum trypsin level is a marker of mast-cell activation and supports a presumption of cold-induced anaphylaxis.
2 ReferencesRichard J. Morris, M.D.
William F. Schoenwetter, M.D.
Park Nicollet Medical Center, Minneapolis, MN 554161
Horton BT ,Brown GE ,Roth GM . Hypersensitiveness to cold with local and systemic manifestations of a histamine-like character: its amenability to treatment. JAMA 1936;107:1263-1269
Web of Science2
Sigal C ,Mitchell JC . Essential cold urticaria: a potential cause of death while swimming. Can Med Assoc J 1964;91:609-611
Web of Science | Medline
To the Editor:
Modell recommends that the Heimlich maneuver be used for drowning victims after mouth-to-mouth ventilation fails. We are unaware of any controlled, scientific studies showing that mouth-to-mouth ventilation is effective as initial therapy for drowning, without previous drainage of the lungs.
Modell states that water enters the lungs by active respiration. He has reported that 85 percent of drowning victims aspirate up to 10 ml of water per pound of body weight (1500 ml in a 150-lb [68 kg] victim); 15 percent aspirate more1. The trachea and nasopharynx are filled and obstructed by only 150 ml of water. Modell notes that fresh water is absorbed (from the alveoli), but he does not mention that it is replaced by more water in submersed victims; fresh water is not absorbed from the tracheobronchial tree, and absorption ceases with cardiac arrest. Salt water is not absorbed2.
Intubation is not needed for the Heimlich maneuver; other methods of draining water from the lungs may require intubation. Lay rescuers can rapidly apply the Heimlich maneuver, but intubation requires special training and equipment.
It is speculated that the Heimlich maneuver may increase the risk of regurgitation and aspiration. However, vomiting occurs in 86 percent of those receiving cardiopulmonary resuscitation (CPR)3. A report of a case of vomiting and aspiration after the use of the Heimlich maneuver, cited by Modell, has been proved inaccurate, since the tracheal aspirate was basic, rather than acidic2.
Valuable time is wasted by ineffective efforts at ventilation when the airway is obstructed by fluid. The Heimlich maneuver expels water from the airway and should precede mouth-to-mouth ventilation2.
3 ReferencesHenry J. Heimlich, M.D., Sc.D.
Eric G. Spletzer, Ph.D.
Heimlich Institute, Cincinnati, OH 452061
Modell JH ,Davis JH . Electrolyte changes in human drowning victims. Anesthesiology 1969;30:414-420
CrossRef | Web of Science | Medline2
Heimlich HJ ,Patrick EA . Using the Heimlich maneuver to save near-drowning victims. Postgrad Med 1988;84:62-73
Web of Science | Medline3
Manolios N ,Mackie I . Drowning and near-drowning on Australian beaches patrolled by life-savers: a 10-year study, 1973-1983. Med J Aust 1988;148:165-171
Web of Science | Medline
To the Editor:
Dr. Modell attributes to us the report of survival of near-drowning victims with “prolonged submersion, delay in the initiation of effective cardiopulmonary resuscitation, severe metabolic acidosis (pH <7.1), asystole on arrival at a medical facility, fixed, dilated pupils, and a low Glasgow coma score (<5).” In our article, we actually reported the death or severe neurologic impairment of all patients in our series who arrived in the emergency department without a perfusing cardiac rhythm.1 We believe that asystole in the emergency department is an absolute predictor of a poor neurologic outcome or death in victims of warm-water drowning.
1 ReferencesPerry Everett, M.D.
Mark Nichter, M.D.
All Children's Hospital, St. Petersburg, FL 337311
Nichter MA ,Everett PB . Childhood near-drowning: is cardiopulmonary resuscitation always indicated? Crit Care Med 1989;17:993-995
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Modell replies:
To the Editor: Naureckas is correct that a child who can swim is not “drown-proof.” Pools still should be fenced and vigilance practiced. When a child accidentally falls into the water, there is a greater chance of survival if he or she can swim.
Cold-induced anaphylaxis is a consideration in cold climates, as noted by Morris and Schoenwetter, but an infrequent cause of drowning.
I inadvertently implied that Everett and Nichter reported on cases of survival; they were actually concerned with predicting poor neurologic outcome and death. Although the factors listed may predict a very low survival rate, survival has been reported by others, as noted in my article. Thus, these are not “absolute predictors.”
Countless victims of submersion who were apneic or asystolic and underwent CPR have survived. To withhold such therapy for “controlled, scientific studies” would be inappropriate. Heimlich and Spletzer quote me as stating that 85 percent of drowning victims aspirate up to 10 ml of water per pound. They have misinterpreted my numerous published papers on this subject. My point is that, of drowning victims who could not be resuscitated, only 15 percent have evidence of aspirating a greater quantity of fluid than that. The other 85 percent, plus vast numbers who have been successfully resuscitated, aspirated much less. The emphasis should be placed on the fact that few victims aspirate large quantities of water.
Heimlich and Spletzer also state that absorbed aspirated fresh water is “replaced by more water in submersed victims.” If that were true, the tracheas and lungs of all persons found dead in the water would be literally filled with water, but this has not been demonstrated by autopsy in the majority of such victims. Drowning victims, however, may swallow large quantities of water, which, if aspirated, will make matters worse. That vomiting occurs in many patients receiving CPR does not minimize the risk of regurgitation and aspiration with the Heimlich maneuver. The pH of stomach contents can vary considerably and is not always acidic.
The first line of defense for the drowning victim is basic CPR. The Heimlich maneuver should be reserved for instances in which obstruction of the larynx with solid material is suspected and ventilation cannot be undertaken with traditional mouth-to-mouth methods. Basic CPR has saved countless victims from death due to drowning. There are insufficient data to justify abandoning this therapy in favor of the Heimlich maneuver.
Jerome H. Modell, M.D.
University of Florida College of Medicine, Gainesville, FL 32610-0254
