Pediatric Annals

Adolescent Drownings: Swimming Boating, Diving and Scuba Accidents

James P Orlowski, MD, FAAP, FCCP

Abstract

Injury rates and deaths, including accidental injury, homicide and suicide, all peak significantly in the adolescent and young adult age groups.1,2 Drowning is the second leading cause of death due to unintentional injury in this age group (Table 1) and the second leading cause of years of potential life lost (Table 2), exceeded only by motor vehicle traffic accidents.3 Adolescent males predominate in drowning deaths with the peak at age 18 (Figure). The contrast between male and female drowning rates after age 10 is believed to reflect differences between the sexes in exposure to hazardous activities including cultural expectations, alcohol and drug use, and biological make-up. The male to female ratio for boat related drownings is 12:1 and for non-boat related drownings is 5:1.

More than any other type of injury, drownings occur disproportionately on Saturdays and Sundays and during the months of May through August.1 Although these temporal variations are heavily influenced by recreational patterns, the weekend peak is also influenced by alcohol use, which plays a prominent role in adolescent and young adult drownings (Table 3).4,5 Whereas swimming pools are the predominant site for drowning accidents in children, natural bodies of water account for most adolescent drownings. Despite the proximity to bodies of salt water and the popularity of boating in states along the coasts, salt water drownings are very uncommon. Even in states bordering large bodies of salt water, the vast majority of drownings still occur in swimming pools and bodies of fresh water.

Teenage boys usually get into trouble in the water on a dare when their ability to swim is exceeded, or when they are under the influence of drugs or alcohol. Drugs and alcohol can compromise and endanger even the good swimmer and result in drowning or near-drowning accidents. Alcohol use has been associated with about 50% of drownings among teenagers and young adults.46

Hypoxic lap swimming is a risk factor for expert competitive swimmers.7 Hypoxic training, in which swimmers hold their breath for a number of laps, is commonly used to improve endurance and build tolerance to the oxygen debt that develops during races. The effort to overcome normal hypercapnic and hypoxic respiratory drives can result in loss of consciousness and drowning or near-drowning accidents. Similar accidents with loss of consciousness and drowning have been blamed on the practice of hyperventilating before breath-holding and underwater swimming.8 Hyperventilation-induced hypocarbia can result in unconsciousness or can delay the hypercapnic drive to breathe sufficiently to permit hypoxiainduced unconsciousness to intervene.

Table

Cerebral arterial air embolism occurs as a result of pulmonary overinflation with rupture of the alveolarcapillary basement membrane, which allows air to enter the pulmonary vasculature. Air travels through the left side of the heart and out the aorta. These intraarterial air bubbles may be carried to any part of the body, but are most likely to travel through the carotid arteries to the brain where they cause cerebral arterial occlusions with focal or global neurologic deficits. Cerebral arterial air embolism usually manifests when the diver surfaces although symptoms may be delayed for a short time after surfacing. Other complications of alveolar overinflation may accompany cerebral arterial air embolism, including mediastinal emphysema, pneumothorax and subcutaneous emphysema. Recompression therapy with a hyperbaric oxygen chamber is usually very effective in reversing the symptoms of alveolar overinflation and arterial air embolism.12

Decompression sickness or "the bends" has a slower onset of symptoms than arterial gas embolism. Its symptoms also appear as the diver ascends, usually from depths of 80 feet or more, and are due to nitrogen gas bubbles forming in blood vessels and tissues resulting from too…

Injury rates and deaths, including accidental injury, homicide and suicide, all peak significantly in the adolescent and young adult age groups.1,2 Drowning is the second leading cause of death due to unintentional injury in this age group (Table 1) and the second leading cause of years of potential life lost (Table 2), exceeded only by motor vehicle traffic accidents.3 Adolescent males predominate in drowning deaths with the peak at age 18 (Figure). The contrast between male and female drowning rates after age 10 is believed to reflect differences between the sexes in exposure to hazardous activities including cultural expectations, alcohol and drug use, and biological make-up. The male to female ratio for boat related drownings is 12:1 and for non-boat related drownings is 5:1.

More than any other type of injury, drownings occur disproportionately on Saturdays and Sundays and during the months of May through August.1 Although these temporal variations are heavily influenced by recreational patterns, the weekend peak is also influenced by alcohol use, which plays a prominent role in adolescent and young adult drownings (Table 3).4,5 Whereas swimming pools are the predominant site for drowning accidents in children, natural bodies of water account for most adolescent drownings. Despite the proximity to bodies of salt water and the popularity of boating in states along the coasts, salt water drownings are very uncommon. Even in states bordering large bodies of salt water, the vast majority of drownings still occur in swimming pools and bodies of fresh water.

Teenage boys usually get into trouble in the water on a dare when their ability to swim is exceeded, or when they are under the influence of drugs or alcohol. Drugs and alcohol can compromise and endanger even the good swimmer and result in drowning or near-drowning accidents. Alcohol use has been associated with about 50% of drownings among teenagers and young adults.46

Hypoxic lap swimming is a risk factor for expert competitive swimmers.7 Hypoxic training, in which swimmers hold their breath for a number of laps, is commonly used to improve endurance and build tolerance to the oxygen debt that develops during races. The effort to overcome normal hypercapnic and hypoxic respiratory drives can result in loss of consciousness and drowning or near-drowning accidents. Similar accidents with loss of consciousness and drowning have been blamed on the practice of hyperventilating before breath-holding and underwater swimming.8 Hyperventilation-induced hypocarbia can result in unconsciousness or can delay the hypercapnic drive to breathe sufficiently to permit hypoxiainduced unconsciousness to intervene.

Table

TABLE 1Major Causes of Accidental Death in Teenagers and Young Adults

TABLE 1

Major Causes of Accidental Death in Teenagers and Young Adults

Another important and yet under-emphasized cause of drowning in adolescents and young adults is drowning while attempting to rescue other drowning persons. In large population-based studies 2% to 3% of drownings have occurred during rescue attempts.6 A drowning person is struggling wildly, maximally panicked, and can defeat all efforts of another individual attempting rescue, drowning the rescuer also. For this reason water-safety and life-saving training teach reaching, throwing or rowing techniques, and recommend only as a last resort approaching (with back-up support) a struggling, drowning victim.

About 90% of recreational boating deaths result from drowning. In 1980, approximately 1,200 drownings involved recreational boats, and alcohol use was a prominent factor in many of the teen and young adult drownings. ' Almost 60% of the boats were less than 16 feet long and the majority were open motor boats. Capsizing or falling overboard caused about two thirds of the deaths.9 Drownings involving boats occur most often in lakes and ponds with only 3% of fatalities occurring in salt water. In 20% of all these deaths, the boats had too few or no personal flotation devices. More than 90% of the recreational boating fatalities in one study involved only one boat and were not the result of two-boat collisions.9 Drowning accidents while fishing are not uncommon and frequently involve the combination of alcohol imbibing and an open motor-boat. The story of the fisherman who has been drinking beer, stands up in the boat to urinate overboard, falls out of the boat and drowns is wellknown among coroners.

Table

TABLE 2Ten Leading Causes of Premature Mortality Due to Unintentional Injury

TABLE 2

Ten Leading Causes of Premature Mortality Due to Unintentional Injury

It is estimated that there are 700 to 800 diving injuries per year. Most of the victims are adolescent or young adult males with little or no formal training in diving. In 40% to 50% of cases, consumption of alcoholic beverages, primarily beer, has been documented. The victim usually was unfamiliar with the area or pool where the dive was made, and the fateful dive was usually the first attempt. Death or quadriplegia are the most serious injuries sustained in diving accidents. In most cases, the diver is removed from the water by friends who are unaware of the spine injury and have not used a spine board or proper spine and neck stabilizing techniques. ,0 Over 70% of diving accidents occur as a result of diving into a shallow water area of 4 feet or less.

Entrapment injuries and deaths are another hazard of swimming pools and spas. Body part entrapment and hair entanglement in pool and spa drains with suction fittings are the most common causes of these accidents; 10 Body part entrapment usually involves an arm and in the majority of cases, the spa drain grate cover is missing or broken. Hair entanglement typically involves females with shoulder length or longer hair which becomes snarled and knotted in drain outlets on the side wall of the spa.

Drowning is also the leading cause of death in sport scuba divers, usually due to exhaustion or panic. Scuba (self-contained underwater breathing apparatus) diving is becoming increasingly popular among adolescents and young adults with an estimated 200,000 persons completing diving courses each year." National certifying agencies have a minimum age requirement of 12 years for course entry and certification. At least 60% of the scuba fatalities are the result of drowning, and although alcohol and drug use are common contributors to other adolescent and young adult drownings, they are not believed to play a significant role in most scuba drownings.12 In one epidemiologic study in Florida, despite the proximity and attraction of salt water areas, the majority of underwater diving deaths and scuba deaths occurred in fresh water, and the majority of these involved underwater cave diving and exploring.13 The vast majority of underwater diving deaths are the result of inexperience or carelessness. An important cause of loss of consciousness and drowning or near-drowning in scuba divers is cerebral arterial air embolism, due to pulmonary overinflation. Another cause of drowning or neardrowning specific to scuba divers is decompression sickness, more commonly known as "the bends."

Table

TABLE 3Contributing Factors to Adolescent Drowning Accidents

TABLE 3

Contributing Factors to Adolescent Drowning Accidents

Figure. Death rates from drowning.

Figure. Death rates from drowning.

Cerebral arterial air embolism occurs as a result of pulmonary overinflation with rupture of the alveolarcapillary basement membrane, which allows air to enter the pulmonary vasculature. Air travels through the left side of the heart and out the aorta. These intraarterial air bubbles may be carried to any part of the body, but are most likely to travel through the carotid arteries to the brain where they cause cerebral arterial occlusions with focal or global neurologic deficits. Cerebral arterial air embolism usually manifests when the diver surfaces although symptoms may be delayed for a short time after surfacing. Other complications of alveolar overinflation may accompany cerebral arterial air embolism, including mediastinal emphysema, pneumothorax and subcutaneous emphysema. Recompression therapy with a hyperbaric oxygen chamber is usually very effective in reversing the symptoms of alveolar overinflation and arterial air embolism.12

Decompression sickness or "the bends" has a slower onset of symptoms than arterial gas embolism. Its symptoms also appear as the diver ascends, usually from depths of 80 feet or more, and are due to nitrogen gas bubbles forming in blood vessels and tissues resulting from too rapid ascent. Obstruction to blood flow and pressure on tissues results in skeletal joint and muscle pain, neurologic disturbances, and pulmonary edema or respiratory distress syndrome. Decompression sickness can present minutes to hours after a dive. The treatment of decompression sickness includes recompression therapy in a hyperbaric oxygen chamber.14

RESTRICTIONS ON SWIMMING AND WATER SPORTS

Very few absolute contraindications preclude an adolescent's swimming or participation in water activities. Swimming and water activities are valuable sources of fun and exercise and medical restrictions will stigmatize the adolescent as different or abnormal and are unlikely to be obeyed. Perforated tympanic membranes, fractured cribiform plate, or recurrent ear infections are relative contraindications, although ear or nose plugs can reduce the risk of infection and these problems are usually temporary.

Recent studies have demonstrated a four to five times increased risk of drowning and near-drowning accidents in patients with epilepsy.15·16 At greatest risk for submersion accidents are patients with epilepsy who are poorly controlled on anticonvulsant medications, have had recent changes in their antiepileptic drugs, or who are mentally subnormal. Most experts feel that the data on increased risk of submersion accidents for patients with epilepsy should not lead to restrictions of swimming or water activities, but instead to increased vigilance and care around water. The normal maturation of teenagers involves some rebellion and some adolescents with seizure disorders may reduce or stop their anticonvulsant medications without parental or physician knowledge. It is important to emphasize to teenagers with epilepsy the increased risk of all types of accidents, including drownings, from having sub-therapeutic antiepileptic drug levels. Alcohol and various recreational drugs can also lower the seizure threshold.

There are various contraindications or disqualifying conditions for scuba diving including chronic pulmonary disease, cardiac disease which limits exercise tolerance, chronic tympanic membrane perforation or polyethylene tubes, and chronic sinusitus or otitis media.11 Diving is a physically demanding sport and requires sound judgment to assess diving conditions and the diver's capabilities in order to minimize risk.

TREATMENT OF NEAR-DROWNING

The single most important step in the treatment of submersion accident victims is the institution of resuscitative measures at the earliest possible opportunity.17 This means that for the apneic victim, mouth-to-mouth resuscitation is begun as soon as the rescuer reaches the victim. Unfortunately, external cardiac compressions cannot be effectively performed in the water, so assessment for pulses and performance of external cardiac massage must be delayed until the victim is out of the water.

There is no logic to attempting to drain water from the lungs in fresh water drowning, since the water has rapidly moved out of the lungs and into the vascular system. The airway should be assessed and cleared of any debris or vomitus that may be obstructing the airway or mouth before rescue breathing is begun. If the victim cannot be ventilated, obstructed airway maneuvers are indicated to clear the airway. I have grave reservations about using the abdominal thrust Heimlich maneuver in submersion accident victims because of its propensity to induce vomiting.18 Emesis and aspiration of gastric contents are major problems in submersion accident victims. The emesis also interferes with technical aspects of performing mouth-tomouth resuscitation.

In salt water submersion accidents, there may be some logic in attempting to drain water and pulmonary edema fluid from the lungs if their presence is interfering with effective ventilation. However, a lot of time should not be wasted in attempting to drain fluid from the lungs in the apneic victim since the single most important step is the immediate institution of resuscitation.

Cardiopulmonary resuscitation should be continued for as long as needed during transport to an emergency facility. Oxygen at the highest concentration attainable should be provided to the victim as soon as available.

Near-drowning victims who were submerged for more than a minute, were cyanotic or apneic, or required mouth-to-mouth resuscitation, should be hospitalized or observed in an emergency holding area for a minimum of 24 hours, no matter how well or normal they appear on arrival. There are a number of cases in the literature of near-drowning accident victims who appeared normal on assessment in an emergency department and even had a normal chest x-ray, who developed fulminant pulmonary edema as long as 12 hours after the accident. It is unclear whether this late-onset pulmonary edema is delayed respiratory distress syndrome or neurogenic pulmonary edema secondary to anoxia. Late-onset neurologic deterioration secondary to cerebral edema has also been described. Both require careful observation and assessment for at least 24 hours after the submersion accident to prevent a fatal outcome.

In addition to pulmonary injury, anoxic- ischemic cerebral insult is the most significant and important complication of near-drowning accidents. Most of the late deaths and long-term sequelae of near-drowning accidents are neurologic in origin. Every effort in the early stages after rescue of a near-drowning victim should be directed at resuscitating the brain and preventing further neurologic damage. These steps include provision of adequate oxygenation and perfusion and careful monitoring for development of cerebral edema. One should also be cognizant of possible head or spine trauma or drug and alcohol intoxication contributing to the submersion accident.

CONCLUSION

Adolescent males are at the greatest risk for drowning and near-drowning accidents. Alcohol and drug use play an important role in these accidents. Efforts at reducing recreational use and abuse of alcohol and drugs by young adults as well as reducing risk-taking and hazardous activity exposure by teenagers are the most promising steps in preventing these needless accidents and their toll in years of potential life lost.

REFERENCES

1. Baker SP, O'Neill B, Karpf RS: The lnrury Fact Book. Lexington, MA. DC Heath & Cb, 1984.

2. Rie D, BarancikJI, Charterjee BF: Northeastern Ohio Trauma Study II: Injury rales by age, sex. and cause. AmJ ??& Heakk 1984; 74:473-478.

3. Centers for Disease Control: Mortality due to unintentional injuries - United States, 1983. MMWR 1986; 35:353-356.

4. DieB PE, Baker SP: Drowning - Epidemiology and prevention. Arn J Public Health 1974; 64:303-312.

5. Wintemute GJ, Kraus JF, Teret SP, et al: Drowning in childhood and adolescence: A population-based study. AmJ PuMic Heoitf. 1987; 77:830-832.

6. Centers for Disease Control: North Carolina drownings- 1980- 1984. MMWR 1986; 35:635-638.

7. Higgins P, Siminski J, Pearson RD: Hypoxic lap swimming - A cause oí near-druwning. N Engt J Md 1986; 315:1552-1553.

8. Craig AB Jr: Causes of loss of consciousness during underwater swimming. J Appi Physiol 1961; 16:583-586.

9. Centers for Disease Control: Recreational boating fatalities - Ohio. 1983-1986. MMWH 1987; 36:321-324.

10. United Stares Consumer Product Safety Commission and National Spa and ftx>l Institute: National JW and Spa Safety Con/erence: Final Rej»rt May 14, 1985. pp 1-48

11. Dembert ML. Keith JF: Evaluating the potential pediatric scuba diver. AmJ Dis Child 1986; 140:1135-1141.

12. Zwingelben; KM, Green JW, Powers EK: Primary causes of drowning and neardrowning in scuba diving. Physician and Sports Medicine 1986; 14:145-151.

13. Centers for Disease Control: Underwater diving deaths- Rorida. MMWR 1980; 29:69-71.

14. Arthur DC, MarguliesRA: A short course in diving medicine. ArmEmergMed 1987; 16:689-701.

15. Orlowski JP, Rothner AD, Luders H: Submersion accidents in children with epilepsy. AmJ Dis ChM 1982; 136:777-780.

16. Feam JH: Epilepsy and drowning in children. Br Med J 1977; 1:1510-1511.

17. Orlowski JP: Drowning, near-drowning and ice- water submersions, ftdiorr CIm North Am 1987; 34:75-92.

18. Orlowski JP: Vomiting as a complication of the Heimlich maneuver. JAMA 1987; 258:512-513.

TABLE 1

Major Causes of Accidental Death in Teenagers and Young Adults

TABLE 2

Ten Leading Causes of Premature Mortality Due to Unintentional Injury

TABLE 3

Contributing Factors to Adolescent Drowning Accidents

10.3928/0090-4481-19880201-09

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