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Debunking the Existence of Dry or Delayed/Secondary Drowning
Date Published: August 12, 2024
Does the evidence available on delayed or secondary or dry drowning support the clinical phenomenon of delayed onset of respiratory symptoms in a drowning survivor following a period of being asymptomatic?
The existence of secondary/delayed/dry drowning has been debunked by multiple organizations, it continues to be presented to the public by the media and their consultants. It has terrified parents into believing their child could die following any submersion or exposure to in-water activities.
ANSWER
Recently, reports in the news media and social media have called attention to the problem of dry drowning or secondary/delayed drowning. These describe mostly children who had recreated in the water at some point, had no immediate breathing difficulty, seemed well after and then deteriorated or died days later. These reports vary and lack final medical assessment but assign these medical diagnoses. These media accounts have spread fear among parents who worry about the risk of letting their child participate in water related activities and the need for long term vigilance for deterioration. Emergency departments are reporting that families are showing up with their children for evaluation of dry drowning.
While among the major causes of injury death to preschoolers, the second major injury cause of death to school age children and the third major cause of injury death to teens and young adults, parents/families need correct and medically credible information about the risks of drowning and the signs and symptoms of drowning.
- What is a drowning?
The medical definition of drowning is “the process of experiencing respiratory impairment from submersion/immersion in liquid.”i Thus, if a person was in water and had no breathing troubles the person did not drown. - There are no medically accepted conditions known as “near-drowning”, “dry drowning”, “secondary drowning” or delayed drowning.
The World Health Organization,ii the International Liaison Committee on Resuscitation,iii the Wilderness Medical Society,iv the Utstein Style system,v the International Lifesaving Federation,vi the International Conference on Drowning,vii Starfish Aquatics Institute,viii the American Red Cross,ix and the US Centers for Disease Control and Prevention (CDC)x,xi,xii,13 all discourage use of these terms. A scientific review of the medical literature showed no evidence to support these conditions exist.14 - Here are why these conditions don’t make sense and are not approved:
- Near-drowning: People who drown either die or survive (with or without morbidity (brain damage). The term near-drowning was used to refer to drowning victims who survived but it has been used in so many ways it caused confusion. Imagine using terms like “near burns,” “near cardiac arrest”, or “near car collisions”. To be clear about whether the victim died or lived after a drowning event, the terms that should be used are fatal drowning (died) or nonfatal drowning (lived).
- Dry drowning: The terms dry and wet drowning were abandoned decades ago when the real culprit in drowning injury was understood. Drowning injury is caused by lack of oxygen; it is not about water entering the lungs. In the past, these terms were used to try to explain that some fatal drowning victims had very little water in their lungs at autopsy. Now it is understood that little water enters the lungs during drowning. Moreover, when water enters the lungs, it is rapidly absorbed when breathing starts again. The amount of water that enters the lung does not determine the amount of injury or determine the treatment of drowning. The amount of injury from drowning is due to how long the victim is without oxygen.15 Thus, not being able to breathe for longer than a few minutes leads to death or survival with severe damage. Not getting breathing restored after rescue also leads to death. The care of the drowning victim is the same regardless of whether water is present in the airways and lungs. The treatment of drowning is restoring breathing and oxygenation.
- Secondary drowning: Sometimes known as “delayed drowning”, has no currently accepted medical definition. It was originally used because drowning victims may sometimes worsen after drowning, rescue, and resuscitation. The terminology was used before drowning injury was understood, and before prehospital care and emergency departments could evaluate breathing with the care they do now. Cases of rescued drowned persons who have some mild symptoms, such as cough or confusion, are fortunately far more common than fatal drowningsx.iii For kids, it is estimated that for every fatal drowning, there are 5 non-fatal drownings.xiii
What to watch for after a person was submerged and then rescued4, 9,14
Victims who after exiting the water are completely normal, with no symptoms, did not drown. Of course, if that person develops cough, breathing difficulty or confusion or other concerning symptoms at any time, he should seek medical attention. This would be rare after returning to normal, and in fact there are no known reported instances of a death from drowning after a person has returned to a period where they were completely normal.
- Victims who when rescued have minimal symptoms (like the sputtering and coughing after swallowing water down the wrong pipe at the dinner table) that resolve AND resolve quickly AND the victim returns immediately to normal with no breathing difficulty, can be observed by an attentive caretaker. These victims will either get better or worse within 2-3 hours. If the victim develops coughing, breathing difficulties, sleepiness, or confusion, they should seek medical attention.
- Victims who when rescued have excessive or prolonged cough, fast or hard breathing, isn’t breathing normally, or isn’t acting right should seek medical care. Usually, alert persons who had a drowning event can be observed for 4-6 hours in an emergency department and sent home if normal.
- Deaths due to drowning do not occur due to unexpected deterioration days or weeks later with no preceding symptoms. Brand new symptoms that develop days later are extremely unlikely related to the drowning episode. Importantly, the person should be evaluated for other conditions that might have caused the deterioration.
Bottom line. “Near”, “dry”, “wet”, “delayed”, and “secondary” drownings are not medically accepted conditions. If a child has been the water, is breathing, walking and talking normally then later gets sick, the child needs be seen by a health-care provider immediately. But it is not drowning. The most important way to “treat” drowning is to prevent drowning. What works are swim lessons, adequate supervision for children and adolescents, lifejacket usage, 4-sided pool fencing, and swimming where there is a lifeguard. Parents and those supervising others in the water should learn water safety, what is adequate supervision, how to perform a safe rescue, and CPR.16
References
- Waletzko, B., Lin, P. L., & Lopez, S. M. C. (2023). "Hot Tub Lung" With M. avium complex in an Immunocompetent Adolescent. The Pediatric infectious disease journal, 42(3), e84–e87. https://journals.lww.com/pidj/abstract/2023/03000/_hot_tub_lung__with_m__avium_complex_in_an.22.aspx
- Blazovic, S., Jamal, Z., & Quinn, K. (2022). Pool Safety. In StatPearls. StatPearls Publishing.
- Hageman, S. M., Chakraborty, R. K., & Murphy-Lavoie, H. M. (2022). Immersion Pulmonary Edema. In StatPearls. StatPearls Publishing.
- McCall, J. D., & Sternard, B. T. (2022). Drowning. In StatPearls. StatPearls Publishing.
- Chen, M., Zhu, X., Cong, Y., Chen, H., Hou, Q., Hong, N., Chen, X., Lei, W., Cai, J., Lu, X.,Shuai, L., Li, X., Deng, S., Xu, J., Liao, W., Pan, W., Xu, H., & de Hoog, S. (2022). Genotypic diversity and antifungal susceptibility of Scedosporium species from clinical settings in China. Mycoses, 65(12), 1159–1169. https://onlinelibrary.wiley.com/doi/10.1111/myc.13507
- Kattih, O., Almoosa, Z. A., & Alibraheem, A. (2022). Contained Jejunal Perforation Secondary to Ingestion of Magnet Balls in a Nonfatal Drowning Child. Cureus, 14(9), e29741. https://doi.org/10.7759/cureus.29741
- Tsuneya, S., Nakajima, M., Makino, Y., Torimitsu, S., Yamaguchi, R., & Iwase, H. (2022). The effect of ethanol or long-time reaction on the diatom test in water samples using sodium hypochlorite. Legal medicine (Tokyo, Japan), 57, 102054. https://doi.org/10.1016/j.legalmed.2022.102054 Shi, X. W., Li, S. T., Lou, J. P., Xu, B., Wang, J., Wang, X., Liu, H., Li, S. K., Zhen, P., & Zhang, T. (2022). Scedosporium apiospermum infection of the lumbar vertebrae: A case report. World journal of clinical cases, 10(10), 3251–3260.
- Ghasemian, R., Bandegani, A., Kermani, F., Faeli, L., Roohi, B., Yousefi-Abdolmaleki, E., T Hedayati, M., Roilides, E., & Shokohi, T. (2021). Fatal pulmonary Scedosporium aurantiacum infection in a patient after near-drowning: A case report. Current medical mycology, 7(4), 38–42. https://doi.org/10.18502/cmm.7.4.8410
- Maeda, A., Nakajima, Y., Yanagisawa, K., Sugimoto, T., Harano, K., Kaki, Y., Sasaki, J., Dohi, K., & Hayashi, M. (2021). Combination therapy with levofloxacin and cefepime to treat severe respiratory infection due to Aeromonas caviae after a near-drowning accident in river water. Acute medicine & surgery, 8(1), e708. https://doi.org/10.1002/ams2.708
- Cervera-Hernandez, M. E., Szymczak, W., Puius, Y. A., & Shuter, J. (2021). Lung, Brain, and Spinal Cord Abscesses After a Near-Drowning Episode. The American journal of medicine, 134(11), e546–e547. https://doi.org/10.1016/j.amjmed.2021.04.039
- Burkart, K. G., Brauer, M., Aravkin, A. Y., Godwin, W. W., Hay, S. I., He, J., Iannucci, V. C., Larson, S. L., Lim, S. S., Liu, J., Murray, C. J. L., Zheng, P., Zhou, M., & Stanaway, J. D. (2021). Estimating the cause-specific relative risks of non-optimal temperature on daily mortality: a two- part modelling approach applied to the Global Burden of Disease Study. Lancet (London, England), 398(10301), 685–697. https://doi.org/10.1016/S0140-6736(21)01700-1
- Barranco, R., Bonsignore, A., & Ventura, F. (2021). Immunohistochemistry in postmortem diagnosis of acute cerebral hypoxia and ischemia: A systematic review. Medicine, 100(25), e26486. https://doi.org/10.1097/MD.0000000000026486
- Peng, N., Xu, W., Luo, H. M., Ouyang, P. W., Jiang, B., Zhang, Z. H., Cao, Y. D., Tan, L. M., Qu, P. H., & Xie, L. Y. (2021). Pigmentibacter ruber gen. nov., sp. nov., a novel bacterium of the family Silvanigrellaceae isolated from human blood. Antonie van Leeuwenhoek, 114(6), 731– 739. https://doi.org/10.1007/s10482-021-01553-3
- Smith, S. E., Butler, S. A., Martin, J., Gerard, D., & Sikora Newsome, A. (2021). Angiotensin II for Near Drowning: A Case Series. Critical care explorations, 3(5), e0434. https://doi.org/10.1097/CCE.0000000000000434
- Barcala-Furelos, R., Abelairas-Gómez, C., Alonso-Calvete, A., Cano-Noguera, F., Carballo- Fazanes, A., Martínez-Isasi, S., & Rodríguez-Núñez, A. (2021). Safe On-Boat Resuscitation by Lifeguards in COVID-19 Era: A Pilot Study Comparing Three Sets of Personal Protective Equipment. Prehospital and disaster medicine, 36(2), 163–169. https://doi.org/10.1017/S1049023X2100011X
- Bichali, S., Giroux, N., Benbrik, N., & Liet, J. M. (2021). Unexplained near-drowning can reveal ALCAPA in children. Archives de pediatrie : organe officiel de la Societe francaise de pediatrie, 28(3), 252–254. https://doi.org/10.1016/j.arcped.2020.12.001
- Szpilman, D., & Morgan, P. J. (2021). Management for the Drowning Patient. Chest, 159(4), 1473–1483. https://doi.org/10.1016/j.chest.2020.10.007
- Şık, N., Şenol, H. B., Öztürk, A., Yılmaz, D., & Duman, M. (2021). A reappraisal of childhood drowning in a pediatric emergency department. The American journal of emergency medicine, 41, 90–95. https://doi.org/10.1016/j.ajem.2020.12.059
- Seese, L., Kilic, A., Turbendian, H. K., Sanchez, P. G., Diaz-Castrillon, C. E., & Morell, V. O. (2021). The Impact of Donor Asphyxiation or Drowning on Pediatric Lung Transplant Recipients. Transplantation, 105(3), 620–627. https://doi.org/10.1097/TP.0000000000003262
- Grimes, A. D., Kennedy, R., Quang, C., Albrecht, R., & Blair, S. (2021). The Management of Acute Respiratory Distress Syndrome After Near Drowning and Low-Voltage Electrocution. The American surgeon, 3134820983189. Advance online publication.
- Barcala-Furelos, R., Szpilman, D., Abelairas-Gómez, C., Alonso-Calvete, A., Domínguez- Graña, M., Martínez-Isasi, S., Palacios-Aguilar, J., & Rodríguez-Núñez, A. (2020). Plastic blanket drowning kit: A protection barrier to immediate resuscitation at the beach in the Covid- 19 era. A pilot study. The American journal of emergency medicine, 38(11), 2395–2399. https://doi.org/10.1016/j.ajem.2020.08.101
- Amodeo, A., Erdil, T., Vanetta, C., Steigmiller, K., Schmiady, M., Schweiger, M., Pretre, R., & Dave, H. (2020). Serum lactate at 24 hours is associated with outcome in children requiring extracorporeal membrane oxygenation for pulmonary causes - a retrospective, observational study. Swiss medical weekly, 150, w20358. https://doi.org/10.4414/smw.2020.20358
- Han, L. Y., Gao, Y. H., Yu, G. L., Shi, Y., Li, W. P., Wang, Z. Q., Li, Y. J., & Jin, F. G. (2020). Zhonghua jie he he hu xi za zhi = Zhonghua jiehe he huxi zazhi = Chinese journal of tuberculosis and respiratory diseases, 43(9), 772–777. https://doi.org/10.3760/cma.j.cn112147-20191028-00717
- Kanamori, H., Aoyagi, T., Kuroda, M., Sekizuka, T., Katsumi, M., Ishikawa, K., Hosaka, T., Baba, H., Oshima, K., Tokuda, K., Hasegawa, M., Kawazoe, Y., Kushimoto, S., & Kaku, M. (2020). Chromobacterium haemolyticum Pneumonia Associated with Near-Drowning and River Water, Japan. Emerging infectious diseases, 26(9), 2186–2189. https://doi.org/10.3201/eid2609.190670
- Markarian, T., Loundou, A., Heyer, V., Marimoutou, C., Borghese, L., Coulange, M., & Michelet, P. (2020). Drowning Classification: A Reappraisal of Clinical Presentation and Prognosis for Severe Cases. Chest, 158(2), 596–602. https://doi.org/10.1016/j.chest.2020.01.035
- Samprathi, M., Agarwal, A., Jayashree, M., Bansal, A., Baranwal, A., Nallasamy, K., & Angurana, S. K. (2020). Better Groundwork Can Avoid Troubled Waters: A Developing Country Perspective on Drowning. Journal of tropical pediatrics, 66(4), 458–460.
- Ploumpidis D. (2020). Living with covid-19. Psychiatrike = Psychiatriki, 31(3), 197–200. https://doi.org/10.22365/jpsych.2020.313.197
- Barcala-Furelos, R., Aranda-García, S., Abelairas-Gómez, C., Martínez-Isasi, S., López- Mesa, F., Oleagordia-Aguirre, A., Palacios-Aguilar, J., & Szpilman, D. (2020). Recomendaciones de salud laboral para socorristas ante emergencias acuáticas en la era Covid-19: prevención, rescate y reanimación [Occupational health recommendations for lifeguards in aquatic emergencies in the Covid-19 era: prevention, rescue and resuscitation.]. Revista espanola de salud publica, 94, e202006074.
- Lee, H. K., Kim, H. S., Ha, S. O., Park, S., Lee, H. S., Lee, S. K., & Lee, S. H. (2020). Clinical outcomes of extracorporeal membrane oxygenation in acute traumatic lung injury: a retrospective study. Scandinavian journal of trauma, resuscitation and emergency medicine, 28(1), 41. https://doi.org/10.1186/s13049-020-00733-w
- Maguire, M. J., Jackson, C. F., Marson, A. G., & Nevitt, S. J. (2020). Treatments for the prevention of Sudden Unexpected Death in Epilepsy (SUDEP). The Cochrane database of systematic reviews, 4(4), CD011792. https://doi.org/10.1002/14651858.CD011792.pub3
- Ho, B. J., Crowe, J. E., Dorfman, S. R., Camp, E. A., Yusuf, S., & Shenoi, R. P. (2020). Correlation of clinical and chest radiograph findings in pediatric submersion cases. Pediatric radiology, 50(4), 492–500. https://doi.org/10.1007/s00247-019-04588-x
- Heyman, S. N., Gorelik, Y., Zorbavel, D., Rosenberger, C., Abassi, Z., Rosen, S., & Khamaisi, M. (2020). Near-drowning: new perspectives for human hypoxic acute kidney injury. Nephrology, dialysis, transplantation : official publication of the European Dialysis and Transplant Association - European Renal Association, 35(2), 206–212. https://doi.org/10.1093/ndt/gfz016
ARC SAC REFERENCES
American Red Cross Scientific Advisory Council. Statement on Secondary Drowning. American Red Cross Scientific Advisory Council, May 2014What to Read Next
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- What is a drowning?