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Near drowning refers to surviving — temporarily, at least — the physiologic effects of hypoxemia and acidosis that result from submersion in fluid. Hypoxemia and acidosis are the primary problems in victims of near drowning.
Near drowning occurs in three forms:
❑ dry: The victim doesn’t aspirate fluid but suffers respiratory obstruction or asphyxia (10% to 15% of patients)
❑ wet: The victim aspirates fluid and suffers from asphyxia or secondary changes due to fluid aspiration (about 85% of patients)
❑ secondary: The victim suffers recurrence of respiratory distress (usually aspiration pneumonia or pulmonary edema) within minutes or 1 to 2 days after a near-drowning incident.
Near drowning results from an inability to swim or, in swimmers, from panic, a boating accident, a heart attack or a blow to the head while in the water, drinking heavily before swimming, or a suicide attempt.
Regardless of the tonicity of the fluid aspirated, hypoxemia is the most serious consequence of near drowning, followed by metabolic acidosis. Other consequences depend on the kind of water aspirated.
After freshwater aspiration, changes in the character of lung surfactant result in exudation of protein-rich plasma into the alveoli. This, plus increased capillary permeability, leads to pulmonary edema and hypoxemia.
After saltwater aspiration, the hypertonicity of sea water exerts an osmotic force, which pulls fluid from pulmonary capillaries into the alveoli. The resulting intrapulmonary shunt causes hypoxemia. Also, the pulmonary capillary membrane may be injured and induce pulmonary edema. In both kinds of near drowning, pulmonary edema and hypoxemia occur secondary to aspiration.
Near-drowning victims can experience a host of signs and symptoms: apnea, shallow or gasping respirations, substernal chest pain, asystole, tachycardia, bradycardia, restlessness, irritability, lethargy, fever, confusion, unconsciousness, vomiting, abdominal distention, and a cough that produces a pink, frothy fluid.
A history of near drowning along with characteristic features and auscultation of crackles and rhonchi is required for a diagnosis. Supportive tests include:
❑ arterial blood gas (ABG) analysis: shows hypercarbia, hypoxemia, and metabolic acidosis
❑ electrocardiography: may show arrhythmias.
❑ Begin emergency treatment: Administer cardiopulmonary resuscitation and 100% oxygen.
❑ Stabilize the patient’s neck in case he has a cervical injury.
❑ Intubate the patient, and provide respiratory assistance, such as mechanical ventilation with positive end-expiratory pressure, if needed.
❑ Assess arterial blood gas and pulse oximetry values.
❑ If the patient’s abdomen is distended, insert a nasogastric tube. (Intubate the patient first if he’s unconscious.)
❑ Start an I.V. line; insert an indwelling urinary catheter.
❑ Give medications as necessary. Much controversy exists about the benefits of drug treatment of near-drowning victims. However, such treatment may include sodium bicarbonate for acidosis, a corticosteroid for cerebral edema, an antibiotic to prevent infections, and a bronchodilator to ease bronchospasms.
❑ Observe the patient for pulmonary complications and indications of delayed drowning (confusion, substernal pain, adventitious breath sounds). Suction often. Pulmonary artery catheters may be useful in assessing cardiopulmonary status.
CLINICAL TIP: Remember, all near-drowning victims should be admitted for an observation period of 24 to 48 hours because of the possibility of delayed drowning.
❑ Monitor vital signs, intake and output, and peripheral pulses. Check for skin perfusion. Watch for signs of infection.
❑ To facilitate breathing, raise the head of the bed slightly.
❑ To prevent near drowning, advise swimmers to avoid drinking alcohol before swimming, to observe water safety measures, and to take a water safety course sponsored by the Red Cross, YMCA, or YWCA.
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Copyright notice for book excerpts: Copyright © 2008 Lippincott Williams & Wilkins. All rights reserved.
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More About This Book:
Title: Handbook of Diseases Authors: Springhouse Publisher: Lippincott Williams & Wilkins Copyright: 2003 ISBN: 1-58255-266-5 
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