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‘Dry drowning’ and other myths

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MYTHS AND SLOPPY TERMINOLOGY

“Near drowning,” “dry drowning,” “wet drowning,” “delayed drowning,” and “secondary drowning” are not medically accepted diagnoses,3,4,19 and many organizations and lifesaving institutions around the world discourage the use of these terms.19,20 Unfortunately, these terms still slip past the editors of medical journals and are thus perpetuated. The terms are most pervasive in the nonmedical media, where drowning seems to be synonymous with death.3,19,21 We urge all authors and stakeholders to abandon these terms in favor of understanding and communicating drowning as a process that can vary in severity and have a fatal or nonfatal outcome.

Near-drowning

Historically, drowning meant death, while near-drowning meant the victim survived, at least initially (usually for at least 24 hours).

Before 2002, there were 13 different published definitions of near-drowning.21,22 This variability has caused a great deal of confusion when trying to describe and monitor drowning.

A person can drown and survive, just as a person can have cardiac arrest and survive.4,21 Just as there is no recognized condition of “near-cardiac arrest,” there is also no condition of near-drowning. Using near-drowning as a medical diagnosis hides the true burden of drowning and consequently amplifies difficulties in developing effective prevention, rescue, and treatment programs.

Dry drowning

Dry drowning has never been an accepted medical term, although it has been used to describe different parts of the drowning process. While many authors use it as a synonym for secondary drowning (described below), in the past it was usually used in cases in which no water was found in the lungs at autopsy in persons who were found dead in the water.2–4,21 This occurred in about 10% to 15% of cases and was also called drowning “without water aspiration.”

Perhaps some victims suffer sudden cardiac death. It happens on land—why not in the water? Modell et al stated, “In the absence of the common finding of significant pulmonary edema in the victim’s respiratory system, to conclude his or her death was caused by ‘drowning without aspiration’ is unwise.”23

Laryngospasm is another proposed explanation. It could play a role in the fewer than 2% of cases in which no other cause of death is found on clinical examination or autopsy,11,12,19,23 but it does not occur in most cases of drowning, or it is brief and is terminated by the respiratory movements that allow the air in the lung to escape and water to be inhaled.

The problem with the term dry drowning is the harm caused by misdiagnosing cases of sudden death as drowning, when an alternative cause is present. Most importantly, the management is the same if small amounts of water are present or not; therefore, no clinical distinction is made between wet and dry drowning.

Secondary drowning

Secondary drowning, sometimes called delayed drowning, is another term that is not medically accepted. The historical use of this term reflects the reality that some patients may worsen due to pulmonary edema after aspirating small amounts of water.

Drowning starts with aspiration, and few or only mild symptoms may be present as soon as the person is removed from the water. Either the small amount of water in the lungs is absorbed and causes no complications or, rarely, the patient’s condition becomes progressively worse over the next few hours as the alveoli become inflamed and the alveolar-capillary membrane is disrupted. But people do not unexpectedly die of drowning days or weeks later with no preceding symptoms. The lungs and heart do not “fill up with water,” and water does not need to be pumped out of the lungs.

There has never been a case published in the medical literature of a patient who underwent clinical evaluation, was initially without symptoms, and later deteriorated and died more than 8 hours after the incident.6,10,21 People who have drowned and have minimal symptoms get better (usually) or worse (rarely) within 4 to 8 hours. In a study of more than 41,000 lifeguard rescues, only 0.5% of symptomatic patients died.6

Drowning secondary to injury or sudden illness

Any injury, trauma, or sudden illness that can cause loss of consciousness or mental or physical weakness can lead to drowning. Physicians need to recognize these situations to treat them appropriately. Drowning that is secondary to other primary insults can be classified as24:

  • Drowning caused by injury or trauma (eg, a surfing, boating, or a hang-gliding accident)
  • Drowning caused by a sudden illness such as cardiac disease (eg, myocardial ischemia, arrhythmias, prolonged QT syndrome, hypertrophic cardiomyopathy) or neurologic disease (eg, epilepsy, stroke)
  • Diving disease (eg, decompression sickness, pulmonary overpressurization syndrome, compression barotrauma, narcosis [“rapture of the deep”], shallow water blackout, immersion pulmonary edema).
Figure 1. Drowning chain of survival.

Figure 1. Drowning chain of survival.

Bystanders, first responders, and health professionals need to be aware of the complete sequence of actions required when dealing with water distress or drowning (Figure 1).25

PREVENTION IS BEST

Drowning is a leading and preventable cause of death worldwide and for people of all ages. The danger is real, not esoteric or rare, and healthcare providers should use any opportunity to discuss with patients, parents, and the media the most important tool for treating drowning: primary prevention.

For example, small children should be continuously and uninterruptedly supervised within arm’s reach while in the water, even if a lifeguard is present. Other preventive measures are lifejackets, fences completely enclosing pools or ponds, and swimming and water safety lessons. Drowning often occurs in a deceptively pleasant environment that may not seem dangerous.

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