Drowning, the Burden of Fatality: A Case Report

This case reports the events surrounding a teenager who suffered from drowning and unfortunately had the final outcome of death after a fortnight period. This experience is indeed a very sad one to the physician, care givers, family members and friends. This outcome has been reported in several instances. Drowning can take place in any form of liquid, commonly in large bodies of water; however  in children it can even occur in shallow water.³ It has been known that drowning is noted to be more in men just as this case report presents. ^{4, 5, 6 ,7} The reason being that males tend to be more adventurous, engage in risky practices and tend to use alcohol and recreational drugs that are more likely to impair judgement.⁴  The modal  age group varies from different reports from Nigeria. Mckeever and  Hossain  reports that the modal age group of drowning cases is 10-19 years which this index case falls into;  with more than half of the cases being below 20 years.⁶  Uchendu et al and Seleye-Fubara et al had modal ages to be the 3^rd & 4^th decades and 50-59 age group in their own studies respectively. ^{5, 7}  Freshwater bodies are also known to have higher frequency of drowning incidents not because it is more hazardous to the lungs than sea water(salt water) , but because unguarded inland waters and swimming pools are visited more frequently.³   Salt water bodies comprises of sea water and  its offshoots such as tributaries, rivers, deltas and creeks . Port Harcourt is in Rivers State which is a coastal part of Nigeria where this case of drowning occurred. It is characterized by both fresh and salt water bodies.⁸  Rivers were noted to be the most common place where accidental drowning takes place just as it was in this case. ^{5, 6, 7} It is known that those with chronic health challenges such as epilepsy are likely to have a higher risk of drowning. ^{1, 4, 9} The patient had received bystander resuscitative measures basically chest compressions which helped in saving his life in the immediate time prior presentation to a health facility. Bystander resuscitative measures such as basic cardio-pulmonary resuscitation using chest compressions and mouth breaths is being taught in different schools and amongst different career persons including athletes in Nigeria.^{10, 11}  Basic life support  resuscitation has been known to increase survival in drowning patients by up to 91% of cases in the initial stage after rescue.¹² The long term survival has been noted to be poor in those with submersion time more than 30 minutes just as it was in this index case.¹³ Most deaths occurred after termination of initial resuscitation or during initial hospitalization just as it was  seen in this case.  Factors that have been known to influence long-term survival include older age, illicit substance use, pre-drowning activity, submersion duration, cardiopulmonary resuscitation duration, intubation, defibrillation, medications and inpatient markers of illness severity.¹⁴

The patient in this case had no chronic medical condition which may have reduced the risk of immediate fatal death. It has been seen in a study group in Canada that fatal drowning is higher in those with physical disabilities, cardiovascular disease, seizure disorder and neurocognitive disease which cuts across all age groups and gender .¹⁵ Sickle cell trait has been linked with sudden death in extreme physical conditions particularly under high altitude such as underwater activities particularly if they develop sickle cell crisis.¹⁶ This patient did not have any of these risk factors.

The clinical presentation of drowning patients vary individually however it has been noted that aspiration of both water and foreign substances including micro-organisms can occur which was as in this case.¹ Hypothermia is a common phenomenon although in this case his body temperature on admission into the facility was high, this is understandable since it was a referred case and the body have warmed up after being pulled out of water. Fever experienced in this case was likely due to an infection which had resulted in pneumonia as documented in other cases.¹⁷ Diarrhoea in this case can also be as a result of systemic infection or electrolyte imbalance as seen in this index case.  A variety of other clinical manifestations can also be seen in a drowning patient such as ocular bobbing and pontine haemorrhage reported in an older adult in India.⁹ Neurological, cardiac and respiratory problems are also predominant in drowning victims.^{1, 4} Management of drowning is aimed at correcting hypoxemia and acidosis, maintaining core body temperature and treatment of infections.¹ This patient received all the needed care available within the facility as he even made some  clinical improvement; however he worsened and had to receive intensive care in another facility. Mechanical ventilation has been noted to combat acute respiratory disease found in drowning patients. ^{1, 2, 18} The use of continuous positive airway pressure (CPAP) if available is advised if oxygen saturation is low and if the patient is still dyspneic despite being  on 100% oxygen.¹ If it is not available,  early intubation, with appropriate use of positive end-expiratory pressure (PEEP) is encouraged.¹ Hyperoxemia may be a complication and should be looked out for by assessing arterial blood gases and oxygen saturation.¹ Despite all these interventions the damage done during drowning may not be fully reversed. In a study done in Australia revealed that the non-fatal cases were in higher proportion when compared to the fatal cases and survival has improved over the years; however females were more likely to survive than males.¹⁹ Adolescents where also likely to survive more than toddlers.¹⁹ The hospital admission rate was also higher for non- fatal cases just as this index case was also admitted. The increase in survival rates seems to pose a threat in the campaign for prevention; as the best bet in drowning is to prevent all the risky behaviours and ultimately supervise the young children since the general outcome remains unpredictable and it still carries a high burden of fatality. ^{1, 4, 14, 19}