• Debunking the Existence of Dry or Delayed/Secondary Drowning

    Lifeguard overseeing families swimming in a public pool.

    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.

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    1. 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.
    2. 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
    3. Here are why these conditions don’t make sense and are not approved:
      1. 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).
      2. 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.
      3. 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.

    1. 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.
    2. 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.
    3. 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

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    ARC SAC REFERENCES
    American Red Cross Scientific Advisory Council. Statement on Secondary Drowning. American Red Cross Scientific Advisory Council, May 2014

    Is Dry Drowning Real? Facts vs. Fiction

    Watch as Dr. Joshua M. Tobin, Chief, Division of Trauma Anesthesiology Los Angeles County Hospital/Keck School of Medicine, Commander in the U.S. Navy Reserve, discusses dry drowning – and separates fact from fiction. With a dry drowning definition and information on what to do after a drowning incident, we can help you understand when to seek medical attention and keep your child safe.

    So, there's this whole spectrum of drowning from patients who sadly die to those who live. And so, we want to be sure that people understand that if you've had a drowning incident, if you've had some trouble in the water, and you're coughing and sputtering, you need to seek medical attention.

    The idea, however, that several days later you can sort of spontaneously die because you've had a drowning incident probably is not accurate. What's more accurate is to say that the drowning incident initiated a process that would merit more careful medical evaluation.

    Now as a parent, okay, well, what the heck does this mean to me? What do I do if I'm at the pool and my kid's playing underwater tag and someone holds him under for a second too long, and then he's coughing and sputtering? What should I do?

    Well, the thing that I would do is to watch my child at home and if I had any concerns whatsoever that they're having trouble breathing, that they are continuing to cough, if they just didn't seem like themselves, I would take them to the emergency department and get a more thorough medical evaluation.

    Sign up for a CPR class as well as the free American Red Cross course, Water Safety for Parents and Caregivers.

    If you observe any of the signs below, please seek medical attention:

    Information provided by a member of the American Red Cross Scientific Advisory Council.

    Dr. Joshua M. Tobin, Chief, Division of Trauma Anesthesiology Los Angeles County Hospital/Keck School of Medicine, Commander in the U.S. Navy Reserve.

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