Lessons in the News: Secondary Drowning

Did Little Johnny Drown During His Nap?

SOUTH: 6/5/08 – As Cassandra Jackson watched her 10-year-old son Johnny splash around in their neighborhood pool last week, she had no reason to believe anything was wrong – let alone that her son was slowly drowning.

“He seemed to be fine,” Jackson, 41, told ABCNEWS.com from her home in Goose Creek, S.C. “I noticed nothing out of the ordinary, other than him taking a little bit of water in and coughing and then calming down.”

Jackson estimated that Johnny had been in the pool for 45 minutes and had been wearing floatation devices on each arm, in addition to being monitored by an adult in the pool, as well as herself and a friend watching from pool chairs nearby.

But less than two hours after getting out of the pool, Johnny had defecated in his pants twice and was complaining of being tired.

After being bathed and dressing himself, Johnny walked to his bed unaided, leading his mother to believe that he was simply tired from playing in the water.

But shortly after leaving him to nap, Jackson discovered her son unconscious and his face covered in a foam-like substance.

“My friend went back into the room where Johnny was sleeping and noticed what appeared to be cotton balls stuffed in his nose,” Jackson said of what turned out to be the foam from his nose and mouth. “She asked if I put them there and I said no – I went in and saw him and screamed for help.

“I rolled him over and his body was very limp and I realized he’d soiled himself again and was very purplish-blue looking,” said Jackson, who then called 9-1-1. “His tongue was really swollen, too.”

Johnny suffered from cardiac arrest on the way to the hospital, his mother said, and was pronounced dead upon arrival.

Berkeley County Coroner Glenn Rhoad examined Johnny’s body after the incident and told ABCNEWS.com that the preliminary autopsy showed the cause of death was asphyxiation due to drowning. Rhoad added that the boy had a lot of water in his lungs.

While Johnny had been diagnosed with Attention Deficit Disorder and autism, there is no reason to believe that either condition had anything to do with his death, the coroner said.

How Johnny managed to walk out of the pool and into his bed, communicating with his mother along the way, seems mysterious – but doctors said Johnny may have suffered from a sort of secondary drowning or near drowning, as some refer to it.

What Happened to Johnny?

“With primary drowning, you inhale water and you can’t breathe and you die right away,” said Stephen Epstein, a spokesman for the American College of Emergency Physicians. “But with secondary drowning, you die because of a secondary injury to the lung caused by a small amount of the water getting into the lung.”

Johnny would have only had to inhale four ounces of water to drown, and even less to injure his lung enough to become a victim of secondary drowning, Epstein said.

“Depending on what’s in the fluid, it can have numerous effects on the lung,” said Epstein, who practices at Boston’s Beth Israel Deaconess Medical Center. “One of the things that keeps the breathing bubbles in your lungs – alveoli – open is a chemical called surfactant, which can get diluted [when fluid enters the lungs].”

What results when the surfactant is diluted and the lung is not working properly, said Epstein, is that the body’s natural reactor kicks in and sends other fluids from your body to help – flooding your lungs with fluids.

“Sometimes the body has a natural reaction that is not helpful,” Epstein said of this phenomenon. “The fluid comes out of your blood stream and invades the lung, and then we have a lot of fluid inside the lung, leaving no room for the air.

“Then you have pulmonary edema,” said Epstein.

Pulmonary edema, or the accumulation of fluid in the lungs, Epstein explained, can later result in cardiac arrest, as oxygen is prevented from getting into the blood stream and eventually stops the heart from beating.

Johnny’s death may have also been a result of the chlorine in the pool water, Epstein said.

“The concentration of the water [Johnny swallowed] could have caused a lot of inflammation in the lung,” Epstein said. “And then, the body’s reaction to inflammation is to send in all sorts of fluids to fight it – and with that, your lungs are filled with fluid.”

Parents Must Monitor Swimming Children Closely

Water safety experts advise parents to keep a constant eye on their playing children, and be aware of complaints of difficulty breathing.

“People – especially children – need to be supervised around the water with vigilance, even if there are lifeguards present,” said Gerald Dworkin, a water safety expert, who has developed safety training programs since 1984 for Life Saving Resources. “Anyone who has been submerged and has aspirated should seek medical attention.”

The Centers for Disease Control estimates there were 3,582 fatal unintentional drownings in the United States in 2005, the most recent year for which data is available, and more than one in four drownings are children, 14 and younger. The CDC does not keep statistics on the number of secondary drownings.

Jackson says she is certain there is nothing she could have done to prevent her son’s death, but hopes that, by sharing her story, other parents looking ahead to a summer filled with swimming, will be more cautious.

“If your child comes out of the pool and seems sleepy or lethargic, watch them very, very closely,” Jackson said. “Rush them to the hospital or call 9-1-1 immediately.”

“It’s better to be safe than sorry.”

What Do We Know

  • There are three generally accepted types of drowning (though the labels for each type may not be accurately stated, this is how they are commonly known) – all of us are aware of the first, fewer are aware of the other two
    • wet drowning – water enters the lungs (it may only be a small amount) and interferes with the transfer of oxygen into the blood; distress is immediate
    • secondary drowning – a tiny amount of water enters the lungs causing irritation and the fluid produced in the lungs as a result can accumulate to cause drowning up to 72 hours after the exposure
    • dry drowning – muscle spasms in the area around the voice box block the airway; these spasms prevent both air and water from entering the lungs; it can be induced by cold water shock or by means other than exposure to water, e.g., repeated breathing of helium or other gases
  • Dry and secondary drownings are not common – we do not need to panic or think that every instance of a child choking in a swimming pool is an emergency. Every day children choke and aspirate water when playing in swimming pools – any water in the lungs is potentially serious, but only rarely is the result like Johnny’s.

What Should We Do

  • Be aware – secondary and dry drownings are exposures most of us have never considered. After any water experience where children aspirate water, including bathing, the adults in charge should be alert for
    • difficulty breathing – a possible sign of inadequate oxygen supply
    • extreme or unusual tiredness – another possible sign of inadequate oxygen
    • unusual behavior – especially slurred speech or other signs that the brain may not be functioning normally; untypical may be a better descriptive term for behavior that triggers an alarm – e.g., urinary or bowel control issues where normally there are none, lethargy in a usually active child, an observed reduction in coordination, reasoning, or perceptive skills, etc.
  • Be cautious…
    • Pool operators:
      • if you have a near drowning or significant case of water aspiration at your pool, call 911, just as you would for any serious incident – transfer care of the individual to those most qualified, the medical professionals
      • share the information in this document with your patrons – put it in your news letter, post it on your website, place it on your bulletin board. It is the parents who will be with the child after any water exposure and the parents are who will know what is unusual for their specific child
    • Counselors / Childcare workers / Daycare staff: if you took your kids to the pool and any of them had choking or water aspiration experiences
      • inform the parents of the incident
      • warn the parents to be alert for any of the symptoms described above
      • advise the parents to get medical assistance if the symptoms present themselves
    • Parents: pay attention to your children after all water submersion or immersion experiences, especially if you witnessed or were informed of them choking on or aspirating water
      • watch for the symptoms listed above
      • if one or more present, call 911 or go to a medical facility that has the necessary knowledge and tools to help

Children aren’t machines and their behavior may be inconsistent, which can make it difficult to discern if their behavior actually matches the symptoms above. If you are uncertain, get medical help – it is better to err on the side of caution. Delay may be fatal and the repercussions quick – Johnny had less than two hours.