Submersion Injury: Epidemiology, Prevention, and Management

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Symposium on Injuries and Injury Prevention

Submersion Injury Epidemiology, Prevention, and Management

Daniel A. Spyker, Ph.D., M.D. *

Webster defines drowning as suffocation by submersion, especially in water. Because drowning implies death, we prefer the term submersion injury, which reflects the nonfatal nature and emphasizes that submersion does result in another type of injury to the body. The following definitions will be used throughout this paper: Drowning: death from asphyxia while submerged, or within 24 hours of the submersion. Secondary Drowning: death following a submersion from complications (usually respiratory distress syndrome) more than 24 hours after the drowning, but directly attributable to the submersion. Immersion Syndrome: sudden death, probably vagally mediated, due to cardiac arrest follOwing contact with cold water. Intoxication with alcohol or other sedative hypnotics predisposes to this syndrome,17 Submersion Injury (serious immersion accident): any submersion resulting in a hospital admission or death. Save: water rescue, or simply removal from the water by anyone who felt the victim was in peril of submersion injury. This article describes the epidemiology of submersion injury, approaches to preventing the occurrence of the injury (primary prevention), and efforts to minimize the extent of injury once submersion has occurred (secondary prevention).

EPIDEMIOLOGY

Mortality Submersion injury is unique among types of unintentional injury in its high mortality to morbidity ratio. In the United States the death rate from submersion injury has fallen about 20 per cent in the last decade to about 2.5 deaths/100,OOO.3 About 85 per cent of these deaths are male, with a !

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*Associate Professor, Department ofInternal Medicine, University of Virginia School of Medicine, Charlottesville, Virginia

Pediatric Clinics of North America-Vol. 32, No.1, February 1985

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maximum incidence in the lO to 19 year old age group. Drowning represents the third most common cause of death overall and ranks second only to motor vehicle injuries in the adolescent age group. The adjusted death rate is five times greater for males than females, and nearly three times greater for blacks than for whites. 9 Figure 1 illustrates the bimodal nature of the drowning rates. The complete absence of the second peak for females suggests some sex-specific etiology among male victims. The International Classification for Diseases (ICD) separates drowning deaths into two major groups: those related to boats and those not related to boats. About 6000 non-boat related and about 1200 boat-related drownings occur annually in the United States. Drowning statistics often exclude these water transport deaths. Another 500 drownings each year are classified as motor vehicle deaths due to a submerged vehicle. Suicidal drownings and drownings of undetermined intent add about another 1000 deaths annually.:3 These may also be excluded when drowning rates are reported. A five state study of 1201 drownings showed that more than two thirds of the victims were classified as nonswimmers. Of the 292 drownings in

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the 10 to 19 year old age range, 28 per cent occurred in lakes, 18 per cent in rivers, 17 per cent in ponds, 5 per cent in quarries, 5 per cent in public swimming pools, and 3 per cent in private swimming pools.34 Even in Hawaii, fresh water drownings outnumber salt water drownings. 28 Figure 2 shows the drowning mortality data for the State of Virginia between 1967 and 1982. Although some fluctuation appears from year to year, the last 10 years suggest a decline, particularly in the 20 to 34 year old age group. Drowning deaths in Virginia from 1975 to 1977 were examined by location of the drowning and age of the victim. Of these 598 deaths, 7 per cent were children less than five; 5 per cent were five to nine year olds; 11 per cent were ten to 14 year olds; and 19 per cent were adolescents 15 to 19 years old. Twenty per cent occurred in rivers; 28 per cent in lakes, ponds, and reservoirs; and 9 per cent in swimming pools. 38 Although Virginia has several hundred miles of seacoast and estuary, the ocean and bay shores account for only 5 per cent and three per cent of the drownings respectively. Nine per cent of the 102 drownings related to boat use were in children accounting for only 5 per cent of all childhood drowning. Thus the majority of drownings occur in pools, ponds, lakes, streams and rivers, at sites either near the victim's home or a summer residence.

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A EPa A TIN G YEA A Figure 2. Drowning mortality injury for Virginia, 1967 to 1982. Ages (bottom to top): 1-4, 5-19, 20-34, >34.

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A small but preventable number of infant drowning tragedies occur in homes each year in bathtubs and large pails. The bathtub ranks second to the swimming pool as a site of child drowning in the home. Of 140 cases of submersion injury in Hawaii, 5 per cent occurred in bathtubs. In a study of bathtub submersion injuries, the father had responsibility for the infant in four of seven cases, and in five of these cases an older sibling had immediate care of the infant.27 Scott and Eigen called attention to the frequent immersion injury in pails of water in the home. They described three cases, all in lO-month-old children, who fell head first into five gallon pails of water. One child survived without sequelae, one sustained permanent neurologic deficit, and one child died. 35 An investigation of sociodemographic factors surrounding childhood submersion injuries found an overrepresentation of bathtub drownings in the lower socioeconomic homes. Children of older parents and children who were members of large families were at greater risk from submersion injury. Children with single parent families did not appear to be at increased risk.23 Craig has called attention to the risk of hyperventilation prior to breath-hold diving. In 58 cases collected during a 15-year period, he found the problem occurring primarily in males between 16 and 20 years of age. All victims were known to be good swimmers, and in most instances the victim was comIleting to see how far he could swim under water. All victims had previously learned the value of hyperventilation in extending the distance or time under water. 6

Morbidity Reliable data for the incidence of nonfatal submersion injuries are sketchy, at best. Peterson recorded 72 near drownings at a time when 60 children drowned in San Diego. 30 The ratio of submersion injuries to drownings depends on one's definition for data-gathering of submersion injuries, but this ratio of 72 to 60 suggests the relatively high mortality of this injury class. Although not strictly a submersion injury, some comment seems appropriate regarding diving injuries. The majority of the approximately 7000 spinal cord injuries involving aquatic accidents cause permanent paralysis. In a lO-year study, diving, surfing, and water skiing accounted for 77 per cent of all spinal injuries. Spinal cord injuries from diving alone exceed the total reported from all other sportS.29 Staff from the Virginia Childhood Injury Prevention Program (see Foreworcf) visited emergency departments of 16 hospitals representing 30 per cent of the population of the State of Virginia. They abstracted ED records for all children aged 0 to 15 who came to that facility following injury from poisoning, burns, falls, submersions, or bikes. Of the 11,639 ED records abstracted, only 21 (0.2 per cent) of the ED visits were for submersion injuries. Table 1 summarizes the rate of admissions and fatalities for this study population. That three of the 10 (30 per cent) deaths were from drowning emphasizes the relatively high mortality rate for submersion injuries. Dietz and Baker studied 117 drownings in the State of Maryland. Forty of these 117 victims were swimming at the time of the injury; only

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4 of those were in swimming pools. Eleven swimming victims were seen to lose control and panic, eight were said to be poor swimmers who went too far from shore, two drowned while attempting to rescue companions, and four purposely dove beneath the surface but did not emerge. In a separate study population where alcohol blood levels were available, approximately half of all drowning victims (47 per cent) were found to have significant ethanol blood levels. 9 Saves The low frequency of submersion injuries hampers the study of prevention activities. In well-managed pools and beaches the frequent assistance to bathers in distress exceeds actual submersion injuries. The Virginia Childhood Injury Prevention Project developed a method for counting saves, both at the beach and at the swimming pool. At the beach, lifeguards voluntarily filled out reports on each save. During the summer of 1980, 42 assists were reported. Only four required medical assistance and transport suggesting a ratio of roughly 10 saves for each submersion injury. Most saves (25) occurred between 2 and 6 P.M. In contrast to submersion injuries in which males outnumber females by about six to one, in these reported beach saves, males (10) and females (14) were almost equally represented. Since we have no estimate of the total group of beach users at these locations, it is impossible to calculate rates or make any statement about the relative beach assistance needs of the different age or racial groups involved. To determine the frequency of saves in toddler pools and to examine the characteristics of toddlers requiring lifeguard assistance, a 5 per cent sample of all pool times was drawn from each of two cooperating toddler pools in 1980 in Richmond, Virginia. A voluntary record of each pool save was kept by the pool managers. Thirty-five saves were reported, for an estimated overall rate of 34.8 saves per 10,000 child exposures. In only 17 of the cases did the lifeguard indiate how the child got into trouble, with "water too deep"8 and "fell in"6 as the major reasons. Only eight of the toddlers had had any form of swimming instruction or "water safing" prior to their incident, and five of these had been taught at the age of two.

Table 1.

Morbidity and Mortality Rates by Injury Type*

INJURY TYPE

NUMBER ED VISITS

NUMBER ADMITTED

PERCENT ADMITTED

NUMBER

FATALITY

OF DEATHS

RATEt

Falls Bikes Poisoning Burns Submersions

4,853 3,294 2,520 951 21

434 276 346 88 5

8.9 8.4 13.7 9.3 23.8

3 0 4 NA 3

*From review of 11,639 emergency department records in Virginia. tFatality Rate = number of deaths/lOO,OOO ED visits. NA = Data not available.

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159 NA 14,286

DANIEL A. SPYKER

118 PRIMARY PREVENTION

The preceding discussion suggests several approaches to preventing submersion injury. Because of the relatively high frequency of serious injury from submersion, this section will examine pathophysiology, triage, and treatment of submersion injury. Toddler Swimming Because the greatest proportion of drowning occurs in nonswimmers, the protective value of swimming lessons seems easy to support. The efforts of the National Red Cross have been consistent and extensive in this area and are certainly deserving of our full support. The value of toddler swimming lessons has been heatedly debated for many years. Because many children die within inches of the edge, its detractors express concern that caretakers, believing their child is "water safe" or nearly so, have a tendency to become complacent. Proponents do not claim that toddler swimming education is a substitute for adult supervision. How to Watersafe Infants details an approach to teaching toddler swimming and its rewards. 4O The Virginia study of toddler pool saves found that children who underwent some form of swimming lessons, most of whom at 18 months of age, were only half as likely to require retrieval from the pool. (Chi square =4.0, p=0.46.) Several case reports now document the hazard, although rare, of toddler lessons as a source of water intoxication and severe hyponatremia. 15-1S These children were between five and 12 months of age. In each case the initial nausea, vomiting, and seizures came on within one hour of the exposure. The serum sodium values range from 118 to 123. Principal risk factors for this severe complication seem to be related to intentional involuntary submersion, and duration of lessons. The YMCA offers ten guidelines for swimming instruction for children under three years of age and encourages participation in programs following these guidelines. The salient features include strict prohibition of forced submersion and limitation of the inwater class time to 30 minutes. The American Academy of Pediatrics supports the stance of the YMCA.4. 15 On this basis, we feel that some form of toddler or early childhood swimming lessons not only provides a degree of improved survivability for the young child, but also may place the child in a swimmer category at an earlier age and improve his survival as an adult swimmer. DRUGS AND SWIMMING Of 600 drownings in Australia each year, more than one third are directly attributed to alcohol intake,2 and two thirds are males. 31 Studies describe an immersion syndrome where the immersed person "does not appear to struggle or surface even when pulled immediately from the water." The effects of ethanol and other sedative/hypnotics generally proceed in a cranial caudal fashion; that is, the higher functions of reasoning and decision-making are compromised at the lowest ethanol levels. To

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reach the "legally drunk" 100 mg/dl level, the average 70 kg male need consume only 52 ml of ethanol (four beers) in one hour. The observation that almost one half of drowning victims had a significant blood ethanol level9 comes as no surprise. From the simple pharmacologic perspective, we have no doubt that other sedativelhypnotic drugs with a similar effect represent a similar risk to the swimmer. Any steps (education, regulation, enforcement) which reduce the frequency of intoxication among swimmers will reduce the rate of injury and death. PROTECTION OF POOLS Considerable scientific evidence from Queensland26 and Hawaii25 shows that four-foot-high fences and self-locking gates around pools can substantially reduce the death rate from drowning. There is little legislation relevant to swimming pool design or water safety in the Commonwealth of Virginia. Fairfax County, however, has legislated comprehensive safety regulation. The death rate for drowning for 1982 was 1. 6 for the 620,000 population, as compared with 17.3 for the remainder of Virginia. Because fencing in pools is a passive intervention, requiring no action on the part of the child, a very high priority is placed on its implementation in any jurisdiction where this form of regulation is not already present. REGULATION As mentioned, fencing has reduced the incidence of submersion injury. The lack of federal, state, and in most cases, local regulation or standards for swimming pools seems quite remarkable. While laws and regulations are certainly not the only answer, minimal awareness and action on the part of our legislators could have a positive effect on this very high mortality and morbidity disease. MANAGEMENT OF SUBMERSION INJURY The very high frequency of fatal and serious injuries following submersion and the very low frequency of minor injury requires our attention to the triage of the submersion victim and a discussion of the pathophysiology and management of this injury. Cold and Dead Is Not Dead The possibility of survival in submersion injuries occurring in cold water (less than 70° F, 21° C) cannot be overemphaSized. However, some of the prognostic factors used in drowning usually do not appear in coldwater submersion. Children and adults (age five to 40) have been submerged for up to 40 minutes with normal neurologic recovery. The absence of spontaneous

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pulse on arrival at the ER has been cited as a poor prognostic factor, although total normal recovery has followed when up to 2V2 hours of CPR were required to reestablish a pulse. Thus, "hypothermia (less than 32° e) may confer substantial protection to the CNS. "41 Pathophysiology Hypoxemia represents the principal problem in all submersion injuries. Drowning without aspiration (dry drowning), resulting from glottic spasm, occurs in about 10 per cent of victims. These patients seem more likely to respond to CPR. Aspiration of fluid into the lung results in a large alveolar-arterial oxygen gradient and hypoxia. Aspiration of 2.2 ml/kg in dogs lowers p02 to 60 mmHg, compared with 44 mllkg, which is usually fatal. Most human victims (80 per cent) probably aspirate less than 22 mll kg. 20 The classic distinction between salt and fresh water effects (hypervolemia versus hypovolemia) seems to be unimportant clinically. Submersion injury victims are usually hypervolemic. lO Hematologic and electrolyte abnormalities from submersion injury are usually minimal and never life-threatening. 19 Chlorinated water does not appear to pose any special management problems. 22 Fluid absorbed through the lung decreases surfactant and increases alveolar suface tension, resulting in atelectasis and pulmonary edema. 14 Pulmonary edema is common (although rare in animal studies) and x-ray usually shows patchy infiltrates, more central in location. Sea water (3.5 per cent NaCl) causes greater pulmonary insult per ml, and greater pulmonary edema occurs as water and protein are drawn into the alveolus. Acute renal failure commonly occurs, but resolution in about 10 days is the rule (80 per cent). Desimulated intravascular coagulation (Ole) has been reported in several cases of fresh water submersion injury and suggests careful monitoring of clotting parameters. 33 CNS injury from hypoxia represents the complication of greatest concern. As with other anoxic insults, severe neurologic defects may develop days to weeks after drowning. 32 Prognosis History (duration of submersion, adequacy of resuscitation), blood gases, electrolytes, and hematocrit proVide important information but do not predict outcome. In a series of 42 fresh-water submersion injuries in California, coma and fixed-dilated pupils were found to be a 100 per cent predictor of neurologic sequelae or death.!1 In a study of 40 submersion injuries at Stanford University, patients with beating heart and spontaneous respiration had a uniformly good outcome, and 17 of 21 patients requiring CPR in the hospital had either serious deficits or fatal outcome. 24 Among 20 near-drowned children admitted to Children's Hospital in Los Angeles with a Glasco Coma score of three, a uniformly poor outcome resulted in children who developed intracranial pressure above 20 torr.8 Modell and Conn have developed a simple classification of submersion injury based on neurologic status at the time of arrival at the first emergency department. 18 In a series of 217 submersion injuries,5. 21 all patients

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arriving awake had normal outcomes. Among those considered "blunted," 8 per cent died and the remaining 92 per cent had good outcomes. Among those arriving in coma, 34 per cent died and 18 per cent had subsequent neuro-deficits. In Conn's series of 96 children, none of the 57 arriving awake or blunted suffered brain damage or death. They further subdivided the 39 comatose patients into three categories: CI-Decorticate indicates flexion response to pain and Cheyne-Stokes respiration; C2-Decerebrate indicates extensor response to pain and central hyperventilation; and C3-Flaccid indicates no response to pain and apneustic breathing. Conn's Toronto group advocates maximal cerebral resuscitation for any comatose patient. 21 Their recommendations include aggressive treatment of hyperhydration, hyperventilation, cooling to 30° C, barbiturate coma, and complete muscle paralysis with monitoring of intracerebral pressure. They designate this regimen as H. Y. P. E. R.

PREHOSPITAL TREATMENT OF SUBMERSION INJURY VICTIMS 1.

Pull the victim from the water as soon as possible.

2.

Begin mouth-to-mouth resuscitation immediately. This should be initiated WHILE IN THE WATER if the rescuer is so trained. a. b. c.

In cold water (below 70° F, 21° C) rescue personnel should put on wet suits while enroute if possible. A safety line to the rescuer is advisable in lakes, ponds, and bays and MANDATORY on frozen lakes, frozen streams, and swiftly running rivers. Wild water rescue requires personnel trained in negotiating and operating in swift water.

3.

Suspect a head or neck injury if there is suspicion of a fall or diving accident. Slide the patient QUICKLY onto a backboard without stopping to tie the patient down, and remove quickly from the water.

4.

Evaluate breathing and pulse once on dry land or boat.

5.

Begin resuscitation (CPR) in a pulseless patient if the length of submersion was less than one hour. Temperature of the water is critical to patient survival. Patients have been resuscitated successfully after 40 minutes submersion in cold water «70° F, 21° C),36 but the survival rate drops dramatically in warm water unless the victim is pulled from the water within four to six minutes. The LENGTH of SUBMERSION must be KNOWN POSITIVELY by a bystander. If there is any doubt or confusion ATTEMPT RESUSCITATION. a. b.

begin and maintain CPR, insert esophageal airway. stabilize head and neck more securely if a neck or head injury is suspected.

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c. d.

A.

SPYKER

ventilate with 100 per cent oxygen. start IV with D5W at keep open rate.

6.

Resuscitation is not indicated if there is evidence of putrefaction or it is positively known that the patient was submerged more than two hours.

7.

If the patient has an adequate pulse and ventilation: a. b. c. d.

start 100 per cent oxygen with a non-rebreathing mask. stabilize the head and neck more securely if a neck or head injury is suspected. start IV with D5W at keep open rate. monitor vital signs closely and be prepared to ventilate the patient if needed.

8.

If patient has any CNS depression then transport to Regional Medical Center with intensive care unit and capability for cerebral resuscitation.

9.

Before leaving the scene try to determine: a. b. c.

length of time submerged. estimate of water temperature. estimate of water cleanliness (is it a river, swimming pool, septic tank ... ). DO NOT DELAY patient transport to get these facts.

HOSPITAL MANAGEMENT OF SUBMERSION INJURY VICTIM Our treatment protocols are derived from the recommendations of Conn5 and a concensus of faculty from Anesthesia, Pediatrics, Neurosurgery, and Medicine. CATEGORY A-Alert on arrival at Emergency Department 1.

Admit to hospital and observe for neurologic or pulmonary injury 12 to 24 hours

2.

History, physical, arterial blood gases, electrolytes, blood and throat cultures, chest x-ray. Document Glasgow Coma Score. 7

3.

Reevaluate after 12 to 24 hours.

CATEGORY B-Blunted consciousness on arrival (normal pupillary reflexes and purposeful responses to pain). 1.

Admit to the INTENSIVE CARE UNIT and monitor (as for category A) for 24 to 48 hours.

2.

History, physical, arterial blood gases, electrolytes, blood and throat cultures, chest x-ray. Document Glasgow Coma Score. 7

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3.

Until fully conscious a. b. c.

Initial diuresis, then halt maintenance fluids. Increased oxygenation (Fi0 2). Maintain normothermia.

CATEGORY C-Comatose on arrival: The 30 per cent mortality and 20 per cent residual neurological deficit demands MAXIMAL CEREBRAL RESUSCITATION-Patients must be TRANSPORTED IMMEDIATELY to a medical center able to deliver age-related multiple system intensive care. In addition to evaluation outlined above: 1.

Stabilize circulation and respiration. Monitoring should include hemodynamic profiles via Swan-Ganz, arterial line, and intracranial pressure (ICP). Monitoring via central venal pressure (CVP) catheter is probably inadequate.

2.

Keep patient in low fluid balance (euvolemic to dehydrated state) to minimize risk of pulmonary edema and increased ICP. Use isotonic solutions. Adjust fluids to maintain urine flow 0.5-1 ml/kglhr and normal cardiovascular function. Follow serum osmolality to maintain < 310 mosmollL. Diresis if necessary may be obtained via furosemide (Lasix) 0.5 to 1 mg/kg as required.

3.

Maintain normal p02 (80 + I - 20 mm Hg). If Fi0 2 >45 per cent required then add PEEP. (5 to 10 cm H 20 usually suffices.)

4.

Monitor ICP and treat aggressively to maintain pressure below 20 mmHg with one or more of the following measures. Cerebral perfusion pressure (mean arterial pressure minus mean ICP) is felt by some to be a better indication of cerebral perfusion status and should be maintained less than 60 mmHg. a. b.

c. d. 5.

Hyperventilate. Adjust ventilation to pC02 25 to 35 mmHg. Pentobarbital to blood level 30 to 40 mglL. Although smaller doses are commonly used, achieving these blood level usually requires 20 to 30 mglkg. Give the loading dose slowly over at least one hour. A maintenance dose of approximately 1 mglkglhr usually suffices as a maintenance dose. Cool patient to 32°C to 34°C by use of cooling blanket and ice packs. Treat shivering, combativeness, coughing, etc. with pancuronium 0.1 mg/kg hourly or p.r.n.

Examine sputum and urine and culture sputum, blood, and urine initially and as appropriate. Reserve antibiotics for evidence of specific infection. RECOMMENDATIONS

The following recommendations are offered to reduce the mortality and morbidity due to submersion injury.

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SPYKER

1.

Develop and improve swimming skills by exposing children to water at an early age through toddler swimming programs, and encouraging participation in continued swimming courses.

2.

Develop water safety skills by acquiring and maintaining current certification in the following Red Cross safety courses: Advanced Life Saving, First Aid, and Cardiopulmonary Resuscitation (CPR).

3.

For the symptomatic or severely injured submersion patient, develop triage and transfer protocols at all beaches, pools, and other recreational swimming sites.

4.

Support water safety legislation by finding out what water safety regulation exists in your community, and by amending existing laws and support development of strong legislation to reduce submersion hazards.

5.

Follow the Red Cross basic personal safety rules for boating and swimming,37 inlcuding the following: a.

b.

Boating 1. At least one adult swimmer for each nonswimmer. 2. Do not overload the boat or allow standing in small boats. 3. Have a personal flotation device for each person in the boat; to be worn by all nonswimmers. 4. No drinking of alcoholic beverages. Swimming 1. Learn to swim well enough to survive in an emergency. 2. Swim only with a buddy who can help you when necessary. 3. Swim in a supervised area, and follow the rules set up for a swimming area. 4. Never consume, or allow consumption of, alcohol near a swimming or boating area.

REFERENCES !. Anonymous Pediatric Notes: Tufts University School of Medicine. 1980. 2. Anonymous. Alcohol and drowning. Med. J. Aust., 1:157-158, 198!. 3. Baker, S. P., O'Neill, B., and Karpf, R. D.: The Injury Fact Book. Lexington; DC Heath and Company, 1984, pp. 155-164. 4. Committee on Pediatric Aspects of Physical Fitness, Recreation and Sports. Swimming instructions for infants. Pediatrics. 65:847, 1980. 5. Conn, A. W., Montes, J. E., et al.: Cerebral salvage in near-drowning following neurological classification by triage. Can. Anaesth. Soc. J., 27:201-210, 1980. 6. Craig, A.: Summary of 58 cases of loss of consciousness during underwater swimming and diVing. Med. Sci. Sports, 8:171-175, 1976. 7. Dean, J. M., Kaufman, N. D.: Prognostic indicators in pediatric near-drowning: The Glasgow Coma Scale. Crit. Care Med., 9:536-539, 198!. 8. Dean, J. M., and McComb, J. G.: Intracranial pressure monitoring in severe pediatric near-drowning. Neurosurgery; d:627, 198!. 9. Dietz, P.E., and Baker, S. P.: Drowning: Epidemiology and prevention. A.J.P.H. 64:303-312, 1974. 10. Donaldson, J. C., Royall, J. D.: Drowning and near-drowning. Postgrad. Med., 64:7179,1978.

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11. Frates, R. C.: Analysis of predictive factors in the assessment of warm-water near-drowning. Am. J. Dis. Child., 135:1006-1008, 1981. 12. Goldberg, G. N., Lightner, E. S., Morgan, et al.: Infantile water intoxication after a swimming lesson. Pediatrics, 74:599--600, 1982. 14. Goldfrank, L., and Mayer, G.: Salt and fresh water (drowning). Hosp. Phy. 32:30-49, 1979. 15. Infant/preschool special committee of the National YMCA operating council on aquatics. YMCA parent and infant water enrichment program and infant guidelines. January 1982. 16. Kropp, R. M., and Schwartz, J. F.: Water intoxication from swimming. J. Pediatr., Dec, 101:947-948, 1982. 17. Levin, D. L.: Near-drowning. Crit. Care Med., 8:590--595, 1980. 18. Modell, J. H. and Conn, A. W.: Current neurological considerations in near-drowning. Editorial. Can. Anaesth. Soc. J. 27:197-198, 1980. 19. Modell, J. H., Davis, J. H., Giammona, S. T., et al.: Blood gas and electrolyte changes in human near-drowning victims. J. A. M.A., 203:337-343, 1968. 20. Modell, J. H., Graves, S. A., and Ketover, A.: Clinical course of 91 consecutive near drownings. Chest, 70:231-237, 1976. 21. Modell, J. H., Graves, S. A., and Kuck, E. J.: Near-drowning: Correlation of level of consciousness and survival. Can. Anaesth. SOC. J., 27:211-214, 1980. 22. Modell, J. H.: The pathophysiology and treatment of drowning. Acta Anaesth., Scand., 29:263-279, 1968. 23. Nixon, J., and Pearn, J.: An investigation of socio-demographic factors surrounding childhood drowning accidents. Soc. Sci. Med., 12:387-390, 1978. 24. Oaks, D. D., Sherck, J. P., Maloney, J. R., et al.: Prognosis and management of victims of near-drowning. J. Trauma, 22:544, 1982. 25. Peam, J., III, and Hsia, E. Y.: Swimming pool drownings and near-drownings involving children. A total population study from Hawaii. Milit. Med., 190:15-18, 1980. 26. Peam, J., and Nixon, J.: Prevention of childhood drowning accidents. Med. J. Aust., 1:616-618, 1977. 27. Peam, J. H., Brown, J., III, Wong, R., et al.: Bathtub drownings: Report of seven cases. Pediatrics, 64:68-70, 1979. 28. Peams, J. H., Wong, R. Y. K., Brown, J., et al.: Drowning and near-drowning involving children: A five-year total population study from the city and county of Honolulu. A.J.P.H. 69:450-454, 1979. 29. Perspectives in Disease Prevention and Health Promotion. M.M.W.R., 31:417-419, 1982. 30. Peterson, B.: Morbidity of childhood near-drowning. Pediatrics, 59:364, 1977. 31. Pleuckhahv, V. D.: Drowning: Community aspects. Med. J. Aust., 2:226-228,1979. 32. Plum, F., Posner, J. B., and Hain, R. F.: Delayed neurological deterioration after anoxia. Arch Intern. Med., 110:57-63, 1962. 33. Ports, T. A., and Duel, T. F.: Intravascular coagulation in fresh-water submersion: Report of three cases. Ann. Intern. Med., 87:60-61, 1977. 34. Press, E., Walker, J., and Crawford, I.: An interstate drowning study. A.J.P.H., 12:22752289, 1968. 35. Scott, P. H., and Eigen, H.: Immersion accidents involving pails of water in the home. J. Pediatr., 96:282-284, 1980. 36. Siebke, H.: Survival after 40 minutes submersion without clinical sequelae. Lancet, 1:1275-1276, 1975. 37. Sitt, V. J.: Drowning in North Carolina: How you can prevent unnecessary loss of life. N.C. Ed. J., 43:432-433, 1982. 38. Virginia Dept of Health Bureau of Vital Records and Health Statistics. Vital statistics monthly report. Richmond, Virginia, 1978. 39. Water babies intoxication. Med. Let. Tex. Med., 78:6, 1983. 40. Whitehead, L., and Curtis, L.: How to watersafe infants and toddlers. Tucson, H P Books, 1983. 41. Young, R. S. K., Zaineraitis, E. D., and Dooling, E. D.: Neurological outcome in'cold water drowning. J.A.M.A., 244:1233-1235, 1980. Box 484--Medical Center University of Virginia Charlottesville, Virginia 22908