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neurologic deterioration CLINICAL PEARLS AND PITFALLS Outcome of submersion victims depends on duration of submersion, degree of pulmonary damage by aspiration, and effectiveness of initial resuscitative measures Supplemental O2 should be given as needed to victims of submersion to maintain adequate oxygenation (SaO2 >92%) Consider the early initiation of ECMO for hypothermic patients with cardiorespiratory insufficiency Current Evidence The World Congress on Drowning defines drowning as “the process of experiencing respiratory impairment from submersion/immersion in liquid.” The term near-drowning that was used to describe survival beyond 24 hours after resuscitation created confusion, and today only two categories of drowning are used—fatal or nonfatal Recently, dry drowning and secondary drowning were introduced to describe cases in which autopsy did not reveal any water in the lungs of persons found dead in water and delayed symptoms after aspirating small amounts of water, respectively Both terms can lead to misdiagnosis of sudden death as drowning or failure to identify underlying conditions The term submersion injury may be used instead to describe injury from events where the entire body, particularly the airway, is found below the liquid surface Drowning affects all age groups and males two to three times more often than females Individuals with epilepsy have a 15- to 19-fold higher risk of drowning when compared to the general population Drowning is the leading cause of death worldwide in boys between the ages of and 14 years, and in the United States drowning is the second leading cause of injury death in children to 14 years of age (after motor vehicle crashes) Older infants and toddlers are disproportionately represented in drownings, with lower survival rates They are vulnerable to immersion in household buckets, baths, hot tubs, swimming pools, and other bodies of water near their homes Young teenagers are also at greater risk because adult supervision decreases and impulsive behavior increases However, coexisting trauma (head and cervical spine), drug or alcohol use, and especially suicidal intent must be considered in each case Fresh water aspirated into the lungs is rapidly taken up into the circulation, resulting in a transient rise in circulating blood volume and hemodilution Saltwater aspiration causes decreased intravascular volume and hemoconcentration