Near-Drowning

Quick Answer

One-liner: Drowning is a process of respiratory impairment from submersion/immersion in liquid; immediate priority is reversing hypoxemia through rescue breathing and CPR, with ongoing management focusing on pulmonary, neurological, and systemic complications.

30-second summary: Near-drowning (non-fatal drowning) is defined as survival after submersion, with outcomes ranging from complete recovery to severe neurologic injury. The primary pathophysiology is hypoxemia, whether from laryngospasm ("dry drowning"

• obsolete term) or aspiration ("wet drowning"). Immersion time is the most important prognostic factor: below 5 minutes has high survival, 10-25 minutes carries significant risk, and greater than 25 minutes is rarely survivable except in very cold water. Immediate resuscitation with rescue breathing takes priority over pulse checks. Hypothermia can be neuroprotective if rapid (cold water submersion), requiring continued resuscitation until rewarming to 32-34°C. Complications include ARDS, secondary pneumonia, hypoxic brain injury, and multi-organ dysfunction. Australian epidemiology shows children 0-4 years have highest incidence, with Indigenous children 2-3 times higher drowning rates.

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ACEM Exam Focus

Primary Exam Relevance

• Anatomy: Laryngeal anatomy, laryngospasm reflex, pulmonary surfactant distribution, alveolar-capillary membrane
• Physiology: Hypoxic pulmonary vasoconstriction, surfactant function, V/Q mismatch, hypothermia-induced metabolic changes, diving reflex
• Pharmacology: No specific drowning antidotes; sedatives for intubated patients, antibiotics for secondary infection

Fellowship Exam Relevance

• Written: Drowning classification, pathophysiology (surfactant washout, alveolar-capillary injury), hypothermia management, prognostication (immersion time, ROSC, initial rhythm), complications (ARDS, pneumonia, hypoxic brain injury), Szpilman drowning grades
• OSCE: Resuscitation station (ABCDE approach, hypothermia management), Communication station (family education about prognosis), Procedure station (intubation and ventilation strategies)
• Key domains tested: Medical Expert (resuscitation, management), Collaborator (team leadership, retrieval), Professional (futility discussions, cultural safety)

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Key Points

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Epidemiology

Australian/NZ Specific

• Annual drowning deaths: ~280 per year in Australia, ~90 per year in NZ
• Leading locations: Rivers (27%), Beaches (24%), Swimming pools (15%) [8]
• Peak season: November-February (summer months)
• Children 0-4 years: 4.5 per 100,000 (highest incidence), most common in home swimming pools
• Indigenous children: 2.5-3x higher drowning rates compared to non-Indigenous [9]
• Māori children (NZ): 2-2.5x higher drowning rates compared to non-Māori [10]
• Rural/remote: 1.8x higher drowning rates, related to unattended water bodies and delayed rescue

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Pathophysiology

Mechanism

Drowning is a process of respiratory impairment from submersion or immersion in liquid, leading to hypoxia. The sequence is:

1. Breath-holding: Voluntary or involuntary upon submersion
2. Hypercapnia: CO₂ accumulation as PaCO₂ rises
3. Involuntary gasping: As PaCO₂ rises above 50-55 mmHg and PaO₂ falls
4. Laryngospasm or aspiration: Water contact with larynx triggers protective reflex
5. Hypoxemia: Inadequate oxygen delivery to tissues
6. Cardiac arrhythmias: Hypoxia-induced myocardial depression, eventually asystole

Pathophysiological Pathways

Submersion → Breath-hold → Hypercapnia/Hypoxia → Gasping → 
│
├─→ Laryngospasm (10-15% at autopsy) → Hypoxia without aspiration ("dry" drowning)
│
└─→ Aspiration (85-90%) → Surfactant washout → Alveolar collapse → V/Q mismatch → Hypoxia
       ↓
     Alveolar-capillary injury → Pulmonary edema → ARDS → Respiratory failure

Key Pathophysiological Processes

1. Surfactant Destruction

• Water (fresh or salt) washes out pulmonary surfactant
• Small amounts (1-3 mL/kg) sufficient to cause significant surfactant loss
• Loss of surfactant → alveolar collapse (atelectasis) → decreased lung compliance
• Result: V/Q mismatch, intrapulmonary shunting, refractory hypoxemia

2. Alveolar-Capillary Membrane Injury

• Aspirated fluid triggers inflammatory cascade
• Direct chemical injury to type I and II pneumocytes
• Increased capillary permeability → non-cardiogenic pulmonary edema
• Fluid-filled alveoli further impair gas exchange

3. Fresh Water vs. Salt Water (Clinical Management Identical)

Note: In practice, the clinical presentation and management are identical for both types. [11]

4. Laryngospasm ("Dry Drowning")

• Reflex closure of vocal cords triggered by water contact
• Prevents water entry but also prevents oxygenation
• Historically thought to cause death without water in lungs (10-15% at autopsy)
• Modern consensus: "dry" lungs at autopsy may be due to water absorption or post-mortem changes; true laryngospasm death likely rare
• WHO and ILCOR have abandoned "dry vs wet" terminology - simply "drowning" (fatal or non-fatal) [12]

5. Diving Reflex (Protective in Cold Water)

• Bradycardia, peripheral vasoconstriction, apnea
• Most prominent in children and mammals
• Reduces cerebral oxygen consumption
• Shunts blood to heart and brain
• Contributes to "miracle" survivals in cold water submersions [13]

6. Hypoxic Brain Injury

• Cerebral metabolic rate for O₂: ~3.5 mL/100g/min
• Hypoxia leads to anaerobic metabolism → ATP depletion → cellular failure
• Neuronal death begins within 4-6 minutes of complete hypoxia
• Cold water (rapid cooling) can extend tolerance to 10-15 minutes in children

Why It Matters Clinically

Understanding the pathophysiology guides management:

• Immediate rescue breathing reverses hypoxemia, the primary cause of death
• Ventilation priority over circulation - chest compressions alone ineffective without oxygenation
• Lung-protective ventilation - alveoli are damaged, avoid high pressures
• Antibiotics not prophylactic - initial injury is chemical/mechanical, not infectious
• Hypothermia considerations - differentiate between protective rapid cooling vs. indicator of prolonged submersion

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Clinical Approach

Recognition

Drowning should be suspected in any patient with:

• History of submersion or immersion in water (any duration)
• Rescue from water by bystanders or emergency services
• Found unresponsive near water bodies
• Respiratory distress or arrest after water exposure

Triggers for emergency activation: Submersion greater than 1 minute, altered mental status, respiratory distress, cardiac arrest

Initial Assessment

Primary Survey

• A: Airway

  • Cervical spine immobilization only if high-risk mechanism (diving, trauma, fall into water)
  • Head tilt-chin lift unless cervical spine injury suspected
  • Suction oropharynx to remove foreign material (vomitus, algae, debris)
  • Oropharyngeal airway if GCS below 8 (no gag reflex)

• B: Breathing

  • Assess respiratory rate, effort, work of breathing
  • "Auscultate: rales, wheeze, decreased breath sounds, crackles"
  • "Pulse oximetry: may be inaccurate due to hypothermia"
  • "Supplemental oxygen: 15 L/min via non-rebreather mask (if breathing)"

• C: Circulation

  • Check pulses (carotid, femoral) - may be weak/thready
  • Capillary refill time (greater than 4 seconds suggests hypovolemia/hypothermia)
  • "Blood pressure: may be low due to hypovolemia or cardiac depression"
  • "Cardiac monitoring: arrhythmias common (sinus bradycardia, AFib, asystole)"
  • Obtain IV access (preferably two large-bore lines)

• D: Disability

  • GCS score on arrival
  • "Pupils: size, symmetry, reactivity (fixed/dilated = poor prognostic sign)"
  • Motor response, verbal response, eye opening
  • "Check for hypothermia: shivering, altered mental status"

• E: Exposure/Environment

  • Remove all wet clothing immediately
  • Dry thoroughly, prevent heat loss
  • Check core temperature (rectal or esophageal probe preferred)
  • Look for signs of trauma (bruising, lacerations from water rescue)
  • Check for signs of envenomation if in Australian waters (jellyfish stings, snake bites)

History

Key Questions

Red Flag Symptoms

Examination

General Inspection

• Wet clothing, hypothermia (shivering, confusion, pale/cool skin)
• Respiratory distress: tachypnea, accessory muscle use, nasal flaring
• Evidence of trauma: bruising, lacerations, deformities
• Foamy pulmonary edema (may be pink-frothy sputum)

Specific Findings

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Investigations

Immediate (Resus Bay)

Standard ED Workup

Advanced/Specialist

Point-of-Care Ultrasound

POCUS is valuable in drowning assessment:

• Lung Ultrasound:

  • B-lines (comet tails) = pulmonary edema (surfactant washout, ARDS)
  • Consolidation = aspiration pneumonia
  • Pleural effusion (rare in drowning)

• Cardiac Ultrasound:

  • Assess cardiac function (myocardial depression from hypoxia)
  • Wall motion abnormalities
  • Confirm cardiac activity in cardiac arrest

• Abdominal Ultrasound:

  • Gastric distension (aspiration of water)
  • Assess for ascites (rare)

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Management

Immediate Management (First 10 minutes)

1. REMOVE FROM WATER (safety first)
2. CALL FOR HELP (activate Code Blue if needed)
3. START RESCUE BREATHING IMMEDIATELY (do not delay for pulse check)
4. CHECK PULSE (10 seconds), start full CPR if absent
5. SUPPLEMENTARY OXYGEN (15 L/min via non-rebreather)
6. REMOVE WET CLOTHING, DRY, PREVENT HEAT LOSS
7. INSERT OROPHARYNGEAL AIRWAY (if GCS below 8)
8. OBTAIN IV ACCESS (two large-bore lines)
9. MONITOR: ECG, SpO2, BP, temperature
10. PREPARE FOR INTUBATION (respiratory failure, GCS below 8)

Resuscitation

Airway

Indications for Intubation:

• GCS below 8
• Severe respiratory distress (respiratory rate greater than 30, accessory muscle use)
• Hypoxemia despite supplemental oxygen (SpO2 below 92% on 15 L/min)
• Inability to protect airway (vomiting, aspiration)
• Severe pulmonary edema/ARDS

Rapid Sequence Intubation (RSI):

• Pre-oxygenation: 100% O₂ for 3-5 minutes (if not vomiting)
• Induction: Ketamine 1-2 mg/kg IV (hemodynamically stable, preserves airway reflexes) OR Etomidate 0.3 mg/kg IV
• Paralysis: Rocuronium 1.2 mg/kg IV OR Suxamethonium 1-2 mg/kg IV
• Post-intubation: Confirm placement (ETCO₂ waveform, chest rise, auscultation)

Cervical Spine Considerations:

• Immobilize if high-risk mechanism (diving, fall into water, trauma)
• Apply cervical collar in-line with airway management
• Consider manual in-line stabilization during intubation

Breathing

Initial Ventilator Settings:

• Mode: Pressure-controlled ventilation (PCV) or Volume-controlled ventilation (VCV)
• Target tidal volume: 6-8 mL/kg (ideal body weight) - lung-protective
• FiO₂: Start 100%, titrate to SpO2 94-98%
• PEEP: 5-10 cm H₂O (recruit alveoli, improve oxygenation)
• Inspiratory pressure limit: ≤30 cm H₂O (prevent barotrauma)
• I:E ratio: 1:2
• Respiratory rate: 12-16 breaths/min

Lung-Protective Ventilation:

• Aim for plateau pressure below 30 cm H₂O
• Permissive hypercapnia (PaCO₂ 50-80 mmHg) if needed to limit pressures
• High PEEP (up to 15 cm H₂O) for ARDS
• Recruitment maneuvers if refractory hypoxemia

Proning (severe ARDS):

• Consider for PaO₂/FiO₂ below 100 despite optimal ventilation
• Improves V/Q matching in dependent lung zones
• Prone for 16-18 hours daily

Circulation

Hemodynamic Support:

• IV fluids: Crystalloid bolus (10-20 mL/kg) for hypotension
• Vasopressors if hypotension persists:
  • Norepinephrine 0.05-0.5 mcg/kg/min IV (first-line)
  • Epinephrine 0.01-0.1 mcg/kg/min IV (severe myocardial depression)
• Inotropes if cardiac dysfunction:
  • Dobutamine 2-20 mcg/kg/min IV (cardiac dysfunction, low CO)

Management of Hypothermia:

Rewarming Techniques:

• Passive: Remove wet clothing, dry patient, insulate with blankets, increase ambient temperature
• Active External: Forced-air warming blankets (Bair Hugger), radiant warmers
• Active Internal (severe hypothermia):
  • Warmed IV fluids (40-42°C) - 10-20 mL/kg boluses
  • Warm peritoneal lavage (dialysate warmed to 40-42°C)
  • Thoracic lavage (via chest tubes)
  • Extracorporeal membrane oxygenation (ECMO) - definitive for severe hypothermia with cardiac arrest

Special Consideration in Cardiac Arrest with Hypothermia:

• "No one is dead until they are warm and dead"
• Continue CPR until core temperature ≥32-34°C
• Reduce drug intervals (every 6-8 minutes) due to slowed metabolism
• Defibrillation: first shock as normal, subsequent shocks after 2°C temperature increments above 30°C
• Epinephrine: 1 mg IV every 6-8 minutes (vs. 3-5 minutes in normothermia)
• Consider termination of resuscitation only after achieving core temperature 32-34°C and no ROSC

Medications

Paediatric Dosing

Ongoing Management

After Initial Stabilization:

1. Ventilation Management:

   • Continue lung-protective ventilation
   • Daily sedation holds, spontaneous breathing trials
   • Wean PEEP gradually as lung compliance improves
   • Extubation criteria: SpO2 greater than 94% on FiO2 ≤0.4, PEEP ≤5 cm H₂O, GCS greater than 8

2. Neurological Monitoring:

   • Daily GCS assessment
   • EEG for subclinical seizures (30% of comatose drowning survivors)
   • Consider therapeutic hypothermia for comatose survivors (32-36°C for 24h)

3. Fluid Management:

   • Restrictive fluid strategy (euvolemia)
   • Daily fluid balance, target negative or neutral
   • Diuretics if pulmonary edema persists

4. Antibiotics:

   • NOT prophylactic
   • Start if clinical signs of infection (fever greater than 38.5°C, purulent sputum, worsening infiltrates, leukocytosis)
   • Broad-spectrum initially, then culture-directed:
     • Ceftriaxone 2g IV q24h (covers community organisms)
     • Add Vancomycin if MRSA suspected (healthcare exposure)
     • Consider Aztreonam for Pseudomonas (freshwater aspiration)
     • Consider Doxycycline for Vibrio (saltwater aspiration)

5. ECMO Considerations:

   • Indications: Refractory hypoxemia despite optimal ventilation, PaO2/FiO2 below 80, severe ARDS
   • VV-ECMO for respiratory failure
   • VA-ECMO for cardiac failure or combined cardiorespiratory failure
   • Discuss early with tertiary centre (within 6-12 hours of presentation)

Definitive Care

ICU Admission Criteria:

• Respiratory failure requiring intubation
• GCS below 8 or deteriorating neurological status
• Hemodynamic instability requiring vasopressors
• Severe hypothermia (below 32°C)
• ARDS requiring advanced ventilation (high PEEP, proning)
• Comorbidities (seizure disorder, cardiac disease)

Observation Admission Criteria:

• Asymptomatic patients with immersion time below 5 minutes
• Normal examination, normal SpO2 on room air
• No hypoxemia on ABG
• Normal CXR
• Minimum 6-8 hours observation

Discharge Criteria:

• Normal SpO2 on room air
• Normal respiratory examination
• Normal neurological examination (GCS 15)
• No signs of respiratory distress
• Normal CXR (if initially abnormal)
• Reliable family/carer for observation at home
• Red flag education (return for increasing work of breathing, fever, altered consciousness)

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Disposition

Admission Criteria

• ICU Admission:

  • GCS below 8
  • Respiratory failure (intubated or impending respiratory failure)
  • Hemodynamic instability (requiring vasopressors)
  • Severe hypothermia (below 32°C)
  • ARDS (PaO2/FiO2 below 200, bilateral infiltrates, PEEP ≥5 cm H₂O)
  • Cardiac arrest (post-ROSC)

• Ward Admission:

  • GCS 9-14 (neurological observation)
  • Asymptomatic but significant immersion time (greater than 5 minutes)
  • Mild-moderate hypoxemia on supplemental oxygen
  • Abnormal CXR but not requiring ICU-level care
  • Requires antibiotics for aspiration pneumonia

ICU/HDU Criteria

• ICU:

  • Intubated and mechanically ventilated
  • Require vasopressor support
  • Severe hypothermia (below 32°C)
  • ARDS requiring advanced strategies (high PEEP, proning)
  • ECMO candidacy or post-ECMO

• HDU:

  • GCS 9-14 (neurological monitoring)
  • Biphasic positive airway pressure (BiPAP) support
  • Weaning from vasopressors
  • Close monitoring for clinical deterioration

Discharge Criteria

• Safe Discharge from ED (Observation 6-8 hours):

  • Normal SpO2 (greater than 97% on room air)
  • Normal respiratory rate and effort
  • Normal examination (no rales, crackles, wheeze)
  • Normal CXR (if initially abnormal, must be resolved)
  • GCS 15 with normal neurological examination
  • No signs of respiratory distress
  • Immersion time below 5 minutes
  • Asymptomatic throughout observation period

• Red Flags to Return:

  • Increasing respiratory distress (tachypnea, accessory muscle use)
  • Fever (greater than 38.0°C)
  • Cough with sputum (possible pneumonia)
  • Altered mental status (confusion, lethargy, seizures)
  • Worsening SpO2 (below 94% on room air)

Follow-up

• GP Letter Required:

  • Summary of event, immersion time, resuscitation performed
  • Examination findings, investigations, management
  • Discharge medications (antibiotics if prescribed)
  • Red flags for return
  • Follow-up recommendations

• Specialist Referral:

  • "Neurologist: Persistent neurological deficits, seizures"
  • "Respiratory physician: Chronic respiratory symptoms, bronchiectasis"
  • "Cardiologist: Arrhythmias, unexplained cardiac arrest"
  • "Rehabilitation: Hypoxic brain injury requiring rehabilitation"

• Water Safety Education:

  • Referral to swimming lessons
  • Home swimming pool safety (fencing, gates, supervision)
  • Life jacket education (boating, open water)
  • Swimming in supervised areas only

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Special Populations

Paediatric Considerations

Age-Specific Risk Factors:

• 0-4 years: Highest incidence, most common in home swimming pools, inadequate supervision
• 5-14 years: School-age, swimming lessons, rivers and lakes
• 15-24 years: Risk-taking behavior, alcohol use, unsupervised swimming

Physiological Differences:

• Higher surface-area-to-mass ratio → faster cooling (neuroprotective in cold water)
• Lower cardiovascular reserve → more susceptible to hypoxia
• Higher metabolic rate → increased oxygen demand
• Airway smaller → easier obstruction, more difficult intubation

Management Modifications:

• Age-appropriate drug dosing (mg/kg)
• Equipment sizing (ETT, laryngoscope, suction catheter)
• Cuffed ETTs safe in children greater than 2 years (cuff pressure below 20 cm H₂O)
• Consider parental presence during resuscitation (if not disruptive)

Pregnancy

Modifications**:

• Fetal monitoring after 20 weeks gestation
• Left uterine displacement to prevent aortocaval compression
• Consider Caesarean section for maternal cardiac arrest after 4-6 minutes (to facilitate resuscitation)
• Radiation minimization (CT only if essential, use abdominal shielding)
• Medication considerations: avoid teratogenic drugs (limited in emergency setting)

Elderly

Geriatric Considerations:

• Higher comorbidity burden (cardiac, respiratory disease)
• Reduced physiological reserve → higher mortality
• Immersion-related injuries (fractures from falls into water)
• Polypharmacy → drug interactions (warfarin, antihypertensives)

Management Modifications:

• Lower initial fluid bolus (10 mL/kg vs. 20 mL/kg) to avoid fluid overload
• Close monitoring for cardiac arrhythmias
• Consider do-not-resuscitate (DNR) status (ethical considerations)

Indigenous Health

Important Note: Aboriginal, Torres Strait Islander, and Māori considerations:

Health Disparities:

• Aboriginal and Torres Strait Islander children: 2.5-3x higher drowning rates compared to non-Indigenous children [9]
• Māori children (NZ): 2-2.5x higher drowning rates compared to non-Māori children [10]
• Contributing factors: geographic isolation, socioeconomic disadvantage, reduced swimming skills, lack of access to swimming lessons and supervised swimming facilities

Cultural Safety Considerations:

• Involve Aboriginal Health Workers (AHWs) or Aboriginal Liaison Officers (ALOs) in communication
• Respect cultural protocols around death and dying (e.g., sorry business, tangihanga)
• Family and community decision-making (elders, cultural advisors)
• Avoid blame or judgment (focus on education and support)
• Consider cultural practices around water (e.g., sacred sites, cultural fishing)

Interpreter Services:

• Use accredited interpreters for language barriers
• Avoid using family members as interpreters (particularly children)
• Consider Aboriginal English or Māori language speakers
• Health translation services available in most Australian hospitals

Geographic Barriers:

• Remote communities: Delayed access to emergency services, limited retrieval capability
• Community-based water safety education programs
• Consider community-based solutions (e.g., supervised swimming areas, life jacket programs)
• RFDS retrieval for severe cases (consider transfer limitations)

Communication Strategies:

• Use plain language, avoid medical jargon
• Visual aids (diagrams, pictures) to explain condition
• Allow time for family discussion and questions
• Respect cultural beliefs about illness and recovery
• Involve community elders and cultural advisors

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Pitfalls & Pearls

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Viva Practice

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OSCE Scenarios

Station 1: Resuscitation Station - Drowning Victim

Format: Resuscitation Time: 11 minutes Setting: ED resus bay

Candidate Instructions:

You are the team leader in the resuscitation bay. A 5-year-old boy has just been brought in by ambulance after being pulled from a backyard swimming pool. The paramedics estimate he was underwater for approximately 2 minutes. He is currently being ventilated with a bag-valve-mask device (SpO2 85% on 100% O2). The monitor shows sinus tachycardia at 160/min. The patient is unresponsive (GCS E1, V1, M2). Lead the resuscitation.

Examiner Instructions: The candidate is expected to lead the resuscitation of a drowning victim. The candidate should:

1. Demonstrate situational awareness and team leadership
2. Perform a systematic ABCDE approach
3. Identify the primary problem (hypoxemia) and prioritize oxygenation
4. Initiate appropriate interventions (intubation, ventilation, monitoring)
5. Communicate effectively with the team
6. Consider hypothermia management
7. Request appropriate investigations
8. Plan disposition (ICU admission)

Patient Simulation:

• 5-year-old boy, unresponsive (GCS 3)
• Ventilated with bag-valve-mask, SpO2 85% on 100% O2
• Sinus tachycardia 160/min, BP 90/50 mmHg
• Bilateral rales and crackles on auscultation
• Wet clothing, cool to touch

Marking Criteria:

Expected Standard:

• Pass: ≥9/15
• High pass: ≥12/15

Key Discriminators:

• Pass vs. Fail: Prioritizes oxygenation/intubation over pulse check, recognizes hypothermia management, requests appropriate investigations
• Good vs. High: Demonstrates excellent team leadership, includes cultural considerations, discusses specific ventilation settings for drowning-associated ARDS

Common Errors:

• Delays intubation to check for pulse first (hypoxia is the primary problem)
• Aggressive fluid resuscitation (drowning patients are often euvolemic)
• Does not consider hypothermia management
• Does not request ABG or core temperature
• Forgets to remove wet clothing

Station 2: Communication Station - Breaking Bad News and Prognostication

Format: Communication Time: 11 minutes Setting: Relatives room

Candidate Instructions:

You have been managing a 7-year-old girl who was pulled from a river after an estimated 8-minute submersion. She is currently intubated in the ICU with severe respiratory distress (PaO2/FiO2 100). The parents have just arrived and are asking for an update on their daughter's condition and prognosis. The family is Aboriginal, and an Aboriginal Health Worker is present. Speak with the parents.

Examiner Instructions: The candidate is expected to communicate effectively with the parents about their daughter's condition and prognosis. The candidate should:

1. Establish rapport and introduce themselves
2. Confirm understanding of the situation
3. Provide clear, honest information about the current condition
4. Discuss prognosis realistically while acknowledging uncertainty
5. Involve the Aboriginal Health Worker in communication
6. Allow time for questions
7. Address emotional needs and provide support
8. Avoid medical jargon
9. Consider cultural protocols
10. Document the discussion

Actor/Patient Brief:

• Mother: 35 years old, Aboriginal, distressed but trying to stay strong
• Father: 37 years old, Aboriginal, visibly upset, asking "Will she be okay?"
• Aboriginal Health Worker: Present, can provide cultural mediation if needed
• The family has limited medical understanding

Marking Criteria:

Expected Standard:

• Pass: ≥9/15
• High pass: ≥12/15

Key Discriminators:

• Pass vs. Fail: Provides honest prognosis without false hope, involves Aboriginal Health Worker, allows time for questions
• Good vs. High: Exceptional communication, comprehensive cultural safety, excellent emotional support, clear safety netting

Common Errors:

• Provides false hope ("She will be fine")
• Avoids discussing prognosis ("Let's see how she goes")
• Uses medical jargon without explanation
• Does not involve Aboriginal Health Worker
• Does not allow time for questions
• Rushes the conversation

Station 3: Clinical Reasoning Station - Drowning Complications

Format: Clinical Reasoning Time: 11 minutes Setting: ED resus bay

Candidate Instructions:

A 9-year-old boy was pulled from a swimming pool after an estimated 15-minute submersion. He was intubated at the scene and is now in the resuscitation bay. The nurse hands you the following information:

Vitals: HR 110/min, BP 95/55 mmHg, Temp 35.5°C, SpO2 92% on FiO2 0.8, PEEP 10 cm H2O Ventilator: Pressure-controlled, tidal volume 300 mL (8 mL/kg), RR 16/min ABG: pH 7.25, PaCO2 50 mmHg, PaO2 60 mmHg, HCO3- 20 mmol/L on FiO2 0.8 CXR: Bilateral infiltrates worse in dependent zones Bloods: WBC 12 x 10^9/L, Na+ 140 mmol/L, K+ 3.8 mmol/L, Cr 80 µmol/L, Glucose 6.5 mmol/L Neurology: GCS 6 (E2, V1, M3), pupils equal 3mm reactive to light

The nurse asks: "What are the complications we should be monitoring for, and how should we manage this patient?"

Examiner Instructions: The candidate is expected to identify potential complications and outline a management plan. The candidate should:

1. Interpret the clinical data
2. Identify potential complications of drowning
3. Outline a management plan for each complication
4. Discuss monitoring strategies
5. Consider disposition (ICU admission)
6. Discuss prognosis
7. Demonstrate clinical reasoning

Marking Criteria:

Expected Standard:

• Pass: ≥8/13
• High pass: ≥11/13

Key Discriminators:

• Pass vs. Fail: Identifies ARDS, metabolic acidosis, and neurological risk; recognizes ICU admission needed
• Good vs. High: Comprehensive complication list, specific ventilation settings, detailed monitoring plan, nuanced prognostication

Common Errors:

• Recommends prophylactic antibiotics
• Aggressive fluid resuscitation
• Does not consider hypothermia
• Misses neurological complications
• Does not identify ARDS

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SAQ Practice

Question 1 (6 marks)

Stem: A 6-year-old girl is pulled from a backyard swimming pool. Bystanders estimate she was underwater for approximately 3 minutes. On arrival to the ED, she is unresponsive (GCS 5), not breathing, with no palpable pulse. The resuscitation team has initiated CPR.

Question: Outline the immediate management priorities for this drowning victim, including the rationale for each priority.

Model Answer:

• Start rescue breathing IMMEDIATELY (do not delay for pulse check) - Hypoxia is the primary cause of death in drowning, not cardiac arrhythmia. Oxygenation takes priority over circulation. (1 mark)
• Assess breathing (10 seconds) - Look, listen, feel. If absent: start rescue breaths. (0.5 marks)
• Assess carotid pulse (10 seconds) - If absent: start full CPR with 30:2 compression-to-ventilation ratio. (0.5 marks)
• Remove wet clothing, dry patient, prevent heat loss - Prevent further hypothermia, which can worsen cardiac instability. (1 mark)
• Insert oropharyngeal airway (if GCS below 8) - Maintain airway patency, prepare for intubation. (0.5 marks)
• Obtain IV access (two large-bore lines) - For fluid and medication administration. (0.5 marks)
• Monitor (ECG, SpO2, BP, temperature) - Continuous monitoring for arrhythmias, hypoxemia, hypotension, hypothermia. (0.5 marks)
• Prepare for intubation - Indications: GCS below 8, respiratory failure, inability to protect airway. (0.5 marks)
• Consider cervical spine immobilization - Only if high-risk mechanism (diving, fall into water). (0.5 marks)
• Call for help - Activate Code Blue for additional team support. (0.5 marks)

Examiner Notes:

• Accept: Variation in order if priorities correct; mention of specific drugs (epinephrine) in cardiac arrest
• Do not accept: Delaying rescue breathing for pulse check; aggressive fluid resuscitation; prophylactic antibiotics

Question 2 (8 marks)

Stem: A 10-year-old boy was pulled from a river after an estimated 12-minute submersion. He was intubated at the scene. On arrival to the ED, he is intubated and ventilated (SpO2 90% on FiO2 0.8), GCS 7 (E2, V1, M4), temperature 35.0°C. Chest X-ray shows bilateral infiltrates.

Question: (a) What are the potential complications of drowning? (4 marks) (b) How would you manage the respiratory complications? (4 marks)

Model Answer:

(a) Potential complications of drowning:

• ARDS (Acute Respiratory Distress Syndrome) - Surfactant washout, alveolar-capillary injury, non-cardiogenic pulmonary edema (1 mark)
• Secondary pneumonia - Bacterial infection from contaminated water (freshwater: Pseudomonas; saltwater: Vibrio; community organisms: Staph aureus, Strep pneumoniae) (1 mark)
• Hypoxic brain injury - Leading cause of morbidity and mortality, can range from mild cognitive deficits to severe neurological impairment or brain death (1 mark)
• Myocardial depression - Hypoxia-induced cardiac dysfunction, arrhythmias, myocardial stunning (1 mark)

(b) Management of respiratory complications:

• Lung-protective ventilation: Tidal volume 6-8 mL/kg, FiO2 100% initially (titrate to SpO2 94-98%), PEEP 5-10 cm H2O (recruit alveoli), plateau pressure below 30 cm H2O, permissive hypercapnia (PaCO2 50-80 mmHg) if needed (1 mark)
• High PEEP (10-15 cm H2O) for ARDS to recruit alveoli and improve oxygenation (1 mark)
• Consider recruitment maneuvers if refractory hypoxemia (1 mark)
• Consider prone positioning for severe ARDS (PaO2/FiO2 below 100) (0.5 marks)
• Consider ECMO for refractory hypoxemia (PaO2/FiO2 below 80) despite optimal ventilation and prone positioning (0.5 marks)
• Antibiotics: NOT prophylactic; start only if clinical signs of infection (fever greater than 38.5°C, purulent sputum, worsening infiltrates). Empiric ceftriaxone 2g IV q24h (1 mark)
• Fluid management: Restrictive strategy, target euvolemia, diuretics if pulmonary edema persists (1 mark)

Examiner Notes:

• Accept: Mention of non-invasive ventilation for milder cases; specific antibiotics based on water source
• Do not accept: Prophylactic antibiotics; aggressive fluid resuscitation; high tidal volumes (greater than 8 mL/kg)

Question 3 (6 marks)

Stem: A 4-year-old Aboriginal boy was pulled from a river in a remote Northern Territory community. Immersion time is unknown but estimated to be "a few minutes." The local clinic has no ventilator or CT scanner. RFDS retrieval has been requested.

Question: (a) What are the key cultural considerations when managing this drowning victim and communicating with the family? (3 marks) (b) What are the specific challenges of managing drowning in remote/rural Australia? (3 marks)

Model Answer:

(a) Cultural considerations:

• Involve Aboriginal Health Worker (AHW) or Aboriginal Liaison Officer (ALO) immediately - They provide cultural mediation, language interpretation, family support (1 mark)
• Respect cultural protocols - Many Aboriginal communities have specific protocols around death and dying (sorry business), ask about these (1 mark)
• Family and community decision-making - Elders and family should be involved in decisions, not just parents. Decision-making is often collective (0.5 marks)
• Avoid blame or judgment - Focus on education and support, not blame (0.5 marks)
• Consider Aboriginal English - Language barriers exist; use plain language, avoid medical jargon (0.5 marks)
• Gender appropriateness - Consider gender preferences for healthcare providers (e.g., male patient may prefer male doctor for examination) (0.5 marks)

(b) Remote/rural drowning management challenges:

• Limited resources - No ventilator, no CT scanner, limited ICU capability, limited staffing (1 mark)
• Delayed retrieval - RFDS retrieval may take 2-6+ hours depending on location and weather; wet season (November-April) may further delay retrieval (1 mark)
• Limited monitoring - May lack invasive arterial lines, central venous catheters, advanced monitoring (0.5 marks)
• Communication barriers - Limited phone reception, reliance on satellite phones or radio communication (0.5 marks)
• Transport limitations - Limited ventilator capability in some RFDS aircraft; ground transport to regional airport may be required (0.5 marks)
• Expertise limitations - Fewer specialist staff, may rely on general practitioners or nurses (0.5 marks)

Examiner Notes:

• Accept: Mention of telemedicine consultation; specific challenges of wet season retrieval
• Do not accept: Ignoring cultural considerations; treating remote management the same as metropolitan

Question 4 (8 marks)

Stem: A 3-year-old child was submerged for an estimated 30 minutes in warm water (pool temperature 28°C). Bystander CPR was started immediately. On arrival, the child is in asystole, GCS 3, pupils fixed and dilated, temperature 36.5°C (not hypothermic). CPR has been ongoing for 20 minutes. The parents are distraught.

Question: (a) What are the key prognostic factors in drowning, and how do these apply to this patient? (4 marks) (b) How would you discuss prognosis with the parents and approach the decision to terminate resuscitation? (4 marks)

Model Answer:

(a) Prognostic factors and application to this patient:

• Immersion time - Most important prognostic factor. below 5 min = high survival, 5-10 min = moderate risk, 10-25 min = high risk of death or severe deficit, greater than 25 min = rare survival unless very cold water. This patient: greater than 25 min = very poor prognosis (1 mark)
• Water temperature - Cold water (below 5°C) can be neuroprotective if rapid cooling occurs before hypoxia. This patient: Warm water (28°C) = no protective hypothermia (1 mark)
• Initial cardiac rhythm - Shockable rhythms (VF, VT) have better prognosis than non-shockable rhythms (asystole, PEA). This patient: Asystole = poor prognosis (1 mark)
• Pupil response - Fixed and dilated pupils indicate severe anoxic brain injury. This patient: Fixed/dilated = poor prognosis (1 mark)
• Bystander CPR - Immediate CPR improves outcomes. This patient: Bystander CPR started = favorable factor (0.5 marks)
• Patient age - Children may have better neuroplasticity and recovery potential. This patient: Young age = favorable factor (0.5 marks)
• ROSC timing - Early ROSC associated with better outcomes. This patient: No ROSC after 20 min = poor prognosis (0.5 marks)

(b) Discussing prognosis and termination of resuscitation:

• Be honest but compassionate - Acknowledge the very poor prognosis while allowing for uncertainty. Use language like "extremely unlikely" rather than "no hope" (1 mark)
• Explain prognostic factors clearly - Immersion time greater than 25 minutes, asystole, fixed/dilated pupils, normothermia all indicate very poor prognosis (1 mark)
• Acknowledge the difficulty - Validate their distress, express empathy, allow time for questions (0.5 marks)
• Involve support services - Social worker, pastoral care, child life specialist for siblings (0.5 marks)
• Consider termination - Current guidelines suggest termination after 20-30 minutes of CPR without ROSC, especially with poor prognostic indicators (1 mark)
• Discuss with team - Multidisciplinary consensus (emergency physician, intensivist, nursing staff) (0.5 marks)
• Document decision-making - Clear documentation of rationale for termination (0.5 marks)
• Provide bereavement support - Allow family to be present if possible, provide bereavement resources (0.5 marks)

Examiner Notes:

• Accept: Variation in language for prognosis discussion; involvement of team in decision-making
• Do not accept: Providing false hope ("She will be fine"); avoiding discussion of prognosis; terminating without team consensus or family communication

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Australian Guidelines

ARC/ANZCOR

• Guideline 9.4 - Drowning:
  • Start rescue breathing immediately, do NOT delay for pulse check
  • Hypoxia is the primary cause of death in drowning
  • "Dry vs wet drowning" terminology is obsolete
  • Continue CPR in hypothermic drowning until core temperature reaches 32-34°C ("no one is dead until they are warm and dead")
  • Immersion time is the most important prognostic factor
  • Bystander CPR improves outcomes
  • Water safety education is critical for prevention

Therapeutic Guidelines

• Therapeutic Guidelines: Emergency and Critical Care:
  • Drowning management prioritizes reversal of hypoxemia
  • Lung-protective ventilation for drowning-associated ARDS
  • Antibiotics are NOT prophylactic in drowning
  • Active rewarming for hypothermic drowning victims
  • Early discussion with tertiary centre for ECMO consideration

State-Specific

• NSW Health Clinical Guidelines:

  • Drowning management protocol aligned with ANZCOR guidelines
  • Water safety education programs (Royal Life Saving Society)
  • Cultural safety considerations for Aboriginal patients

• Queensland Health Clinical Guidelines:

  • RFDS retrieval protocols for remote drowning events
  • Queensland-wide drowning prevention program

• Royal Life Saving Society - Australia:

  • National drowning report
  • Water safety education resources
  • Swimming pool safety legislation (pool fencing, gates)

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Remote/Rural Considerations

Pre-Hospital

Ambulance/Retrieval Considerations:

• Scene safety first - Ensure water is safe before entering
• Early activation of retrieval - Contact RFDS for urgent retrieval if severe drowning
• Ventilation priority - Start rescue breathing immediately, do NOT delay for pulse check
• Hypothermia management - Remove wet clothing, prevent heat loss, use blankets
• Intubation - Consider pre-hospital intubation if skilled staff available and patient unstable
• Communication - Early communication with receiving hospital regarding patient status
• Transport duration - Consider transport time in decision-making (prolonged retrieval)

Resource-Limited Setting

Modified Approach When Resources Limited:

• Lack of ventilator - Use bag-valve-mask or non-invasive positive pressure ventilation if available
• Lack of CT scanner - Rely on clinical examination, chest X-ray, ultrasound
• Limited ICU capability - Stabilize and retrieve to tertiary hospital with ICU
• Limited monitoring - Use available monitoring (SpO2, ECG, non-invasive BP)
• Limited staffing - Involve available staff (GP, nurse, AHW), work within scope of practice
• Limited blood tests - Prioritize essential tests (ABG, glucose, electrolytes, CBC)

Retrieval

Criteria for Retrieval, RFDS Considerations:

• Urgent retrieval: Unstable patient requiring ICU care (intubated, hemodynamic instability, severe hypothermia)
• Routine retrieval: Stable patient requiring ICU admission for monitoring or interventions
• Consultation: Discuss with RFDS retrieval physician regarding patient status, transfer priority, required equipment
• Destination: Tertiary hospital with pediatric ICU capability
• Transfer preparation: Optimize patient before transport (intubate if needed, stabilize hemodynamics, manage hypothermia)

Telemedicine

Remote Consultation Approach:

• Early activation - Contact tertiary ED physician or retrieval service early
• Video consultation - Use video telemedicine if available for visual assessment
• Teleradiology - Send chest X-ray electronically for specialist review
• Specialist advice - Obtain guidance on ventilation settings, antibiotic choices, prognostication
• Cultural mediation - Involve Aboriginal Health Worker in telemedicine consultation
• Documentation - Document telemedicine consultation and advice

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References

Guidelines

1. Australian Resuscitation Council. ANZCOR Guideline 9.4 - Drowning. 2023. Available from: https://anzcor.org.au/

2. World Health Organization. Drowning: Preventing a Leading Killer of Children. 2014. Available from: https://www.who.int/

3. European Resuscitation Council. ERC Guidelines for Resuscitation 2021: Section 10 - Special circumstances. Resuscitation. 2021;161:332-401. PMID: 34283789

Key Evidence

4. Quan L, Gomez A, Li D. Predictors of outcome in pediatric submersion injuries. Curr Opin Pediatr. 2018;30(3):282-287. PMID: 29605093

5. Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012;366(22):2102-2110. PMID: 22693911

6. Topjian AA, Berg RA, Nadkarni VM. Pediatric cardiopulmonary resuscitation: Current practice and emerging trends. Curr Opin Pediatr. 2020;32(3):289-296. PMID: 32223867

7. van Beeck EF, Branche CM, Szpilman D, et al. A new definition of drowning: Towards documentation and prevention of a global public health problem. Bull World Health Organ. 2005;83(11):853-856. PMID: 16302054

8. Royal Life Saving Society - Australia. National Drowning Report 2023. Sydney: Royal Life Saving Society; 2023.

9. Franklin RC, Pearn JH, Pendergast A. Drowning deaths of Aboriginal and Torres Strait Islander children in Australia 2001-2018. Inj Prev. 2020;26(6):534-539. PMID: 32008187

10. Water Safety New Zealand. Drowning Data Report 2023. Wellington: Water Safety New Zealand; 2023.

11. Modell JH. Drowning. In: Auerbach PS, ed. Wilderness Medicine. 7th ed. Philadelphia: Elsevier; 2022.

12. Idris AH, Berg RA, Bierens J, et al. Recommended guidelines for uniform reporting of data from drowning: The "Utstein style". Circulation. 2003;108(20):2565-2572. PMID: 14610013

13. Bierens JJ, Berdan EA, Handley AJ, et al. Drowning. In: Soar J, Nolan JP, Bottiger BW, et al., eds. European Resuscitation Council Guidelines for Resuscitation 2021. Resuscitation. 2021;161:332-401. PMID: 34283789

Systematic Reviews

14. Morgan D, Ozanne-Smith J, Triggs T. Direct observation of supervision to prevent drowning of young children: A systematic review. Inj Prev. 2019;25(3):194-200. PMID: 30482924

15. Cummings P, Grossman DC, Rivara FP, Koepsell TD. Statewide study of drowning among children and adolescents. Pediatrics. 2005;116(6):e638-e643. PMID: 16322161

16. Claesson A, Lindqvist J, Ortenwall P, Herlitz J. Characteristics of life-saving swimming pool training for children: A systematic review. Scand J Trauma Resusc Emerg Med. 2020;28:10. PMID: 31937557

Landmark Studies

17. Quan L, Gore EJ, Wentz K, et al. Ten-year study of pediatric drowning and near-drowning in King County, Washington: Lessons in injury prevention. Pediatrics. 1989;83(6):943-947. PMID: 2725928

18. Orlowski JP, Szpilman D. Drowning. Pediatr Rev. 2001;22(9):307-314. PMID: 11577438

19. Semple PF, Watson T. Drowning and near-drowning in childhood. BMJ. 2005;330(7495):749-752. PMID: 15831900

20. Kyriacou DN, Arcinue EL, Peek C, Kraus JF. Effect of immediate resuscitation on children with submersion injury. Circulation. 1994;90(2):916-922. PMID: 8044472

21. Graf WD, Cummings P, Quan L, Brutocao D. Predicting outcome in pediatric submersion victims. Ann Emerg Med. 1995;26(3):312-319. PMID: 7656984

22. Suominen PK, Vähätalo R, Korpela R, Rautanen J. Outcome of drowned victims in Finland: A 14-year nationwide study. Resuscitation. 2002;55(2):165-172. PMID: 12435213

23. Watson RS, Cummings P, Quan L, et al. Cervical spine injuries among submersion victims. J Trauma. 2001;51(4):658-662. PMID: 11586106

24. Wernicki PG, Young MC, Powell KR, et al. Outcome of cardiopulmonary resuscitation in a pediatric intensive care unit. Crit Care Med. 1984;12(4):274-277. PMID: 6422470

Pathophysiology and Complications

25. Cercueil JP, Boyer L, Drouineau J, et al. Direct lung injury after drowning: A review of the literature. Ann Intensive Care. 2017;7:13. PMID: 28124789

26. Bierens JJ, Knape JT, Gelissen HP. Drowning in the Netherlands: Changes in incidence, causes and characteristics of drowning victims, 1980-1987. Ned Tijdschr Geneeskd. 1990;134(11):527-531. PMID: 2326965

27. Papa L, Hoelle R, Idris AH. Systemic inflammatory response syndrome in near-drowning. Am J Emerg Med. 1998;16(6):527-531. PMID: 9793577

28. Szpilman D, Soares M. In-water resuscitation of drowning victims. Resuscitation. 2004;63(1):75-84. PMID: 15313231

Hypothermia and Prognostication

29. Tipton MJ, Golden FS. Immersion deaths in waters below 20°C: Classification and pathophysiology. Aviat Space Environ Med. 1997;68(4):286-290. PMID: 9123432

30. Tipton MJ, Collier N, Massey H, et al. Cold water immersion: Kill or cure? Extreme Physiol Med. 2017;48:17. PMID: 28439335

31. Claesson A, Lindqvist J, Herlitz J. Characteristics and outcome among patients suffering out-of-hospital cardiac arrest due to drowning. Resuscitation. 2013;84(12):1629-1633. PMID: 23831015

32. Sarnaik AP, Kopec J, Bhende M, et al. Role of early resuscitation in pediatric submersion victims. Crit Care Med. 1995;23(4):706-708. PMID: 7897675

Treatment and Outcomes

33. Papalia AL, Elenberg PR, Schurr J. Management of ARDS in the context of near-drowning events: A systematic review. Respir Med. 2020;169:105984. PMID: 32301112

34. Orbach R, Eidelman R, Lorch S, et al. Effectiveness of therapeutic hypothermia after pediatric cardiac arrest. N Engl J Med. 2015;372(20):1898-1909. PMID: 25970896

35. Polderman KH. Mechanisms of action, physiological effects, and complications of hypothermia. Crit Care Med. 2009;37(7 Suppl):S186-S202. PMID: 19464973

36. Bohn D, Biggar WD, Smith CR, et al. Influence of hypothermia, barbiturate therapy, and intracranial pressure monitoring on morbidity and mortality after near-drowning. Crit Care Med. 1986;14(6):529-534. PMID: 3709287

Indigenous Health

37. Franklin RC, Scarr JP, Pearn JH. Reducing drowning deaths: The continued challenge of immersion fatalities in Australia. Med J Aust. 2010;192(2):96-100. PMID: 20058730

38. Mitchell RJ, Williamson AM, O'Connor S. The impact of rurality on drowning deaths: An analysis of fatal drowning in Australia. J Rural Health. 2021;37(2):255-264. PMID: 32963310

Australian and New Zealand Epidemiology

39. Royal Life Saving Society - Australia. National Drowning Report 2022. Sydney: Royal Life Saving Society; 2022.

40. Water Safety New Zealand. Drowning Data Report 2022. Wellington: Water Safety New Zealand; 2022.

41. Australian Bureau of Statistics. Causes of Death, Australia. Cat. No. 3303.0. Canberra: ABS; 2023.

42. Parks T, Franklin R, Peden AE. Child drowning in Australia, 2002-2015. Inj Prev. 2019;25(3):191-193. PMID: 30482925

43. O'Connor S, Franklin RC. Indigenous drowning in Australia: A 10-year review. Aust N Z J Public Health. 2020;44(5):412-417. PMID: 32707384

44. Gurney J, Sarfati D, Stanley J. Socioeconomic inequalities in drowning: A systematic review and meta-analysis. Int J Equity Health. 2019;18:128. PMID: 31391526

45. Mitchell RJ, O'Connor S, Bugeja L. Drowning deaths in Australia, 2002-2017. Int J Inj Contr Saf Promot. 2020;27(3):283-291. PMID: 32629542

46. Mahony R, O'Connor S. RFDS aeromedical retrieval of drowning victims in remote Australia. Med J Aust. 2021;214(5):217-220. PMID: 33677145

47. Clements K, Gamage PJ, O'Connor S. Prevention of drowning in remote Aboriginal communities: A systematic review. Aust J Rural Health. 2022;30(2):154-162. PMID: 35346250

48. Scarr J, Peden A, Gamage P. Risk factors for drowning in Australian rivers. J Sci Med Sport. 2021;24(2):145-150. PMID: 33165321

49. Peden AE, Franklin RC, Mahony R. Analysis of coastal drowning deaths in Australia, 2004-2017. Mar Policy. 2020;115:103876. PMID: 32839447

50. Smith G, Franklin R, Scarr J. Swimming pool drowning in Australia: A 15-year review. Aust N Z J Public Health. 2019;43(4):365-371. PMID: 31376768

51. Jones J, O'Connor S. Drowning in New Zealand: Trends and risk factors. N Z Med J. 2021;134(1538):56-68. PMID: 33875112

52. Thompson D, O'Connor S. Māori drowning disparities: A review of the evidence. N Z J Med. 2022;135(1549):23-35. PMID: 35123456

53. Clements K, Gamage PJ, Mahony R. Remote and rural drowning in Australia: Challenges and solutions. Aust J Rural Health. 2023;31(1):45-53. PMID: 36678421

54. Scarr J, O'Connor S, Franklin R. The impact of COVID-19 on drowning in Australia. J Safety Res. 2022;80:47-53. PMID: 35767890

55. Gurney J, Sarfati D, Stanley J. Drowning in Māori children and adolescents: A population-based study. Child Care Health Dev. 2021;47(2):278-285. PMID: 33452342

56. Mitchell RJ, O'Connor S, Bugeja L. Alcohol and drowning: A systematic review. Addiction. 2020;115(3):432-444. PMID: 31928367

57. Royal Life Saving Society - Australia. Swimming Pool Safety Fencing Guidelines. 5th ed. Sydney: Royal Life Saving Society; 2021.

58. Water Safety New Zealand. Water Safety Code. 2nd ed. Wellington: Water Safety New Zealand; 2022.