Sudden failure of swimming in cold water

Association between air temperature and unintentional drowning risk in the United Kingdom 2012-2019: A nationwide case-crossover study

OBJECTIVE

Drowning is a leading cause of death. The World Health Organization (WHO) and United Nations (UN) emphasise the need for population-level data-driven approaches to examine risk factors to improve water safety policies. Weather conditions, have the potential to influence drowning risk behaviours as people are more likely to spend time around water and/or undertake risky activities in aquatic spaces as a behavioural thermoregulatory response (e.g., seeking coolth).

METHODS

A case-crossover approach assessed associations between changes in daily maximum air temperature (data from the nearest weather station to each drowning event) and unintentional drowning risk using anonymous data from the validated UK Water Incident Database 2012-2019 (1945 unintentional deaths, 82% male). Control days were selected using a unidirectional time-stratified approach, whereby seven and 14 days before the hazard day were used as the controls.

RESULTS

Mean maximum air temperature on case and control days was 15.36 °C and 14.80 °C, respectively. A 1 °C increase in air temperature was associated with a 7.2% increase in unintentional drowning risk. This relationship existed for males only. Drowning risk was elevated on days where air temperature reached 15-19.9 °C (Odds Ratio; OR: 1.75), 20-24.9 °C (OR: 1.87), and ≥ 25 °C (OR: 4.67), compared with days <10 °C. The greatest elevations in risk appeared to be amongst males and when alcohol intoxication was suspected. Precipitation showed no significant association with unintentional drowning risk.

CONCLUSIONS

Identifying such relationships highlights the value of considering weather conditions when evaluating environmental risk factors for drowning, and may inform water safety policy and allocating resources to prevention and rescue.

[Ice Swimming]

Ice Swimming Abstract: Just a few years ago, no one could imagine that ice swimming could evolve into a competitive sport. In the past, people swimming in ice-cold water were called madmen and, at best, were studied as scientific objects. Today regular competitions in ice swimming over different distances (ice mile, ice km, and shorter distances such as 50m, 100m, and 200m), and different disciplines are organized (freestyle, breaststroke, backstroke, butterfly). National championships, as well as continental and world championships, are also held, with new records set regularly. In this overview, we summarize the historical development of ice swimming up to a competitive sport and explore the risks in this nascent sports discipline.

Influence of Anthropometric Characteristics on Ice Swimming Performance-The IISA Ice Mile and Ice Km

Ice swimming following the rules of IISA (International Ice Swimming Association) is a recent sports discipline starting in 2009. Since then, hundreds of athletes have completed an Ice Mile or an Ice Km in water colder than 5 °C. This study aimed to expand our knowledge about swimmers completing an Ice Mile or an Ice Km regarding the influence of anthropometric characteristics (i.e., body mass, body height, and body mass index, BMI) on performance. We analyzed data from 957 swimmers in the Ice Km (590 men and 367 women) and 585 swimmers in the Ice Mile (334 men and 251 women). No differences were found for anthropometric characteristics between swimmers completing an Ice Mile and an Ice Km although water temperatures and wind chill were lower in the Ice Km than in the Ice Mile. Men were faster than women in both the Ice Mile and Ice Km. Swimming speed decreased significantly with increasing age, body mass, and BMI in both women and men in both the Ice Mile and Ice Km. Body height was positively correlated to swimming speed in women in the Ice Km. Air temperature was significantly and negatively related to swimming speed in the Ice Km but not in the Ice Mile. Water temperature was not associated with swimming speed in men in both the Ice Mile and Ice Km but significantly and negatively in women in Ice Km. In summary, swimmers intending to complete an Ice Mile or an Ice Km do not need to have a high body mass and/or a high BMI to swim these distances fast.

Cold Water Swimming-Benefits and Risks: A Narrative Review

Cold water swimming (winter or ice swimming) has a long tradition in northern countries. Until a few years ago, ice swimming was practiced by very few extreme athletes. For some years now, ice swimming has been held as competitions in ice-cold water (colder than 5 °C). The aim of this overview is to present the current status of benefits and risks for swimming in cold water. When cold water swimming is practiced by experienced people with good health in a regular, graded and adjusted mode, it appears to bring health benefits. However, there is a risk of death in unfamiliar people, either due to the initial neurogenic cold shock response or due to a progressive decrease in swimming efficiency or hypothermia.

Does water temperature influence the performance of key survival skills?

Aquatic survival skills may be compromised in cold water thereby increasing the likelihood of drowning. This study compared physiological, psychological, and behavioral responses of humans treading water and swimming in cold and temperate water. Thirty-eight participants were classified as inexperienced (n = 9), recreational (n = 15), or skilled (n = 10) swimmers. They performed 3 tasks: treading water (120 seconds), swim at "comfortable" pace, and swim at "fast" pace in 2 water conditions (28°C vs 10°C). Heart rate, oxygen uptake, psychometric variables, spatio-temporal (swim speed, stroke rate, and stroke length), and coordination type were examined as a function of expertise. Tasks performed in cold water-generated higher cardiorespiratory responses (HR = 145 ± 16 vs 127 ± 21 bpm) and were perceived about 2 points more strenuous on the Borg scale on average (RPE = 14.9 ± 2.8 vs 13.0 ± 2.0). The voluntary durations of both treading water (60 ± 32 vs 91 ± 33 seconds) and swimming at a comfortable pace (66 ± 22 vs 103 ± 34 seconds) were significantly reduced in cold water. However, no systematic changes in movement pattern type could be determined in either the treading water task or the swimming tasks. Water temperature influences the physical demands of these aquatic skills but not necessarily the behavior. Training treading water and swimming skills in temperate water seems to transfer to cold water, but we recommend training these skills in a range of water conditions to help adapt to the initial "cold-shock" response.

Ice swimming - 'Ice Mile' and '1 km Ice event'

Background

Ice swimming for 1 mile and 1 km is a new discipline in open-water swimming since 2009. This study examined female and male performances in swimming 1 mile (‘Ice Mile’) and 1 km (‘1 km Ice event’) in water of 5 °C or colder between 2009 and 2015 with the hypothesis that women would be faster than men.

Methods

Between 2009 and 2015, 113 men and 38 women completed one ‘Ice Mile’ and 26 men and 13 completed one ‘1 km Ice event’ in water colder than +5 °C following the rules of International Ice Swimming Association (IISA). Differences in performance between women and men were determined. Sex difference (%) was calculated using the equation ([time for women] – [time for men]/[time for men] × 100). For ‘Ice Mile’, a mixed-effects regression model with interaction analyses was used to investigate the influence of sex and environmental conditions on swimming speed. The association between water temperature and swimming speed was assessed using Pearson correlation analyses.

Results

For ‘Ice Mile’ and ‘1 km Ice event’, the best men were faster than the best women. In ‘Ice Mile’, calendar year, number of attempts, water temperature and wind chill showed no association with swimming speed for both women and men. For both women and men, water temperature was not correlated to swimming speed in both ‘Ice Mile’ and ‘1 km Ice event’.

Conclusions

In water colder than 5 °C, men were faster than women in ‘Ice Mile’ and ‘1 km Ice event’. Water temperature showed no correlation to swimming speed.

Ice swimming and changes in body core temperature: a case study

Introduction

‘Ice Mile’ swimming is a new discipline in open-water swimming introduced in 2009. This case study investigated changes in body core temperature during preparation for and completion of two official ‘Ice Miles’, defined as swimming 1.609 km in water of 5°C or colder, in one swimmer.

Case description

One experienced ice swimmer (56 years old, 110.2 kg body mass, 1.76 m body height, BMI of 35.6 kg/m², 44.8% body fat) recorded data including time, distance and body core temperature from 65 training units and two ‘Ice Miles’.

Discussion and evaluation

During training and the ‘Ice Miles’, body core temperature was measured using a thermoelectric probe before, during and after swimming. During trainings and the ‘Ice Miles’, body core temperature increased after start, dropped during swimming but was lowest during recovery. During training, body core temperature at start was the only predictor (ß = −0.233, p = 0.025) for the increase in body core temperature. Water temperature (ß = 0.07, p = 0.006) and body core temperature at start (ß = −0.90, p = 0.006) explained 61% of the variance for the non-significant decrease in body core temperature. Water temperature (ß = 0.077, p = 0.0059) and body core temperature at finish (ß = 0.444, p = 0.02) were the most important predictors for the lowest body core temperature. In ‘Ice Miles’, body core temperature was highest ~6–18 min after the start (38.3–38.4°C), dropped during swimming by 1.7°C to ~36.5°C and was lowest ~40–56 min after finish. The lowest body core temperature (34.5–35.0°C) was achieved ~100 min after start.

Conclusions

In an experienced ice swimmer with a high BMI (>35 kg/m²) and a high percent body fat (~45%), body core temperature decreased by 1.7°C while swimming and by 3.2–3.7°C after the swim to reach the lowest temperature in an official ‘Ice Mile’. The swimmer suffered no hypothermia during ice swimming, but body core temperature dropped to <36°C after ice swimming. Future athletes intending to swim an ‘Ice Mile’ should be aware that a large body fat prevents from suffering hypothermia during ice swimming, but not after ice swimming.

Changes in body core and body surface temperatures during prolonged swimming in water of 10°C-a case report

BACKGROUND

This case report describes an experienced open-water ultra-endurance athlete swimming in water of 9.9°C for 6 h and 2 min.

METHODS

Before the swim, anthropometric characteristics such as body mass, body height, skinfold thicknesses, and body fat were determined. During and after the swim, body core (rectum) and body surface (forearm and calf) temperatures were continuously recorded.

RESULTS

The swimmer (53 years old, 110.5 kg body mass, 1.76 m body height, 34.9% body fat, and a body mass index of 35.7 kg/m2) achieved a total distance of 15 km while swimming at a mean speed of 2.48 km/h, equal to 0.69 m/s, in water of 9.9°C. Body core temperature was at 37.8°C before the swim, increased to a maximum of 38.1°C after approximately 20 min of swimming, and then decreased continuously to 36.3°C upon finishing the swim. The lowest body core temperature was 36.0°C between 35 and 60 min after finishing the swim. Sixty minutes after the swim, the body core temperature continuously rose to 36.5°C where it remained. At the forearm, the temperature dropped to 19.6°C after approximately 36 min of swimming and decreased to 19.4°C by the end of the swim. The lowest temperature at the forearm was 17.6°C measured at approximately 47 min before the athlete stopped swimming. At the calf, the temperature dropped to 13.0°C after approximately 24 min of swimming and decreased to 11.9°C at the end of the swim. The lowest temperature measured at the calf was 11.1°C approximately 108 min after the start. In both the forearm and the calf, the skin temperature continuously increased after the swim.

CONCLUSIONS

This case report shows that (1) it is possible to swim for 6 h in water of 9.9°C and that (2) the athlete did not suffer from hypothermia under these circumstances. The high body mass index, high body fat, previous experience, and specific preparation of the swimmer are the most probable explanations for these findings.

Outcome of accidental hypothermia with or without circulatory arrest: experience from the Danish Præstø Fjord boating accident

BACKGROUND

Resuscitation guidelines for the treatment of accidental hypothermia are based primarily on isolated cases. Mortality rates are high despite aggressive treatment aimed at restoring spontaneous circulation and normothermia.

METHODS

The present report is based on a boating accident where 15 healthy subjects (median age 16 (range 15-45) years) were immersed in 2 °C salt water. Seven victims were recovered in circulatory arrest with a median temperature of 18.4 °C (range 15.5-20.2 °C). They were all rewarmed with extracorporeal membrane oxygenation (ECMO) and were subsequently evaluated with advanced neuroradiological and functional testing. The remaining 7 had established spontaneous circulation without the use of ECMO. One victim drowned in the accident.

RESULTS

The victims that survived the accident without circulatory arrest were predominantly females with a higher body mass index. Victims with circulatory arrest pH on arrival was a median of 6.61 (range 6.43-6.94), with ECMO being established a median of 226 (178-241)min after the accident. Magnetic resonance spectroscopy showed neuronal dysfunction in five. In five victims initial normal white matter spectra progressed to show evidence of abnormal axonal membranes. Based on the seven-level Functional Independence Measure test functional outcome was good in six circulatory arrest victims and in all without circulatory arrest. Mild to moderate cognitive dysfunction was seen in six and severe dysfunction in one circulatory arrest victim.

CONCLUSION

Seven patients with profound accidental hypothermic circulatory arrest were successfully resuscitated using a management approach that included extracorporeal rewarming, followed by successive periods of therapeutic hypothermia and sedated normothermia and intensive neurorehabilitation. Seven other hypothermic victims (core temperature as low as 23 °C) that did not suffer circulatory arrest also survived the accident.

[Water rescue. A unique area of emergency medicine with many facets]

Emergencies on or in water are relatively rare in the rescue service. For this reason, water accident treatment and management does not receive much attention in the training of emergency medicine physicians. Consequently doctors working in emergency medicine often have minimal knowledge in this area. On the other hand, the number of fatal accidents on and in water has increased in recent years. In Germany the number of non-swimmers is also increasing, so it can be assumed that the number of water-related accidents will continue to rise. Drowning accidents and near drowning are important in this context and will be discussed in detail in this review as well as hypothermia (a frequent problem), accompanying injuries and diving accidents.

Self-rescue swimming in cold water: the latest advice

According to the 2006 Canadian Red Cross Drowning Report, 2007 persons died of cold-water immersion in Canada between 1991 and 2000. These statistics indicate that prevention of cold-water immersion fatalities is a significant public health issue for Canadians. What should a person do after accidental immersion in cold water? For a long time, aquatic safety organizations and government agencies stated that swimming should not be attempted, even when a personal flotation device (PFD) is worn. The objective of the present paper is to present the recent scientific evidence making swimming a viable option for self-rescue during accidental cold-water immersion. Early studies in the 1960s and 1970s led to a general conclusion that "people are better off if they float still in lifejackets or hang on to wreckage and do not swim about to try to keep warm". Recent evidence from the literature shows that the initial factors identified as being responsible for swimming failure can be either easily overcome or are not likely the primary contributors to swimming failure. Studies over the last decade reported that swimming failure might primarily be related not to general hypothermia, but rather to muscle fatigue of the arms as a consequence of arm cooling. This is based on the general observation that swimming failure developed earlier than did systemic hypothermia, and can be related to low temperature of the arm muscles following swimming in cold water. All of the above studies conducted in water between 10 and 14 degrees C indicate that people can swim in cold water for a distance ranging between about 800 and 1500 m before being incapacitated by the cold. The average swimming duration for the studies was about 47 min before incapacitation, regardless of the swimming ability of the subjects. Recent evidence shows that people have a very accurate idea about how long it will take them to achieve a given swimming goal despite a 3-fold overestimation of the absolute distance to swim. The subjects were quite astute at deciding their swimming strategy early in the immersion with 86% success, but after about 30 min of swimming or passive cooling, their decision-making ability became impaired. It would therefore seem wise to make one's accidental immersion survival plan early during the immersion, directly after cessation of the cold shock responses. Additional recommendations for self-rescue are provided based on recent scientific evidence.

Physiological and Metabolic Aspects of Very Prolonged Exercise with Particular Reference to Hill Walking

Hill walking is a popular recreational activity in the developed world, yet it has the potential to impose severe stress simultaneously upon several regulatory systems. Information regarding the physiological strain imposed by prolonged walking outdoors in adverse climatic conditions was reported almost four decades ago and recent research has extended some of this work. These data indicate that once the walker fatigues and starts to slow or stops walking altogether, the rate of heat production falls dramatically. This decrease alone predisposes to the development of hypothermia. These processes, in adverse weather conditions and/or during periods when the level of exertion is low (with low heat production), will be accelerated. Since the majority of walkers pursue this activity in groups, the less fit walkers may be more susceptible to fatigue when exercising at a higher relative intensity compared with their fitter counterparts. The best physiological offset for hypothermia is to maintain heat production by means of exercise, and so fatigue becomes a critical predisposing factor; it is as important to facilitate heat loss, especially during periods of high exertion, as it is to maintain heat production and preserve insulation. This can be partly achieved by clothing adjustments and consideration of the intensity of exercise. Failure to provide adequate energy intake during hill walking activities has been associated with decreased performance (particularly with respect to balance) and impaired thermoregulation. Such impairments may increase susceptibly to both fatigue and injury whilst pursuing this form of activity outdoors. The prolonged low to moderate intensity of activity experienced during a typical hill walk elicits marked changes in the metabolic and hormonal milieu. Available data suggest that during hill walking, even during periods of acute negative energy balance, blood glucose concentrations are maintained. The maintenance of blood glucose concentrations seems to reflect the presence of an alternative fuel source, a hormonally induced increase in fat mobilisation. Such enhancement of fat mobilisation should make it easier to maintain blood glucose by decreasing carbohydrate oxidation and promoting gluconeogenesis, thus sparing glucose utilisation by active muscle. During strenuous hill walking, older age walkers may be particularly prone to dehydration and decreased physical and mental performance, when compared with their younger counterparts. In summary, high rates of energy expenditure and hypohydration are likely to be closely linked to the activity. Periods of adverse weather, low energy intake, lowered fitness or increased age, can all increase the participants' susceptibility to injury, fatigue and hypothermia in the mountainous environment.

Exercise and the cold

The generation of heat by the human body has been likened to that of a furnace. In response to winter conditions or prolonged immersion in cold water, heat may be lost from the body more quickly than it is produced leading to hypothermia. Various factors, environmental and individual, predispose a person to hypothermia when walking on dry land or during cold water immersion. Retention of the insulating properties of the clothing worn is of crucial importance in protecting against cold injury both on land and in water. Anthropometric characteristics and behavioural and physiological responses also influence the probability of survival under these conditions. Practical recommendations for behaviour that will enhance survival during prolonged exposure to cold on land or to immersion in cold water are considered.

Immersion deaths and deterioration in swimming performance in cold water

BACKGROUND

General hypothermia (deep body temperature <35 degrees C) has been implicated in immersion-related deaths, but many deaths occur too quickly for it to be involved. We investigated changes in swimming capability in cold water to find out whether such changes could lead to swim failure and drowning.

METHODS

Ten volunteers undertook three self-paced breaststroke swims in a variable-speed swimming flume, in water at 25 degrees C, 18 degrees C, and 10 degrees C, for a maximum of 90 min. During each swim, we measured oxygen consumption, rectal temperature, swim speed and angle, and stroke rate and length. Swim failure was defined as being unable to keep feet off the bottom of the flume.

FINDINGS

All ten swimmers completed 90 min swims at 25 degrees C, eight completed swims at 18 degrees C, and five at 10 degrees C. In 10 degrees C water, one swimmer reached swim failure after 61 min and four were withdrawn before 90 min with rectal temperatures of 35 degrees C when they were close to swim failure. Swimming efficiency and length of stroke decreased more and rate of stroke and swim angle increased more in 10 degrees C water than in warmer water. These variables seemed to characterise impending swim failure.

INTERPRETATION

Impaired performance and initial cardiorespiratory responses to immersion probably represent the major dangers to immersion victims. Consequently, treatment should be aimed at symptoms resulting from near-drowning rather than severe hypothermia.

The increased oxygen uptake upon immersion. The raised external pressure could be a causative factor

The principal cause of the immediate transient elevation in ventilation (VE, L.min-1) and oxygen uptake (VO2, L.min-1), when a human subject is immersed in cold water is considered to be the stimulation of cutaneous cold receptors. The present study demonstrates that the initial VE and VO2 responses are comprised of a thermogenic and a hydrostatic component. The peak values in VE reached (mean +/- SD) 66.8 +/- 22.3, 53.9 +/- 38.1, 32.2 +/- 15.4, 22.5 +/- 3.6, 19.5 +/- 4.6 L.min-1 during the first minute of immersion in 10 degrees, 15 degrees, 20 degrees, 28 degrees and 40 degrees C water, respectively. Similarly, peaks (mean +/- SD) in VO2 of 1.22 +/- 0.25, 1.01 +/- 0.32, 0.98 +/- 0.39, 0.81 +/- 0.09, and 0.78 +/- 0.26 L.O2.min-1, were reached when subjects were immersed in 10 degrees, 15 degrees, 20 degrees, 28 degrees, and 40 degrees C water. It is concluded that the observed increases in VO2 during the first minute of immersion are partly due to the increased hydrostatic pressure causing a shift of venous blood towards the thoracic region, and a transient increase in the uptake of oxygen into the blood.

Respiratory drive during sudden cold water immersion

Sudden decreases in cutaneous temperature induce an immediate ventilatory response, which has been termed the inspiratory or 'gasp' reflex. This respiratory response has been implicated as a contributing factor to cold water immersion drowning. In the present study, five subjects wearing either shorts or a variety of thermal protective apparel were immersed on separate occasions in 10 degrees C water. The observed peak mean skin temperature cooling rates (dTs/dt) for the different conditions varied from 6.9 +/- 2.1 degrees C/min for the shorts condition to 1.8 +/- 0.3 degrees C/min for a helicopter pilot suit made of cotton ventile material. During the immersion, recordings were made of respiratory drive, as indicated by the mouth occlusion pressure at 100 msec following the onset of inspiration (P0.1). The respiratory drive, an indicator of central inspiratory activity, correlated well with peak dTs/dt. The slope P0.1/(dTs/dt) was subject dependent and did not appear to be related to body composition. The substantial intersubject variability in the respiratory response is suggested to result from differences in the central integration of thermoafferent information. It is concluded that the inspiratory reflex is the result of cutaneous thermoreceptor activity.

Multicenter hypothermia survey

A multicenter survey evaluated the clinical presentation, treatment, and outcome of accidental hypothermia. Data were collected from 13 emergency departments, with 401 of the 428 cases presenting during a two-year study period. Core temperatures ranged from 35 C to 15.6 C (mean, 30.57 C +/- 3.53) with 272 cases (63.6%) less than or equal to 32.2 C. There were no significant differences by age in presenting temperature, rewarming strategies, or mortality. The first hour rewarming rate was significantly (P less than .05) faster in the population less than or equal to 59 years (1.08 +/- 1.39 C/hr) than in those greater than or equal to 60 years (0.75 +/- 1.16 C/hr). Male core temperatures averaged 30.27 +/- 3.44 C versus female temperatures of 31.1 +/- 3.61 C. There were no clinically significant differences in male (N = 296) versus female (N = 132) profiles. High ethanol levels (315 to 800 mg%) did not affect outcome. Nine of 27 (33%) patients who received CPR initiated in the field survived, versus six of 14 (43%) with CPR begun in the ED. The profile of the CPR versus non-CPR population differed significantly (P less than .05) in location (outdoors), initial temperature (24.8 +/- 3.77 C vs 30.94 +/- 3.12 C), third-hour rewarming rate (2.28 +/- 1.53 C vs 1.17 +/- 1.18 C/hr), and numerous laboratory parameters. Tracheal intubation was performed without incident in 117 cases, of which 97 were less than or equal to 32.2 C. There were 73 fatalities (17.1%). Of these, 84.9% (N = 62) were less than or equal to 32.2 C. Predisposing conditions in this group included "serious" illness (30), systemic infection (28), trauma (15), immersion (ten), frostbite (seven), and overdose (two). The initial pulse, hemoglobin, and first-hour rewarming rate was lower in the deceased population, while the potassium, urea nitrogen, creatinine, and phosphorus were elevated. Excluding treatment combinations, outcome with exclusive use of a single rewarming strategy was passive external rewarming, 14 deaths below 32.2 C, 13 above; active external rewarming, six deaths below 32.2 C, two above; active core rewarming, 38 deaths below 32.2 C, none above. Refinements of the American Heart Association's CPR standards in hypothermia and a Hypothermia Survival Index are proposed.

Treatment of near drowning--a review of 130 cases

This paper reviews the management and clinical course of patients after rescue from near drowning. Those with adequate ventilation on arrival at hospital had an excellent prognosis. The prognosis of those patients with inadequate ventilation, or who have suffered cardiac arrest, depends on rapid assessment and the institution of vigorous resuscitative measures. The medical management of all types of patients is reviewed in detail, the results tabulated and complications discussed.

The immersion incident

The ever increasing participation in aquatic recreational activities is a major factor in the increasing number of deaths due to accidental immersion. Some of these deaths occur while undergoing resuscitative efforts immediately following rescue, on admission to hospital, or even up to 19 days after the immersion incident. Drowning, either acute or its delayed effects, is chiefly responsible for these deaths, but in a number, hypothermia occurring alone or complicating drowning, is the likely explanation. This paper examines the problem and proposes a regime of management.