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Drowning, Pediatric

Basics

Description

- Prognostic indicators; the following have been correlated with a poor prognosis and may be helpful to ask about: - Age <3 years - Length of submersion >5 minutes - Time to effective CPR >10 minutes - Lack of vital signs at the scene - Length of resuscitation >25 minutes - Warmer water: Submersion in cold water (<5 пїЅC [41 пїЅF]) may have a good prognosis despite submersion time >5 minutes.

- Vital signs with core temperature - Drowning victims with unclear histories must be treated as trauma victims. - Neurologic - Pupillary response, cranial nerve findings, Glasgow Coma Scale (GCS) score, gag reflex - Serial neurologic exams should be performed to assess neurologic outcome. Children with a GCS score <5 after resuscitation usually have a poor neurologic outcome.

- Musculoskeletal - Neck injuries in high-impact drownings

- Breathing - Supplemental oxygen via facemask with any compromise or desaturation following their submersion event - Intubate for apnea, airway protection, or inadequate oxygenation or ventilation - Treatment of bronchospasm

- Disability - Maintenance of eucapnia and adequate oxygenation to prevent further hypoxemia - Elevate the head of the bed once cervical spine is cleared and consider mild hyperventilation for elevated intracranial pressure (ICP). - Other measures for reducing ICP have not proven effective, likely because the brain injury and swelling is secondary to hypoxic cell injury as opposed to a traumatic lesion.

- Exposure - The drowning victim should be dried and warmed. - Most thermometers do not register temperatures below 34 пїЅC (93.2 пїЅF) so a hypothermia thermometer may be necessary: - For core temperatures 32 пїЅC (89.6 пїЅF) to 35 пїЅC (90.5 пїЅF), active external rewarming with heating blankets or radiant warmers - For <32 пїЅC (89.6 пїЅF), active internal rewarming added (heated aerosolized oxygen and IV fluids, gastric and bladder lavage with warm saline) - For severe hypothermia (<28 пїЅC [82.4 пїЅF]) and where available, peritoneal dialysis or hemodialysis, mediastinal irrigation, and cardiac bypass - The cold water drowning victim with hypothermia must be rewarmed to a temperature >34 пїЅC (89.6 пїЅF) before CPR is terminated.

- Most children (about 75%) recover with intact neurologic survival. - Duration and severity of initial hypoxic insult are most important determinants of brain injury and death. - See prognostic factors in "History"пїЅ section. Additional indicators of poor prognosis: - Coma on arrival - Needing CPR in the emergency department - Initial arterial blood pH <7.1

  • Drowning is defined as respiratory impairment from submersion in a liquid medium.
  • The term "drowning"пїЅ does not imply outcome; drowning can be fatal or nonfatal.
  • Historically "near drowning,"пїЅ or submersion injury, was defined as survival, at least temporarily, after suffocation by submersion in water.The World Congress on Drowning and the World Health Organization advocate abandoning confusing terms such as "near drowning,"пїЅ "wet drowning,"пїЅ and "dry drowning"пїЅ; they suggest that the literature should only use the term "drowning."пїЅ

Epidemiology

  • Drowning is second only to motor vehicle collisions as the most common cause of death from unintentional injury in childhood.
  • For every drowning death, another 5 children present to emergency departments for nonfatal submersion events.
  • Bimodal age distribution, with peak in children <5 years of age and again among adolescents 15-19 years of age
  • Bathtub drowning is common in babies; child neglect or abuse should be considered.
  • Adolescent submersion injuries usually involve substance abuse or risk-taking behavior.

Risk Factors

  • Males, children <5 years of age, African Americans, and children of low socioeconomic status are at greatest risk.
  • Other significant risk factors include the following:Direct access to swimming poolsPoor swimming ability or overestimation of abilityUse of alcohol and illicit drugsInadequate adult supervisionChildren with seizure disorders or primary cardiac arrhythmias such as long QT syndrome

General Prevention

  • Most drowning are preventable.
  • Legislation to require adequate 4-sided isolation fencing and rescue equipment for public and residential pools
  • Restriction of sale and consumption of alcohol in boating areas, pools, and beaches
  • Life vests for children of all ages near bodies of water
  • Parental education regarding adequate supervision during bathing and around swimming pools
  • Cardiopulmonary resuscitation (CPR) courses for pool owners, parents, and older children

Pathophysiology

  • Drowning begins with a loss of the normal breathing pattern as panic ensues and subsequent apnea, laryngospasm, or aspiration occurs.
  • Water aspirated into the trachea and lungs washes out surfactant and leads to atelectasis, intrapulmonary shunting, poor lung compliance, increased capillary permeability, and hypoxemia, ultimately resulting in acute respiratory distress syndrome (ARDS).
  • Severe hypoxemia is the final common pathway and results in multisystem organ failure.
  • Cerebral hypoxia results in cerebral edema and increased intracranial pressure and causes the majority of morbidity and mortality associated with drowning.

Commonly Associated Conditions

  • Cervical spine injuries should be considered in older children who have experienced diving accidents but are otherwise relatively rare in drowning events.
  • Signs of child abuse or neglect should be sought in young children.
  • Adolescents may have associated toxic ingestions.

Diagnosis

History

  • MechanismHistory of diving or other high-impact injuryIntoxicationSeizure disorderCardiac arrhythmiaChild abuse
  • Prognostic indicators; the following have been correlated with a poor prognosis and may be helpful to ask about:Age <3 yearsLength of submersion >5 minutesTime to effective CPR >10 minutesLack of vital signs at the sceneLength of resuscitation >25 minutesWarmer water: Submersion in cold water (<5 пїЅC [41 пїЅF]) may have a good prognosis despite submersion time >5 minutes.

Physical Exam

  • Vital signs with core temperature
  • Drowning victims with unclear histories must be treated as trauma victims.
  • NeurologicPupillary response, cranial nerve findings, Glasgow Coma Scale (GCS) score, gag reflexSerial neurologic exams should be performed to assess neurologic outcome. Children with a GCS score <5 after resuscitation usually have a poor neurologic outcome.
  • RespiratoryLower airway findings (rales, tachypnea, wheezing, retractions, nasal flaring)Drowning victims may have deteriorating pulmonary involvement despite an initially normal exam. Watch closely for signs of lower airway involvement.
  • CirculationPerfusion, strength of distal pulses, capillary refill, urine output, cardiac rhythm
  • GI tractAbdominal distention from swallowed water or ventilation
  • MusculoskeletalNeck injuries in high-impact drownings

Diagnostic Tests & Interpretation

Lab

  • Arterial blood gasesTo detect and facilitate treatment of metabolic acidosis in the child with respiratory distress or apnea
  • ElectrolytesNot indicated in the seemingly well child; aspiration of huge amounts of water is required to generate electrolyte shifts.
  • Blood glucoseAn elevated level correlates with poor outcome for comatose submersion victims.
  • Anticonvulsant levels for victims with seizure disorders
  • Toxicology screening when ingestion suspected
  • Children with severe submersion injuries are at risk of multiorgan system failure, and in these patients, end organ labs should be checked including coagulation studies.

Imaging

  • A chest radiograph is indicated for children with signs of pulmonary involvement and after intubation.Caution: Initial chest radiographs may be normal in the drowning victim.
  • Cervical spine films are indicated for victims of high-impact events.
  • Neuroimaging for cerebral anoxic injury

Diagnostic Procedures/Other

  • ECG to document normal rhythm and evaluate for prolonged QTC if indicated by history
  • Serial pulse oximetry to detect early signs of pulmonary involvement

Treatment

Medication

  • Patients may experience bronchospasm and typically respond to conventional management with inhaled beta-agonists.
  • Prophylactic antibiotics or steroids are not indicated.
  • For patients who develop pneumonia, antimicrobial therapy should cover waterborne pathogens (e.g., Pseudomonas, Aeromonas).
  • Seizures should be aggressively controlled with antiepileptics because they increase oxygen consumption.

Additional Therapies

General Measures

  • Good prehospital care and effective bystander CPR dramatically improve chances of neurologically intact survival.
  • Attempts to remove water from the lungs such as abdominal thrusts or Heimlich maneuver delay care and are not recommended.
  • Cervical spine immobilization can interfere with airway management and should only be performed when injury is suspected.
  • Patients who are breathing spontaneously should be placed in the right lateral decubitus position to prevent aspiration.
  • CPR in drowning victims should follow the traditional ABC approach rather than compression-only CPR because prompt rescue breathing increases the chance of survival.
  • Even patients who respond well to bystander resuscitation need to be transported to an emergency department for further monitoring.
  • Pulses may be difficult to appreciate as they can be weak and slow due to hypothermia; some common arrhythmias such as sinus bradycardia and atrial fibrillation need no immediate treatment.
  • The hypothermic patient who is a warm water (>20 пїЅC [86 пїЅF]) drowning victim does not have a good prognosis or need vigorous rewarming.

Inpatient Considerations

Initial Stabilization

  • AirwayProtect the cervical spine if indicated by history.Ensure a patent airway in the comatose victim or patient in cardiac arrest.
  • BreathingSupplemental oxygen via facemask with any compromise or desaturation following their submersion eventIntubate for apnea, airway protection, or inadequate oxygenation or ventilationTreatment of bronchospasm
  • CirculationFor the victim with cardiopulmonary arrest, the asystole protocol should be followed.Because capillary leak may occur after an ischemic/anoxic episode, isotonic fluids (e.g., normal saline solution or Ringer lactate, 10-mL/kg aliquots) should be given for signs of intravascular volume depletion until normalized.ECG monitoring should be provided with appropriate response to dysrhythmias, especially for the hypothermic, cold water drowning victim.For severely hypothermic patients with a core temperature <28 пїЅC (82.4 пїЅF), aggressive rewarming is indicated. Electrical defibrillation and pharmacotherapy may not be successful.
  • DisabilityMaintenance of eucapnia and adequate oxygenation to prevent further hypoxemiaElevate the head of the bed once cervical spine is cleared and consider mild hyperventilation for elevated intracranial pressure (ICP).Other measures for reducing ICP have not proven effective, likely because the brain injury and swelling is secondary to hypoxic cell injury as opposed to a traumatic lesion.
  • ExposureThe drowning victim should be dried and warmed.Most thermometers do not register temperatures below 34 пїЅC (93.2 пїЅF) so a hypothermia thermometer may be necessary:For core temperatures 32 пїЅC (89.6 пїЅF) to 35 пїЅC (90.5 пїЅF), active external rewarming with heating blankets or radiant warmersFor <32 пїЅC (89.6 пїЅF), active internal rewarming added (heated aerosolized oxygen and IV fluids, gastric and bladder lavage with warm saline)For severe hypothermia (<28 пїЅC [82.4 пїЅF]) and where available, peritoneal dialysis or hemodialysis, mediastinal irrigation, and cardiac bypassThe cold water drowning victim with hypothermia must be rewarmed to a temperature >34 пїЅC (89.6 пїЅF) before CPR is terminated.
  • Remember: The saying, "The patient is not dead until he or she is warm and dead"пїЅ only applies to drownings in very cold water.

Admission Criteria

  • Severely ill children require admission to the intensive care unit.
  • Children who were apneic, cyanotic, or pulseless at the scene should be admitted for close observation even if they appear well.
  • Patients who are at all symptomatic should be admitted to a monitored setting.
  • A subset of asymptomatic children may be discharged from the emergency department after being monitored for 6-8 hours.

Ongoing Care

Follow-up Recommendations

  • Long-term follow-up of apparently neurologically intact survivors has shown mild coordination or gross motor deficiencies.
  • Potential increased risk for chronic lung disease, depending on pulmonary involvement

Patient Monitoring

  • Victims who appear well and had relatively minor event:Monitor with pulse oximetry for progressive respiratory distress.If asymptomatic at 6-8 hours postimmersion, can be discharged
  • Victims with significant neurologic injury: Key is to prevent secondary injury.Maintain euvolemia and euglycemia.

Prognosis

  • Most children (about 75%) recover with intact neurologic survival.
  • Duration and severity of initial hypoxic insult are most important determinants of brain injury and death.
  • See prognostic factors in "History"пїЅ section. Additional indicators of poor prognosis:Coma on arrivalNeeding CPR in the emergency departmentInitial arterial blood pH <7.1
  • Children with warm water submersion time >4 minutes who do not receive CPR at the scene and who have absent vital signs or a GCS score <5 in the emergency department usually have a poor prognosis.
  • Victims who have prolonged submersions in very cold water (<5 пїЅC [41 пїЅF]) may have a good prognosis because of core cooling with a concomitant decrease in metabolic rate while the brain is still being perfused.
  • A good prognostic indicator is continuing improvement in the neurologic examination over the first several hours.

Complications

  • Pneumonia
  • Pneumomediastinum or pneumothorax in the patient undergoing ventilation therapy
  • Brain injury secondary to hypoxia
  • Pulmonary injury with intrapulmonary shunting secondary to damage of the alveoli
  • ARDS
  • Metabolic acidosis secondary to hypoxemia
  • Ischemic injury to organs such as liver, kidneys, and intestines
  • Disseminated intravascular coagulation
  • Hypothermia in cold water drowning

Additional Reading

  • American Academy of Pediatrics Committee on Injury, Violence, and Poison Prevention. Prevention of drowning. Pediatrics. 2010;126(1):178-185. пїЅ[View Abstract]
  • Brenner пїЅRA. Prevention of drowning in infants, children, and adolescents. Pediatrics. 2003; 112(2):440-445. пїЅ[View Abstract]
  • Centers for Disease Control and Prevention. Web-based injury statistics query and reporting system (WISQARS) [online]. http://www.cdc.gov/injury/wisqars. Accessed November 30, 2014.
  • Hwang пїЅV, Shofer пїЅFS, Durbin пїЅDR, et al. Prevalence of traumatic injuries in drowning and near drowning in children and adolescents. Arch Pediatr Adolesc Med. 2003;157(1):50-53. пїЅ[View Abstract]
  • Noonan пїЅL, Howrey пїЅR, Ginsburg пїЅCM. Freshwater submersion injuries in children: a retrospective review of seventy-five hospitalized patients. Pediatrics. 1996;98(3, Pt 1):368-371. пїЅ[View Abstract]
  • Papa пїЅL, Hoelle пїЅR, Idris пїЅA. Systematic review of definitions for drowning incidents. Resuscitation. 2005;65(3):255-264. пїЅ[View Abstract]
  • Szpilman пїЅD, Bierens пїЅJJ, Handley пїЅAJ, et al. Drowning. N Engl J Med. 2012;366(22):2102-2110. пїЅ[View Abstract]
  • Thompson пїЅDC, Rivara пїЅF. Pool fencing for preventing drowning of children. Cochrane Database Syst Rev. 2000;(2):CD001047. пїЅ[View Abstract]
  • Vanden Hoek пїЅTL, Morrison пїЅLJ, Shuster пїЅM, et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18)(Suppl 3):S829-S861. пїЅ[View Abstract]

Codes

ICD09

  • 994.1 Drowning and nonfatal submersion

ICD10

  • T75.1XXA Unsp effects of drowning and nonfatal submersion, init

SNOMED

  • 212962007 Drowning and non-fatal immersion (disorder)
  • 40947009 Drowning (event)
  • 87970004 Nonfatal submersion (disorder)
  • 217748000 Accidental drowning and submersion (event)
  • 242014006 Dry drowning (event)

FAQ

  • Q: Should the drowning victim who arrives at the hospital with cardiopulmonary arrest be resuscitated?
  • A: Yes. A brief (10-15 minutes) attempt at resuscitation is indicated until circumstances of the drowning and core temperature are known. Warm water drowning victims who require CPR in the emergency department may rarely (0-25%) have good neurologic recovery, but these patients usually respond quickly (<15 minutes) to therapy.
  • Q: Is artificial surfactant useful in drowning victims?
  • A: Surfactant has not been found to be beneficial for acute lung injury secondary to drowning. Further investigation is needed before it can be recommended for clinical use.