Near Drowning
Near Drowning: Excerpt from The 5-Minute Pediatric Consult
Mercedes M. Blackstone, MDKathy N. Shaw, MD (4th Edition)
Near Drowning - BASICS
Near Drowning - description
- Drowning is a respiratory impairment from submersion in a liquid medium.
- The term “drowning” does not imply outcome; a victim may live or die after a drowning incident.
- Historically “near drowning,” or submersion injury, was defined as survival, at least temporarily, after suffocation by submersion in water.
- American Heart Association and others have advocated for abandoning the term near drowning since it causes confusion; they suggest that the literature should only use the term “drowning.”
Near Drowning - general prevention
- Most drownings are preventable.
- Legislation to require adequate 4-sided 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
- CPR courses for pool owners, parents and older children
Near Drowning - epidemiology
- Drowning is second only to motor vehicle collisions as the most common cause of death from unintentional injury in childhood.
- Bimodal age distribution with peak in children <5 years and again among adolescents 15–19 years
- Bathtub drowning is common in babies, and child neglect or abuse should be considered.
- Adolescent submersion injuries usually involve substance abuse or risk-taking behavior.
- Highest incidence in males, African Americans, children of low socioeconomic status, and residents of southern states
Near Drowning - risk factors
- Children <5 years of age, especially toddlers and boys, who cannot swim and have direct access to swimming pools, are at highest risk.
- Use of alcohol and illicit drugs
- Inadequate adult supervision
- Children with seizure disorders
- Children with primary cardiac arrhythmias such as long QT syndrome
Near Drowning - pathophysiology
- Grossly, the lungs are edematous, but not filled with aspirated fluid, with focal hemorrhages.
- Microscopically, there is thinning of the alveolar septum with emphysematous changes and frothy fluid in the airways.
Near Drowning - etiology
- Drowning begins with a loss of the normal breathing pattern as panic ensues.
- Reflex inspiratory gasps lead to hypoxemia by aspiration or reflex laryngospasm:
- “Dry drowning” was thought to occur through laryngospasm alone without aspiration of water; whether this occurs is controversial and the term has fallen out of favor.
Water is aspirated into the trachea and lungs, washing out surfactant, and leading to atelectasis, intrapulmonary shunting, and hypoxemia.Hypoxemia resulting in multisystem organ failure is the final common pathway.Near Drowning - associated conditions
- Cervical spine injuries should be considered in older children who have experienced diving accidents.
- Signs of child abuse or neglect (burns, whip marks, bruises) should be sought in young children.
- Toxicology screens should be performed on adolescents.
Near Drowning - DIAGNOSIS
Near Drowning - signs & symptoms
Near Drowning - history
- Mechanism:
- History of diving or other high-impact injury
- Intoxication
- Seizure disorder
- Child abuse
- Prognostic indicators; the following have been correlated with better prognosis:
- Length of submersion <2 to 5 minutes
- Time to effective CPR <2 to 5 minutes
- Vital signs at scene
- Length of resuscitation <25 minutes
- Age >3 years
- Water temperature: Submersion in very cold water (<5°C [41°F]) may have a good prognosis despite submersion time >5 minutes
- If child was apneic, cyanotic, or pulseless at the scene, admit for close observation even if he or she appears well at presentation to the hospital.
Near Drowning - physical exam
- Vital signs with core temperature
- Neurologic:
- Pupillary response, cranial nerve findings, Glasgow coma scale (GCS) score
- Serial neurologic examinations should be performed to assess neurologic outcome. Children with a GCS score <5 after resuscitation usually have a poor neurologic outcome.
- Respiratory:
- Lower airway findings (rales, tachypnea, wheezing, retractions)
- Drowning victims may have deteriorating pulmonary involvement, despite an initially normal examination. Watch closely for signs of lower airway involvement.
- Circulation:
- Perfusion, strength of distal pulses, capillary refill, urine output
- Gastrointestinal (GI) tract:
- Abdominal distention from swallowed water or ventilation
- Musculoskeletal
- Neck injuries in high impact submersion injuries
Near Drowning - tests
- Electrocardiogram (ECG) to document normal function and evaluate for prolonged QT
Near Drowning - lab
- Arterial blood gases:
- To detect and facilitate treatment of metabolic acidosis in the child with respiratory distress or apnea
- Renal electrolytes:
- Not indicated in the seemingly well child unless a large volume of water has been swallowed and not evacuated from the stomach
- Blood glucose:
- An elevated level correlates with poor outcome for comatose submersion victims
- Anticonvulsant levels for victims with seizure disorders
- Toxicology screening when suspected ingestion
Near Drowning - imaging
- An initial chest radiograph is indicated for endotracheal tube placement in the intubated child and as a baseline film for those with pulmonary involvement.
- Caution: Initial chest radiographs may be normal in the drowning victim.
- Cervical spine films are indicated for victims of high-impact events.
Near Drowning - differencial diagnosis
Children with smoke inhalation or hydrocarbon ingestion may have similar presentations. However, the history and physical examination should easily determine the diagnosis.
Near Drowning - TREATMENT
Cautions:
- Attempts to remove water from the lungs such as abdominal thrusts are not helpful and should not delay administration of rescue breaths.
- Patients who are breathing spontaneously should be placed in the right lateral decubitus position to prevent aspiration.
- Even patients who respond well to bystander resuscitation need to be transported to an emergency department for further monitoring.
- Search for pulses carefully since they may be very 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°C [86°F]) drowning victim does not have a good prognosis or need vigorous rewarming.
Near Drowning - initial stabilization
- Airway:
- Protect the cervical spine if indicated by history.
- Ensure a patent airway in the comatose victim or patient in cardiac arrest.
- Breathing:
- Supplemental oxygen for oxygen saturations by pulse oximetry <95%
- The drowning victim should be intubated, and positive end-expiratory pressure (PEEP) and ventilation given if apneic or unable to maintain a PaOTreatment of bronchospasm
- Circulation:
- For the victim with cardiopulmonary arrest, asystole protocol should be followed, using epinephrine via the endotracheal tube (ET) or intravenously (IV), with chest compressions.
- Since 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 (tachycardia, poor perfusion) until normalized.
- ECG monitoring should be provided with appropriate response to dysrhythmias, especially for the hypothermic, cold-water drowning victim. For core temperature <29.5°C (85.1°F), attempts at electrical defibrillation are not likely to be successful, and chemical defibrillation with amiodarone or lidocaine and aggressive rewarming are tried.
- Disability:
- Maintenance of eucapnia and adequate oxygenation to prevent further hypoxemia
- There is no indication for measures to reduce intracranial pressure (ICP; barbiturates, mannitol, fluid restoration, ICP monitoring, or steroids) 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°C so a hypothermia thermometer may be necessary:
- For core temperatures 32°C (89.6°F) to 35°C (90.5°F), active rewarming with heating blankets or radiant warmers
- For <32°C (89.6°F), active internal rewarming added (heated aerosolized oxygen and IV fluids, gastric and bladder lavage with warm saline)
- For severe very-cold-water drowning cases (water temp <5°C [41°F]) 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 >32°C (89.6°F) before CPR is terminated.
- Remember: “The patient is not dead until he (or she) is warm and dead.”
Near Drowning - medication
Prophylactic antibiotics or steroids are not indicated.
Near Drowning - FOLLOW UP
- Long-term follow-up of apparently neurologically intact survivors has shown mild coordination or gross-motor deficiencies.
- The victim may be at increased risk for chronic lung disease, depending on the degree of pulmonary involvement.
Near Drowning - prognosis
- Most children (60–95%) recover with intact neurologic survival.
- Duration and severity of initial hypoxic insult are most important determinants of brain injury and death.
- 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°C [41°F]) may have 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 1st several hours.
Near Drowning - 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
- Adult respiratory distress syndrome (ARDS)
- Metabolic acidosis secondary to hypoxemia
- Ischemic injury to organs such as liver, kidneys, and intestines
- Disseminated intravascular coagulation secondary to ischemia
- Electrolyte abnormalities uncommon; may occur if a large volume of freshwater is in the stomach and not removed
- Hypothermia in cold water drowning
Near Drowning - patient monitoring
- Victims who appear well:
- 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
- Aggressively treat any seizures since they increase cerebral oxygen consumption.
Near Drowning - bibliography
- American Academy of Pediatrics. Policy statement: Prevention of drowning in infants, children and adolescents. Pediatrics. 2003;112:437–439.
- Idris AH, Berg RA, Bierens J, et al. Recommended guidelines for uniform reporting of data from drowning: The “Utstein Style.” Circulation. 2003;108:2565–2574.
- Lavelle JM, Shaw KN, et al. Ten year review of pediatric bathtub near-drownings: Evaluation for child abuse and neglect. Ann Emerg Med. 1995;25:344–348.
- Papa, L, Hoelle R, Idris A. Systematic review of definitions for drowning incidents. Resuscitation. 2005;65(3):255–264.
- Quan L, Cummings P. Characteristics of drowning by different age groups. Injury Prevent. 2003;9:163–168.
- Rosen P, Stoto M, Harley J. The use of the Heimlich maneuver in near drowning: Institute of Medicine Report. J Emerg Med. 1995;13:397.
- Thompson DC, Rivara FP. Pool fencing for preventing drowning in children. Cochrane Database Syst Rev. 1998;1.
- Hwang V, Shofer FS, Durbin DR, et al. Prevalence of traumatic injuries in drowning and near drowning in children and adolescents. Arch Pediatr Adolesc Med. 2003;157:50–53.
Near Drowning - CODES
Near Drowning - icd9
994.1 Drowning and nonfatal submersion
Near Drowning - 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: Although useful in neonates, surfactant has not been well studied in drowning victims. In a dog model and in addicts with ARDS, it has not been beneficial. Further investigation is needed before it can be recommended for clinical use.
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Book Source Details
- Book Title: The 5-Minute Pediatric Consult
- Author(s): M. William Schwartz MD; et al.
- Year of Publication: 2008
- Copyright Details: The 5-Minute Pediatric Consult, Copyright © 2008 Lippincott Williams & Wilkins.
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More About This Book:
Title: The 5-Minute Pediatric Consult
Authors: M. William Schwartz MD; et al.
Publisher: Lippincott Williams & Wilkins
Copyright: 2008
ISBN: 0-7817-7577-9
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