Near-drowning

1. Epidemiology
   1. Deaths per year
      1. Worldwide: 140,000
      2. United States: 8,000
   2. Incidence peaks May to August in United States
2. Causes
   1. Home pools (50% of Drowning cases in United States)
      1. Age under 5 years accounts for 90% of cases
   2. Bathtub
      1. Second most common site for preschool Drowning cases
      2. Majority ages 7 to 15 months old
   3. Occupations
      1. Fishing industry (especially Alaska)
   4. Personal Water Craft (e.g. Seadoo)
      1. Relative risk (compared with other boats): 8.5
      2. References
         1. Branche (1997) JAMA 278(8):663-5
   5. Alcohol and Illicit Drugs
      1. Involved in over 50% adolescent Drowning cases
   6. Developmental or neurologic Impairment
   7. Rural Hazards
      1. Ponds
      2. Ditches
      3. Old septic tanks
      4. Water filled buckets
         1. Accounts for 24% of preschool Drowning cases
         2. Toddlers unable to right themselves
   8. Physical Abuse
      1. Accounts for 8% of childhood Drowning cases
      2. References
         1. Gillenwater (1996) Arch Pediatr Adolesc Med 150:298
3. Mechanism
   1. Asphyxia leads to Hypoxemia and Metabolic Acidosis
   2. Dry Drownings on autopsy (no lung water): 10-20%
   3. Small-moderate amount water aspirated (<22 ml/kg): 85%
   4. Freshwater and Saltwater Drownings are treated the same
4. Complications
   1. Adult Respiratory Distress Syndrome
   2. Persistent anoxic-ischemic encephalopathy
   3. Aspiration Pneumonia, Lung Abscess, empyema
      1. Especially if water contaminated
   4. Pneumothorax, Barotrauma from high Ventilatory pressure
   5. Traumatic Myoglobinuria or Hemoglobinuria
   6. Renal Failure (Acute Tubular Necrosis)
   7. Coagulopathy (associated with Hypothermia)
   8. Sepsis
   9. Hypothermia
   10. Hyperglycemia (from Catecholamine release)
   11. Seizures
5. Rad
   1. Chest XRay
      1. Initial XRay may be normal (ARDS findings delayed)
6. Initial Management
   1. Accident site
      1. Do NOT clear airway of aspirated water
         1. Use Heimlich/Abdominal thrust ONLY IF obstruction
      2. Cervical spine precautions
      3. Rescue Breathing and CPR
      4. Keep patient horizontal to maximize brain perfusion
   2. Initial ACLS management
      1. ACLS protocol
      2. Intubation for apnea or unconscious patient
      3. Maintain C-Spine precautions
      4. Hypothermia Management
         1. Mild Hypothermia (Brief immersion in warm water)
            1. Initiate rewarming en route to facility
         2. Severe Hypothermia (T <30C or 86F) - Most cases
            1. Initiate rewarming at medical facility
   3. Medical facility management
      1. Continue ACLS protocol
      2. Reevaluate airway and consider intubation
      3. Glasgow Coma Scale
      4. Nasogastric Tube (decompress swallowed water)
      5. Evaluate C-Spine for suspected injury
      6. Core Rewarming (for severe Hypothermia)
         1. Avoid drugs or stimuli that can trigger v-fib
         2. Administer warm humidified oxygen endotracheally
         3. Administer warm fluid by central IV
         4. Peritoneal or Chest Tube lavage
         5. Esophageal rewarming tube
         6. Cardiopulmonary bypass
7. Triage
   1. Criteria for early discharge from ED
      1. Children and young adults AND
      2. No symptoms AND
      3. No preexisting Neurologic or cardiopulmonary dx
   2. Criteria for routine ward observation for 24h
      1. Patients with minimal symptoms (mild cough) AND
      2. Normal Oxygen Saturation
   3. Criteria for ICU admission
      1. Above criteria not met
      2. Any signs of respiratory distress
8. ICU Management
   1. Monitoring
      1. Continuous O2 Sats and frequent lung auscultation
      2. Urine output
      3. Electrolytes and Glucose
      4. CXR
      5. ABG
   2. Specific Management stratagies
      1. Bronchospasm
         1. Inhaled Beta Agonists
      2. Pulmonary edema from freshwater immersion
         1. Loop Diuretics
      3. Airway protection from aspiration as indicated
         1. Intubation
         2. Nasogastric suction
      4. Hypoxia
         1. CPAP
         2. Mechanical Ventilation indications
            1. pCO2, mental status, work of breathing
      5. Unstable patients require aggressive management
         1. Intubation and Mechanical Ventilation
         2. IV fluids and Pressors (Dopamine) for Hypotension
      6. Metabolic Acidosis
         1. Maximize oxygenation and fluid Resuscitation
         2. Sodium Bicarbonate ONLY for severe acidosis (<7.10)
      7. Hyperglycemia
         1. Pathophysiology
            1. Associated with Catecholamine release
            2. May worsen encephalopathy
         2. Management
            1. Insulin drip to lower glucose <300 mg/dl
      8. Mental status depression or Seizures
         1. Evaluation
            1. Neuro status usually improves with Resuscitation
            2. If Mental status depression/Seizure continues:
               1. Consider CT Head (r/o Head Injury)
               2. Consider Alcohol and Illicit Drug testing
         2. Management Seizures
            1. Supportive care
            2. Prolonged Seizure
               1. Diazepam or Ativan (0.1 mg/kg)
               2. Consider Dilantin loading
9. Prognosis
   1. Predictors of survival and good neurologic outcome
      1. Pulse and detectable Blood Pressure on admit
      2. Hypothermia (Core temp <95F or 35C)
         1. Diving reflex to very cold water is protective
            1. Breath holding, Bradycardia, redistribution
         2. Protection depends on rapid onset Hypothermia
         3. Case reports
            1. Child submerged 66 min in ice cold water
               1. Survived and neurologically intact
      3. Young age
   2. Predictors of poor prognosis
      1. pH < 7.10
      2. GCS < 5
      3. Pupils fixed and dilated on admit
      4. Persistent acidosis and coma 4h after Resuscitation
   3. Outcomes
      1. Children requiring PICU admit for near Drowning
         1. 30% mortality
         2. 10-30% severe brain injury
      2. Overall
         1. 92% Near-drowning survivors recover completely
10. Prevention (from Griffith (1994), Patient Instructions)
    1. Avoid swimming under influence of Alcohol, Illicit Drug
    2. Never swim alone
    3. Install fence around home swimming pool
       1. At least 5 feet high with openings <4 inches
       2. Self closing and lockable gate
    4. All family members should learn to swim
    5. Learn CPR
    6. Safe proof home for infants and toddlers
       1. Never leave infants unsupervised in bath
       2. Avoid leaving standing water in buckets, containers
       3. Do NOT leave water in home plastic wading pools
    7. Water sport participants
       1. Practice standard boating safety
       2. Avoid Alcohol while operating vehicles
       3. Wear personal floatation devices
11. References
    1. Thanel (1998) Postgrad Med 103(6):141-54