Let us lear about managing near drowning or submersion injury in children with PGY3 student , Dr Mohd Zahran Mohamed Zaki. Your comments and suggestions are welcome and will assist us in continuously improving www.redyellowgreenzone.org. Follow us at twitter @RYGZinEM and email to us redyellowgreenzones@gmail.com

1. CME PRESENTATION
Dr Mohd Zahran Mohamed Zaki

2. History
• 6 years old girl
• No previous medical problem/
hospitalization
• Alleged submersion into Ulu Klang river
• Brought by Hosp. Damai with father to ED
HKL

3. Upon arrival at ED HKL @ 1430H
FIRST LOOK

4. Syndromic Interpretations
• Submersion with:
– ? Respiratory distress
– ? Semiconscious
– ? Hypothermia
– ? Trauma
Triage?

5. Focused/Targeted History
• Alleged submersion into Ulu Klang River on 17th
Oct 2015 @ 1330H while having vacation with
family
• Father was trying to park his car, the girl went out
first.
• Found unconconscious in the water – pulled out –
CPR commenced by bystander & father for
15mins – regained spontaneous breathing.
• Duration in water: unsure
• Fresh, non polluted? water.
• Slow Current

6. Cont.
• Sent to Hosp. Damai
– Attempted intubation : unsuccessful
(vomitting)
– Given:
• IV Frusemide 2mg
• IV Ca Gluconate 2mls
– Transferred to ED HKL with HFMO2

7. Rapid Sequence Examination
– Airway: Minimal secretions
– +Spontaneous breathing - tachypnoiec
– Semi-conscious. GCS:7/15 E1V2M4
– Pale & cyanotic
– Coolish on touch
– Temp: 36.2
– BP: 119/84
– PR: 151
– SPO2: 84% under HFMO2
– Estimated BW: 20kg

8. Cont.
• Pupils: 3/3mm reactive bilaterally
• Lungs: Transmitted sound, equal air entry
• CVS: S1S2 no murmur
• Abdomen: Soft. Slightly distended

9. Working Diagnosis
• Near Drowning with
– Type II respiratory failure
– Acidosis – mixed metabolic & respiratory
– ? Hypothermia

10. Package of Management
1. Airway
– Intubated for airway protection with RSI
– ETT size 5.0 (cuffed), anchored @ 15 cm
– Given:
• IV Fentanyl 20mcg
• IV Midazolam 2.5mg
• IV Suxamethonium 30mg
2. Postintubation care:
– IV Mida/Morphine (20/20) in 50 mls NS
– Prop Up 30°
– Insert Ryle’s Tube
– IV Ranitidine 20mg stat

11. 4. Ventilation ; SIMV mode:
– Fio2: 1.0
– PEEP:3
– Tv: 120
– Ps: 12
– I:E: 1:2
5. Hypothermic mx
– IVD ½ Saline D5% 63mls/h – warm saline
– Warm Blanket
6. I/O Charting
7. Refer Paeds Medical & Paeds ICU MO.

12. • ABG Post Intubation:
– pH: 6.895
– pCO2: 107
– pO2: 85.6
– BE: -12
– HCO3: 12.2
• Given:
– IV NS 200mls (20mls/kg)over 1h
– IV NaHCO3 8.4% 20mls over ½h

14. Paediatric Review
• Admit PICU for ventilatory support &
further care
• To cover for aspiration pneumonia:
– IV Augmentin 300mg stat
• Keep NBM; IVD 2/3 Maintainance
• Cerebral Protection
• CBD: monitor urine output

15. PICU Progress
ED
PICU
(17.10)
PICU
(18.10
)
KK6
(19.10
)
MODE PSIMV PSIMV PSIMV PSIMV PSIMV PSIMV PSIMV PSIMV PSIMV PSIMV
HFMO NPO2
FiO2 100 70 50 40 40 40 40 40 40 30
TVin 176 153 160 165 157 154 177
TVex 130 136 134 139 124 111 127
PEEP 3 10 7 7 7 7 7 7 7 6
PIP 20 20 20 20 20 20 17
PreSu
p
12 15 10 10 10 10 10 10 10 10
ABG
ED
Post Int
PICU –17.10.15 @5:35pm PICU -17.10.15 @7.42pm PICU – 18.10.15 @5.10am
pH 6.895 7.32 7.34 7.383
pCO2 107 55 41.2 40.1
pO2 85.6 78.7 187 164
HCO3 12.2 24.3 22 23.5
BE -12 .9 -2.8 -1.1

17. Progress - Investigations
17.10 18.10 19.10
FBC: TWC 15.4 8.46
Hb 10.7 10.9
Plt 277 316
RP: Urea 3.9 3.1 6.4
Na 137 137 139
K 3.69 4.47 3.93
Creat 51 35 33
APTT 29.9 34
PT 12.6 15
INR 1.2 1.5

18. Progress
• Admitted to PICU 17th Oct 2015 1730H
• Extubated 18th Oct 2015 @ 0900H
• Transfer out to KK6 18th Oct 2015 1830H
– Active & Ambulating, tolerating orally well.
Regained full GCS
• Good Neurological Outcome
• Discharged 19th Oct 2015

19. DROWNING & NEAR DROWNING
‘The smallest coffin are the heaviest’

20. Definition
• ‘The process of experiencing respiratory
impairment from submersion/immersion in
liquid’
Van Beeck, Branche, & Szpilman, 2005.( WHO 2002 defnition).

21. Nomenclature
• Drowning – death within 24 hours caused
by suffocation and submersion in liquid,
mostly water
• Near-drowning – survival past 24 hours
• Secondary drowning - death from
complications 24 hours after the submersion
event.
• Immersion syndrome is sudden death,
probably mediated through the vagus nerve,
due to cardiac arrest after contact with cold
water.Levin DL, Morriss FC, Toro LO, Brink LW, Turner GR. Drowning and near drowning. Pediatr Clin North
Am 1993;40:321–36.

22. Update
• Respiratory impairment must be present
for drowning to occur.
• Formerly : dry and wet drowning, near
drowning, secondary drowning  obsolete
• Fatal or non fatal drowning:
– Fatal : patient dies in the drowning process
– Non Fatal :drowning interrupted and patient
survives

23. Sean.A,”Drowning episodes: Prevention and resuscitaion tips”,The Journal of Family Practice |
FEBRUARY 2015 | Vol 64, No 2
NON FATAL DROWNING
WITH NO MORBDITY

24. Epidemiology
• The World Health Organisation (WHO)
reported 388,000 all-age mortalities in 2004
due to drowning(Peden et al., 2008).
• Lower and middle income countries (LMIC) of
Western-Pacific region  highest total fatal
drowning rates : 13.9 per 100,000 children.
• Fatal drowning highest amongst male
children 1–4 years old (Peden et al., 2008).
• Asia reported drowning rates 30 per 100,000
children, aged 1 to 4 years old at the highest
risk (Linnan et al., 2007; Peden et al., 2008).
WHO: Global report on drowning: preventing a leading killer

25. Epidemiology
• Peaks Age:
– Toddler
– Adolescent
– Elderly

26. Malaysia
Amar-Singh HSS , Pui San Tan & Lina Hashim (2014) Childhood drowning in Malaysia, International
Journal of Injury Control and Safety Promotion, 21:1, 75-80, DOI: 10.1080/17457300.2013.792284

27. Pathophysiology
CNS Injury
• Hypoxic/Anoxic Brain
Injury
• Cold vs warm water
Pulmonary Injury
• Contaminated foreign
material
• Particulate matter
• Bacteria
• Vomitus
• Chemical irritants

28. Complicating Factors
• Duration under water, temperature of
water,
• Currents, type of water, water pollution
• Spinal cord injury
• Hypothermia
• Panicking
• Syncope
• Seizures

29. Involuntary Gasp
(Aspiration of water to hypopharynx)
Laryngospasm
(Parasympathetically Mediated)
Dry
10-15%
Wet
85%
Cerebral Hypoxia/ Acidosis/ Cardiac Arrest
Brain Injury/ Brain Death
Pathophysiology

30. Drowning – Wet vs Dry
Dry-drowning
• 10-15% of submersions
• Laryngospasm
• Hypoxia
• Loss of consciousness
Wet-drowning
• 85-90% of submersions
• Aspiration of water
• Dilution of surfactant
• Diminished gas transfer
• Atelectasis
• Ventilation perfusion
mismatch

31. Pathophysiology - Pulmonary Injury
• During submersion liquid enters hypopharynx and triggers
laryngospasm
• In 90%, the laryngospasm stops
• Due to lack of oxygen and hypercarbia
• Involuntary breathing ensues and victim aspirate large
amount of liquid wet drowning
• Contents of the aspirate may complicate mx
• Water enters the lungs and wash away the surfactant.
• Surfactant helps overcome the surface tension and prevent
alveolar collapse.
• This decreases the compliance hence increase work of
breathing
• Compliance : change in volume over change in pressure
• Collapse lung : atelectasis
• Leading to shunt  ventilation perfusion mismatch  ARDS

32. New Theory?
CVS effects of drowning mirror those seen in
hypoxia
– Apnea  ↓ O2 and precipitate tachycardia +
hypertension  Bradycardia + Hypotension
follow  Blood shunted to vital organs (brain,
lungs, heart)  decreased perfusion of
extremeties  swimming failure
– Accelerated in cold water
Sean.A,”Drowning episodes: Prevention and resuscitaion tips”,The Journal of Family Practice |
FEBRUARY 2015 | Vol 64, No 2

33. New Theory?
• “Autonomic Conflict” – additional mechanism
for morbidity & mortality
• Breath holding & immersion in cold water can
induce cardiac arrhythmias.
– Diving reflex: Bradycardia via parasympathetic
activation
– Cold Shock Response: Tachycardia via
sympathetic activation
– Combined: ↑ risk of arythmogenic state due to
opposing chronothropic effects
• Under reported COD in drowning
Sean.A,”Drowning episodes: Prevention and resuscitaion tips”,The Journal of Family Practice |
FEBRUARY 2015 | Vol 64, No 2

34. Pathophysiology – CNS Injury
• Hypoxia causes neuronal injury during the
1st minute of submersion.
• The longer the anoxic episode the higher
the risk of permanent neuronal damage.
• Hypothermia (Temp <35) confers some
protective mechanism to heart.

35. Time is Brain

36. Consideration
• Hypothermia
– Hypothermia associated with drowning can
provide a protective mechanism that allows
persons to survive prolonged submersion
episodes
– Rate of cerebral oxygen consumption is
reduced by ~ 5% for each reduction of 1°C in
temperature within the range of 37°C to 20°C

37. Complications
• Laryngospasm
• Aspiration Pneumonitis
• Negative Pressure Pulmonary Edema
• ALI / ARDS
• Ischemic Cardiomyopathy
• Arrhythmias
• Hypoxic Ischemic Encephalopathy
• MODS
• Hypothermia
• Electrolyte Disturbance
• Associated Trauma E.G. TBI, Spinal Cord Injury
• Sequelae Of Underlying Causes

38. Management
• Drowning is often associated with
hypothermia, so that in the event of cardiac
arrest continue resuscitative efforts for longer
than usual and attempt to normalised the
person’s core temperature as rapidly as
possible before ceasing resuscitative efforts
• Prehospital care
• Hospital Care
• Management of organ injury

39. Approach
• Remember ! Each drowning case is different from
another…be suspicious, have an open mind.
• History  crucial.
• Scenarios :
1. A young man drown in the swimming pool during
party.
2. A 5 year old boy playing in bath tub.
3. A 60 year old man accidentally drive his car into a
lake during winter.
4. A labour worker fell into Klang river.

40. Prehospital Care
• Resuscitation
– Time optimizes outcome
• Removal from water
– C-spine protection
• CPR ASAP
Update : 2010 AHA guideline CPR continue
to support Airway-Breathing- Chest
compression
VF is rare : unlikely to play significant role

41. Updates 2015
• Update : 2010 AHA guideline CPR
continue to support Airway-Breathing-
Chest compression
• VF is rare : unlikely to play significant role
• Don’t attempt to remove water from
victim’s mouth
• Cervical injury uncommon

42. Hospital Care
• (1) support A, B, C
(2) rewarm to 34°C for 24 hrs
(3) prevent secondary brain injury
• NG tube to decompress stomach
• Passive rewarming:
– remove wet clothes, insulate with blankets
• Active rewarming:
– Peripheral (forced air warmer, hot water bottles),
– Central (warmed humidified inspired gases,
warmed IVD, lavage, intravascular thermal
regulation via vascath, haemofiltration,
cardiopulmonary bypass)

43. Hospital Management
• Supportive
• Avoid ARDS
• Pneumonia rare
• Dopamine, epinephrine drips
• 48 hour window

44. Management of Organ Injury
• NEURO:
Head Up, Low Normal CO2, MAP Of 80mmhg (No Need For ICP
Monitoring), Benzodiazepines For Seizures, Therapeutic
Hypothermia (Actively Warm To 34 C), Prevent Secondary Brain
Injury.
• RESP:
ALI and ARDS -> Protective Lung Ventilation, Bronchodilation, Ino,
Prone, ECMO
• METABOLIC:
Severe metabolic acidosis from lactate, in vivo pao2 in cold patient
is much lower than the measured value as it is warmed to 37 C,
rhabdomyolysis
• CARDIOVASCULAR:
Below 28 C VF is common, extravasation of systemic and
pulmonary capillaries + cold diuresis -> hypovolaemia, SIRS post
resuscitation, often require cardiac output monitoring
• INFECTION:
Consider antibiotics if patient submerged in grossly contaminated
water

45. Predictors of Poor Outcome
Scene
– Immersion > 10 min
– Delay to CPR (e.G. No bystander CPR, unwitnessed)
– Time to first breath
– Water temperature (drop in brain temperature 10C doubles time that brain can survive)
– Presence of cardiac arrest (pulseless or absence of respiratory effort upon rescue)
– Identifiable precipitants; e.G. Did the person have a cardiac arrest secondary to an AMI while
in the swimming pool?
ED
– Asystole
– CPR > 25 minutes
– Dilated, non-reactive pupils and ph <7.0
– Dilated, non-reactive pupils and GCS < 5
– Lactate
ICU
– Loss of grey-white matter differentiation on CT within 36 hrs
– Absence of purposeful motor response (GCS < 5) and absence of brainstem reflexes,
pupillary response and spontaneous respiration at 24 h

46. Favourable Outcome
Imersion, drowning and near-drowning F. St C. Golden, M. J. Tripton, R. C. Scott. British
Journal of Anaesthesia. 1997, 79, 214-225

47. Discussions
• Hypothermia
• Electrolytes disturbances
• Prophylactic Antibiotics
• Ventilation strategy

48. Hypothermia
• Commonly caused by submersion injury
• Classification :
– Mild (32-25oC)
• Responsive stage : HR, CO, BP elevated
– Moderate <32oC
• Metabolism slows down  Oxygen consumption and
CO2 production reduces
• Shivering Ceases
• Ne- inotropic and chronotropic  CO, BP drops
– Severe <28oC
• Core temp : rectal, bladder, esophageal
Tintinalli 7th edition page 1336

49. ECG changes
http://lifeinthefastlane.com/ecg-library/basics/osborn-wave-j-wave/

50. Temp: 30oC

51. Other ECG changes
• T inversions
• Prolonged QT
• Sinus bradycardia
• AV nodal block
• VF
• Asystole

52. Principle in management
• Active rewarming remove from source, wet
clothing
• ABC and bear in mind, the myocardium is
highly irritable !!
• Any intervention can ppt VF
• VF maybe refractory until rewarmed
• Oxygen and Warm Fluids
• Anticipate : acidosis, coagulapathy,
electrolyte imbalance, shock (cold diuresis)

53. Pitfalls
• Don’t Declare death until temp 32oC for at
least 30 mint  hypothermic reported to
tolerate hours of CPR with complete recovery
• Resus drugs not effective at temp <30oC 
REWARMINGDrug toxicity once rewarmed
• DIVC and RHABDOMYOLYSIS : keep this
back in your mind!!
• Bjorn C.Westgard, “Know the basics rewarming and resuscitation of hypothermic patient”,
Avoiding Common Errors in Emergency Department, chapter 104, pg 243
• Tintinalli 7th edition page 1336

55. Drowning
• Sea water versus fresh water
• no significant differences in electrolytes
abnormalities or degree of lung injury
despite differences in osmotic gradient
• bacterial burden is greater in fresh water
(gram negatives, anaerobes,
Staphylococci, fungi, algae, protozoans,
Aeromonas)
Orlowski JP, Abulleil MM, Phillips JM. The hemodynamic and cardiovascular effects of near-
drowning in hypotonic, isotonic, or hypertonic solutions. Ann Emerg Med 1989;18:1044-1049

56. Electrolytes Disturbance
• Hypobicarbonatemia, high anion gap,
hypernatremia, and hypokalemia were
common in saltwater near-drowning
patients in the Gulf of Thailand.
• The cause of high anion gap was probably
due to hypoxia and hypotension.

57. Prophylactic Antibiotics
• While prophylactic antibiotics are not
recommended for near-drowning victims,
the threshold for using empirical antibiotics
to treat the probable pathophysiologic
effects of pathogens should be low.
Pneumonia Associated with Near-Drowning Peter T. Ender* and Matthew J. Dolan
Department of Infectious Diseases, Wilford Hall Medical CID 1997;25

58. Pneumonia Associated with Near-Drowning Peter T. Ender* and Matthew J. Dolan Department of Infectious Diseases,
Wilford Hall Medical CID 1997;25

59. Pneumonia Associated with Near-Drowning Peter T. Ender* and Matthew J. Dolan Department of Infectious Diseases,
Wilford Hall Medical CID 1997;25

60. Protective Lung Ventilation
• Protective lung ventilation is the current standard of care for mechanical
ventilation
• it is synonymous with low tidal volume ventilation (4-8 mL/kg) and often
includes permissive hypercapnia
• 6 mL/kg predicted body weight (not actual body weight) is most commonly
quoted as this was the intervention arm of the practice defining ARDSNet
ARMA trial and is physiologically normal for a healthy person
• RATIONALE
– low tidal volume ventilation reduces ventilator-associated lung injury (VALI)
— volutrauma (hyperinflation and shearing injury)
— barotrauma (alveolar rupture and pneumothorax)
— biotrauma (release of inflammatory mediators)
– hypercapnia may also have directly beneficial effects in ARDS
– clear evidence for benefit in ARDS in animals and humans
– growing evidence of benefit in patients without ARDS, as all mechanically ventilated patients
are at risk of VALI

61. No benefit
• Mannitol
• Loop diuretics
• Hypertonic saline
• Fluid restriction
• Hyperventilation
• Controlled hypothermia
• Barbiturate coma

62. References
• Tintinalli – 7th Edition
• Levin DL, Morriss FC, Toro LO, Brink LW, Turner GR. Drowning and
near drowning. Pediatr Clin North Am 1993;40:321–36.
• WHO: Global report on drowning: preventing a leading killer
• Pneumonia Associated with Near-Drowning Peter T. Ender* and
Matthew J. Dolan Department of Infectious Diseases, Wilford Hall
Medical CID 1997;25
• Imersion, drowning and near-drowning F. St C. Golden, M. J.
Tripton, R. C. Scott. British Journal of Anaesthesia. 1997, 79, 214-
225
• Orlowski JP, Abulleil MM, Phillips JM. The hemodynamic and
cardiovascular effects of near-drowning in hypotonic, isotonic, or
hypertonic solutions. Ann Emerg Med 1989;18:1044-1049
• Pediatric Critical Care Medicine: Basic Science and Clinical
Evidence (Wheeler, Pediatric Critical Care Medicine: Basic Science
and Clinical Evidence)

63. Thank You