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Drowning In Children

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Drowning In Children

  1. 1. Drowning David Slocum MD Albany Medical Center
  2. 2. Miracles <ul><li>Matthew Granger </li></ul><ul><ul><li>14 month old </li></ul></ul><ul><ul><li>20-40 minutes </li></ul></ul>
  3. 3. Vocabulary <ul><li>Drowning – death within 24 hours </li></ul><ul><li>Near-drowning – survival past 24 hours </li></ul>
  4. 4. Who? <ul><li>Usually young, healthy individuals </li></ul>
  5. 5. 2006 Drowning <ul><li>U.S.A. – 5000 died </li></ul><ul><li>Worldwide – over 100,000 died </li></ul>
  6. 6. Epidemiology <ul><li>500,000 submersion events annually </li></ul><ul><li>2nd cause of death – children under 15 </li></ul><ul><li>Injury ranges </li></ul><ul><ul><li>Transient </li></ul></ul><ul><ul><li>Profound neurological deficit </li></ul></ul>
  7. 7. Three Peaks <ul><li>Toddlers </li></ul><ul><li>Adolescents </li></ul><ul><li>Elderly </li></ul>
  8. 8. Toddlers <ul><li>Toilets </li></ul><ul><li>Bathtubs </li></ul><ul><li>Buckets </li></ul>
  9. 9. Coastal Areas <ul><li>Swimming pools more likely </li></ul>
  10. 10. Adolescents <ul><li>Stupidity </li></ul>
  11. 11. Young Adults <ul><li>Alcohol </li></ul><ul><ul><li>40% adult drownings </li></ul></ul><ul><ul><li>75% boat drownings </li></ul></ul>
  12. 12. Elderly
  13. 13. Complicating Factors <ul><li>Spinal cord injury </li></ul><ul><li>Hypothermia </li></ul><ul><li>Panicking </li></ul><ul><li>Syncope </li></ul><ul><li>Seizures </li></ul>
  14. 14. Pathophysiology <ul><li>Central Nervous System Injury </li></ul><ul><li>Pulmonary Injury </li></ul>
  15. 15. Dry-drowning <ul><li>10-20% of submersions </li></ul><ul><li>Laryngospasm </li></ul><ul><li>Hypoxia </li></ul><ul><li>Loss of consciousness </li></ul>
  16. 16. Wet-drowning <ul><li>Aspiration of water </li></ul><ul><li>Dilution of surfactant </li></ul><ul><li>Diminished gas transfer </li></ul><ul><li>Atelectasis </li></ul><ul><li>Ventilation perfusion mismatch </li></ul>
  17. 17. Pulmonary Injury <ul><li>Contaminated foreign material </li></ul><ul><li>Particulate matter </li></ul><ul><li>Bacteria </li></ul><ul><li>Vomitus </li></ul><ul><li>Chemical irritants </li></ul>
  18. 18. Prognosis <ul><li>Submersion time </li></ul><ul><li>Physiological scoring systems </li></ul>
  19. 19. Two extremes <ul><li>Fair cardiovascular and neurological function </li></ul><ul><ul><li>Minimal disability </li></ul></ul><ul><li>Unstable cardiovascular function and coma </li></ul><ul><ul><li>Poorly </li></ul></ul><ul><ul><li>Hypoxic CNS injury </li></ul></ul>
  20. 20. End Organ Damage <ul><li>Renal injury </li></ul><ul><ul><li>Hypoxia </li></ul></ul><ul><ul><li>Myoglobinuria </li></ul></ul><ul><ul><li>Hemoglobinuria </li></ul></ul><ul><li>Hematologic </li></ul><ul><ul><li>Hemolysis </li></ul></ul><ul><ul><li>DIC </li></ul></ul>
  21. 21. Treatment
  22. 22. Prehospital Care <ul><li>Resuscitation </li></ul><ul><ul><li>Time optimizes outcome </li></ul></ul><ul><li>Removal from water </li></ul><ul><ul><li>C-spine protection </li></ul></ul><ul><li>CPR ASAP </li></ul>
  23. 23. Airway <ul><li>Breathing </li></ul><ul><ul><li>High flow oxygen by facemask </li></ul></ul><ul><li>Not Breathing </li></ul><ul><ul><li>Bag valve mask </li></ul></ul><ul><ul><li>Endotracheal tube </li></ul></ul><ul><ul><ul><li>Unconscious </li></ul></ul></ul><ul><ul><ul><li>Protect from aspiration </li></ul></ul></ul>
  24. 24. Who to transport? <ul><li>Amnesia </li></ul><ul><li>Loss or depressed consciousness </li></ul><ul><li>Period of apnea </li></ul><ul><li>Period of artificial respirations </li></ul><ul><li>Even if asymptomatic </li></ul>
  25. 25. Don’t Forget <ul><li>Warm patient </li></ul><ul><ul><li>Hypothermia </li></ul></ul><ul><li>Monitor </li></ul><ul><li>IV access </li></ul><ul><ul><li>Warm isotonic fluids </li></ul></ul>
  26. 26. Summary <ul><li>Rapid, cautious rescue </li></ul><ul><li>Spine precautions </li></ul><ul><li>Cardiopulmonary resuscitation </li></ul><ul><li>Supplemental Oxygen </li></ul><ul><li>Transport </li></ul>
  27. 27. ED Treatment <ul><li>Continue EMS care </li></ul><ul><ul><li>Airway </li></ul></ul><ul><ul><li>Oxygen </li></ul></ul><ul><ul><li>Ventilation </li></ul></ul><ul><ul><li>Warmed fluids </li></ul></ul><ul><ul><li>Warming adjunts </li></ul></ul><ul><ul><li>Treat associated injuries </li></ul></ul>
  28. 28. GCS > 12 <ul><li>Oxygen to keep sat > 95% </li></ul><ul><li>Observe 4-6 hours </li></ul><ul><li>Pulmonary exam normal </li></ul><ul><li>Saturation normal </li></ul><ul><li>Discharge home </li></ul><ul><li>No xray or labs needed </li></ul>
  29. 29. GCS > 12 <ul><li>Oxygen to keep sat > 95% </li></ul><ul><li>Observe 4-6 hours </li></ul><ul><li>Pulmonary exam abnormal </li></ul><ul><li>Requires oxygen </li></ul><ul><li>Deteriorates </li></ul><ul><li>Admit to Monitored bed </li></ul>
  30. 30. GCS < 13 <ul><li>High flow oxygen </li></ul><ul><li>Intubation for low PaO2 </li></ul><ul><li>CXR, Labs </li></ul><ul><li>Continuous cardiac monitoring </li></ul><ul><li>Frequent reassessments </li></ul>
  31. 31. Seizure <ul><li>Dilutional hyponatremia </li></ul><ul><li>Control seizures </li></ul><ul><li>Correct electrolytes </li></ul><ul><li>Residual disorder uncommon </li></ul>
  32. 32. ED Arrest <ul><li>Warm water drowning </li></ul><ul><li>Recovery doubtful </li></ul><ul><li>Consider early discontinuation of efforts </li></ul><ul><li>Risk profound neurological handicaps </li></ul>
  33. 33. Hospital Management <ul><li>Supportive </li></ul><ul><li>Avoid ARDS </li></ul><ul><li>Pneumonia rare </li></ul><ul><li>Dopamine, epinephrine drips </li></ul><ul><li>48 hour window </li></ul>
  34. 34. No benefit <ul><li>Mannitol </li></ul><ul><li>Loop diuretics </li></ul><ul><li>Hypertonic saline </li></ul><ul><li>Fluid restriction </li></ul><ul><li>Hyperventilation </li></ul><ul><li>Controlled hypothermia </li></ul><ul><li>Barbiturate coma </li></ul>
  35. 35. Prognosis <ul><li>No CPR </li></ul><ul><ul><li>Full recovery within 48 hours </li></ul></ul><ul><ul><li>May develop ARDS </li></ul></ul><ul><li>Bystander CPR </li></ul><ul><ul><li>Steady recovery </li></ul></ul><ul><ul><li>Steady decline </li></ul></ul><ul><li>ED CPR </li></ul><ul><ul><li>Very poor prognosis </li></ul></ul>
  36. 36. Pediatric Warm Water Drowning <ul><li>500 victims </li></ul><ul><li>100% received ED CPR </li></ul><ul><li>84% died </li></ul><ul><li>16% severe hypoxic encephalopathy </li></ul>
  37. 37. Diving Reflex <ul><li>Mammals </li></ul><ul><li>Bradycardia </li></ul><ul><li>Peripheral Vasoconstriction </li></ul><ul><li>Greatest in cold water </li></ul><ul><li>Preserves oxygen </li></ul>
  38. 38. ICE water submersion <ul><li>Asystole </li></ul><ul><li>Children and Adults </li></ul><ul><li>Complete Recovery </li></ul><ul><li>Rare </li></ul><ul><li>Resuscitate until normothermic </li></ul>
  39. 39. Prevention <ul><li>Infants </li></ul><ul><ul><li>Parental vigilance </li></ul></ul><ul><li>Toddler </li></ul><ul><ul><li>Pool fencing </li></ul></ul><ul><li>Adolescent/Young Adult </li></ul><ul><ul><li>Control Alcohol/Drug Use </li></ul></ul><ul><ul><li>Swimming lessons </li></ul></ul><ul><li>Elderly </li></ul><ul><ul><li>Same as infant/toddler </li></ul></ul>

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