Pediatric Drowning    Carlo Reyes, MD, JD, FACEP, FAAP                        ZUMA BEACH                  OCTOBER 25, 2012
   Terminology              Objectives   Epidemiology   Pediatric    Characteristics:    ◦ Mechanisms of injury    ◦ Ph...
Terminology
 Drowning vs. Near drowning Cold water (<20°C) vs. Warm water  (>20°C) vs. “Very-cold-water” (<5°C) Freshwater vs. salt...
 Drowning Process: respiratory  impairment from submersion/immersion  in liquid. Nonfatal Drowning: drowning process  th...
Epidemiology
 500,000 deaths each year worldwide Leading cause of death worldwide in boys  5-14 2nd leading cause of death in US in ...
1.    What is the leading cause of accidental      death in the U.S. today?     a)   Heart attack     b)   Diabetes     c)...
1.   What is the leading cause of accidental     death in the U.S. today?     a) Heart attack     b) Diabetes     c) Drown...
 Bimodal distribution: toddlers and male  adolescents. Gender: male (over 1 year)    ◦ Males 4x more likely to sustain s...
   Ethnicity:    ◦ African American: 1.3x drowning rate.      Fatal drowning for age 5-14: 3.2x higher    ◦ Am.Indian/Al...
2. Dr. Reyes picked this picture because:a) It represents the correct way to deliver   mouth-to mouth to a drowning female...
   1970:   3.87   1980:   2.67   1990:   1.60   2000:   1.24   2010:   (projected) 1.19Epidemiology: Deaths per 100,0...
   For every one pediatric drowning death:    ◦ 14 children are treated in emergency dept.    ◦ 4 children are hospitaliz...
   Less than one year:    ◦ Bathtubs and buckets    ◦ Child abuse/neglect   Ages 1-4:    ◦ Home or apartment swimming po...
 Bathtubs: location of non-pool drowning Other injuries:    ◦ Slip and fall: Lacerations (most common)    ◦ Burns (scald...
 Aged 10-14 most common to have injury Head, face, and neck injuries    ◦ Children tend to injure head    ◦ Adolescents ...
   Contributing factors: Unattended; no    fence   Location: Pool (bathtub in <1 year)   Unique characteristics: Silent...
 Contributing factors: Male, alcohol, drugs  Location: Pool, ocean, or lake Scenario: Diving, or boating accident Injur...
 Asymptomatic Symptomatic:    ◦ Abnormal vitals    ◦ Respiratory distress or hypoxia    ◦ Alert or altered; Neurologic d...
   “Wet drowning” (90%)    ◦ Asphyxia  relaxation of airway  Aspiration      of fluid (<4ml/kg)      Salt water  surf...
 Hypoxemia  shunts off pulmonary circ. Hypercarbia  acidosis Pulmonary hypertension  ARDS Electrolyte Disturbances ...
   Hypoxia    ◦ Loss of consciousness    ◦ Hypoxic-ischemic encephalopathy Cerebral edema (6-12 hours) Cold-water immer...
   Rule out accidental and non-accidental    trauma    ◦ Intracranial hemorrhage    ◦ Maxillofacial injuries    ◦ Cervica...
CT findings (Rafaat   Early:                   et al., 2008)    ◦ cerebral edema; loss      of grey-white matter      dif...
Pathophysiology- Brain injury(Hutchison, 2008)
   Myocardial ischemia    ◦ Arrhythmia    ◦ Cardiac arrest   “Diencephalic –hypothalamaic storm”    ◦ Late effect due to...
Shallow Water Blackout
 Loss of consciousness while in water due  to cerebral hypoxia from apnea. Hyperventilation drives down CO2, which  is r...
SHALLOW WATER BLACKOUT
http://www.youtube.com/watch?feature=player_detailpage&v=qLe81lUbPNgYoutube- Deep Water Blackout
Pre-Hospital Care
3.   What is the appropriate sequence in     resuscitation for laypersons after a     drowning?a)   A-B-Cb)   C-A-Bc)   B-...
3.   What is the appropriate sequence in     resuscitation for laypersons after a     drowning?a)   A-B-Cb)   C-A-Bc)   B-...
   Remove from water       Pre-Hospital Care   Maintain airway and C    spine precautions   100% FIO2 by mask   BVM; ...
   Poor prognostic factors (non-icy waters)    ◦   Submersion >25 minutes    ◦   PEA on arrival in ED    ◦   Unresponsive...
The Trauma Evaluation
   Airway – Maintain C spine   Breathing   Circulation   IV-O2-Monitor   Disability – GCS, AVPU   Exposure – Remove ...
   100% FIO2 by facemask if hypoxic   BIPAP if awake and facemask not effective   Intubation/RSI and immobilize neck  ...
   Fluid resuscitation with NS PRN   Accucheck, Istats, trauma labs   EKG and telemetry   Rewarming if hypothermic.   ...
 Asymptomatic  consider 8 hour  observation or discharge. Symptomatic    ◦ After stabilization  admit and observe, or ...
 Traditional method is active rewarming in  the ED, especially in setting of V fib arrest  where heart may be unresponsiv...
   Recommended in adult Vfib arrest victims    by AHA (2002)    ◦ Adults – V fib most likely due to heart disease    ◦ Pe...
Prevention
   Toddlers:    ◦ Four-sided fence, 4 ft high, self latching and      opens outward    ◦ Remove toys in pool.    ◦ Consta...
   Children: Constant supervision of all children   Infants and toddlers:    ◦ “Touch supervision”    ◦ Four-sided fence...
   Lifeguards present:    ◦ 6% of all rescued persons needed medical      attention    ◦ 0.5% needed CPR   Bystanders pr...
 Terminology and Definitions Epidemiology Unique characteristics of the pediatric  drowning patient, including:    ◦ Me...
   Avarello, J. Pediatric Major Trauma: An Approach to Evaluation and Management. Emerg Med Clin N Am    25 (2007) 803-80...
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Pediatric drowning zuma

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Created and presented by Carlo Reyes, MD, JD, FACEP, FAAP at Zuma Beach, October 25, 2012

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  • AB1195 Requirement
  • Lethal Injury:50% of submersion victims die at the scene
  • Adding four sided fence to pool decreases incidence of drowning by 50%
  • Bathtubs and buckets – high suspicion of child abuse
  • 156 drownings; all patients with abnormal initial CT scans died (28 pts); 23 of 24 patients with abnormal second CT bad outcome (13 died and 10 persistent vegitative)All pts with abn CTs had GCS of 3; All pts with GCS &gt; 4 had normal CTs; abused children with abnormal CT had higher GCS.
  • This diagram shows the selective areas of hypoxic brain injury in the infant on the right, and the adult and older child, on the left. On the right, the infant’s diencephalon, central part of the brain is most sensitive to hypoxia. This region regulates the autonomic functions of the body, including the blood pressure and heart rate.
  • Fences has decreased submersion injuries by 50%
  • 2003
  • Pediatric drowning zuma

    1. 1. Pediatric Drowning Carlo Reyes, MD, JD, FACEP, FAAP ZUMA BEACH OCTOBER 25, 2012
    2. 2.  Terminology Objectives Epidemiology Pediatric Characteristics: ◦ Mechanisms of injury ◦ Physiology ◦ Social and family issues Treatment Paradigm Prevention
    3. 3. Terminology
    4. 4.  Drowning vs. Near drowning Cold water (<20°C) vs. Warm water (>20°C) vs. “Very-cold-water” (<5°C) Freshwater vs. salt-waterTerminology – Old Classifications
    5. 5.  Drowning Process: respiratory impairment from submersion/immersion in liquid. Nonfatal Drowning: drowning process that is interrupted, and person is rescued. Fatal Drowning: person dies any time as a result of drowning.Terminology–WHO 2002
    6. 6. Epidemiology
    7. 7.  500,000 deaths each year worldwide Leading cause of death worldwide in boys 5-14 2nd leading cause of death in US in kids aged 1-4. ◦ birth defects is the leading cause. ◦ Leading cause of death in some states (CA, AZ)Epidemiology: Pediatric Drowning
    8. 8. 1. What is the leading cause of accidental death in the U.S. today? a) Heart attack b) Diabetes c) Drowning d) Car accident e) Prescription pain medicationsEpidemiology: QUIZ
    9. 9. 1. What is the leading cause of accidental death in the U.S. today? a) Heart attack b) Diabetes c) Drowning d) Car accident e) Prescription pain medicationsEpidemiology: QUIZ
    10. 10.  Bimodal distribution: toddlers and male adolescents. Gender: male (over 1 year) ◦ Males 4x more likely to sustain submersion injury ◦ Males 12x more likely to be involved in boat- related drowningEpidemiology: Gender
    11. 11.  Ethnicity: ◦ African American: 1.3x drowning rate.  Fatal drowning for age 5-14: 3.2x higher ◦ Am.Indian/Alaska Native: 1.8x drowning rate.  Fatal drowning rate for age 5-14: 2.4x higherEpidemiology: Cultural
    12. 12. 2. Dr. Reyes picked this picture because:a) It represents the correct way to deliver mouth-to mouth to a drowning female.b) I’m culturally sensitive to American- Indians, even if this actor may not be American-Indian.c) I’m secretly with Team Jacob.d) Robert Pattinson should not have made up with here) All of the above.Epidemiology: Cultural Quiz
    13. 13.  1970: 3.87 1980: 2.67 1990: 1.60 2000: 1.24 2010: (projected) 1.19Epidemiology: Deaths per 100,000Population
    14. 14.  For every one pediatric drowning death: ◦ 14 children are treated in emergency dept. ◦ 4 children are hospitalized. Annual cost of care per year in chronic facility: $100,000.Epidemiology - Cost
    15. 15.  Less than one year: ◦ Bathtubs and buckets ◦ Child abuse/neglect Ages 1-4: ◦ Home or apartment swimming pools ◦ Child abuse/neglect Ages 5-19: ◦ Lakes, ponds, rivers and pools. ◦ Child abuse/neglect Most common access to water <5 years ◦ Pool without a fenceMechanisms of Injury by Age
    16. 16.  Bathtubs: location of non-pool drowning Other injuries: ◦ Slip and fall: Lacerations (most common) ◦ Burns (scald) ◦ Head and facial injuries most common < 4 yrsBathtub and shower injuries(Mao, 2009)
    17. 17.  Aged 10-14 most common to have injury Head, face, and neck injuries ◦ Children tend to injure head ◦ Adolescents tend to injure neck and extremities Most common mechanism: hitting diving board and/or platform Most common injury: laceration and soft tissue. (spinal cord injury rare)Diving injuries (Day, 2006)
    18. 18.  Contributing factors: Unattended; no fence Location: Pool (bathtub in <1 year) Unique characteristics: Silent drowning Injuries: cardiopulmonary arrest Co-morbidities: seizure (post-ictal state) Unique characteristics: ◦ Child abuse/neglect ◦ Silent drowningToddler Typical Patient Scenario
    19. 19.  Contributing factors: Male, alcohol, drugs Location: Pool, ocean, or lake Scenario: Diving, or boating accident Injuries: HEENT injuries, overdose. Co-morbidities: seizure (post- ictal), arrhythmia, hypoglycemia/diabetes, Unique characteristics: ◦ SuicidalityAdolescent Typical PatientScenario
    20. 20.  Asymptomatic Symptomatic: ◦ Abnormal vitals ◦ Respiratory distress or hypoxia ◦ Alert or altered; Neurologic deficit Cardiopulmonary arrest: ◦ Apnea ◦ Asystole, Vtach/Vfib, Bradycardia Obviously dead: asystole, rigor mortisPresentation Types(Shepherd, 2009)
    21. 21.  “Wet drowning” (90%) ◦ Asphyxia  relaxation of airway  Aspiration of fluid (<4ml/kg)  Salt water  surfactant washout  Fresh water  surfactant destroyed “Dry drowning” (10%) ◦ Laryngospasm  aspiration of minimal amt.Pathophysiology:Wet vs Dry Drowning
    22. 22.  Hypoxemia  shunts off pulmonary circ. Hypercarbia  acidosis Pulmonary hypertension  ARDS Electrolyte Disturbances – usually from ingestion of large amounts of fluid, minor effect from aspiration of fluidPathophysiology:Effects of Drowning
    23. 23.  Hypoxia ◦ Loss of consciousness ◦ Hypoxic-ischemic encephalopathy Cerebral edema (6-12 hours) Cold-water immersion (<20°C) is protective  time-to-injury is prolonged. ◦ Diving reflex: apnea, bradycardia, and vasoconstriction of nonessential vascular beds ◦ Decreases metabolic demandPathophysiology – CNS Injury
    24. 24.  Rule out accidental and non-accidental trauma ◦ Intracranial hemorrhage ◦ Maxillofacial injuries ◦ Cervical injuries Identify signs of anoxic brain injury If CT show signs of anoxic injury  bad prognosisRole of CT in Drownings
    25. 25. CT findings (Rafaat Early: et al., 2008) ◦ cerebral edema; loss of grey-white matter diff. Later: ◦ Injury to hippocampi, thalami, basal ganglia
    26. 26. Pathophysiology- Brain injury(Hutchison, 2008)
    27. 27.  Myocardial ischemia ◦ Arrhythmia ◦ Cardiac arrest “Diencephalic –hypothalamaic storm” ◦ Late effect due to severe CNS hypoxic injury ◦ Hypertension, tachycardia diaphoresis, agitationHypoxic injury: AutonomicDysfunciton
    28. 28. Shallow Water Blackout
    29. 29.  Loss of consciousness while in water due to cerebral hypoxia from apnea. Hyperventilation drives down CO2, which is responsible for respiratory drive. Lack of respiratory drive while in water causes apnea, worsening hypoxia. Compare to Deep water blackout- seen in deep sea divers as they approach the surface and experience rapid depressurisation.Shallow Water BlackoutWhat is it?
    30. 30. SHALLOW WATER BLACKOUT
    31. 31. http://www.youtube.com/watch?feature=player_detailpage&v=qLe81lUbPNgYoutube- Deep Water Blackout
    32. 32. Pre-Hospital Care
    33. 33. 3. What is the appropriate sequence in resuscitation for laypersons after a drowning?a) A-B-Cb) C-A-Bc) B-A-Cd) C-B-Ae) None of the above.Pre-Hospital Care- QUIZ
    34. 34. 3. What is the appropriate sequence in resuscitation for laypersons after a drowning?a) A-B-Cb) C-A-Bc) B-A-Cd) C-B-Ae) None of the above.Pre-Hospital Care- QUIZ
    35. 35.  Remove from water Pre-Hospital Care Maintain airway and C spine precautions 100% FIO2 by mask BVM; don’t delay CPR with intubation Use traditional ABC sequence (not CAB)
    36. 36.  Poor prognostic factors (non-icy waters) ◦ Submersion >25 minutes ◦ PEA on arrival in ED ◦ Unresponsiveness on arrival in ED ◦ Elevated blood glucose ◦ Hypothermia Two important caveats: ◦ Anecdotal reports of survival after icy water submersion. ◦ Factors are not to be used clinically at the scene.Pre-Hospital Care-Poor Prognostic Factors
    37. 37. The Trauma Evaluation
    38. 38.  Airway – Maintain C spine Breathing Circulation IV-O2-Monitor Disability – GCS, AVPU Exposure – Remove clothes, secondary surveyThe Trauma Evaluation
    39. 39.  100% FIO2 by facemask if hypoxic BIPAP if awake and facemask not effective Intubation/RSI and immobilize neck Bronchoscopy- consider if hypoxic despite mechanical ventilation. ECMO – tertiary care center PICUs may consider.Initial Interventions- Airway
    40. 40.  Fluid resuscitation with NS PRN Accucheck, Istats, trauma labs EKG and telemetry Rewarming if hypothermic.  If Vfib- single defibrillation, then resume CPR and rewarm Trauma films: CXR +/- 3 v Cspine Evacuate gastric contents Consider Utox, BAL CT brain, C spine if altered or comatose Consults: Trauma, Critical Care, Neurology, Suicidality?Initial Trauma Interventions
    41. 41.  Asymptomatic  consider 8 hour observation or discharge. Symptomatic ◦ After stabilization  admit and observe, or transfer to Tertiary Care with PICU backup. Unstable, critical care ◦ Transfer to PICUAppropriate Disposition
    42. 42.  Traditional method is active rewarming in the ED, especially in setting of V fib arrest where heart may be unresponsive due to hypothermia. New Research on Therapeutic Hypothermia ongoing as means of cerebral protection ◦ Not specifically endorsed by AAP for ED use in pediatric patients.Therapeutic Hypothermia
    43. 43.  Recommended in adult Vfib arrest victims by AHA (2002) ◦ Adults – V fib most likely due to heart disease ◦ Peds – V fib most likely due to hypoxia/shock No studies in peds; 38% PICUs use it Target: 32°C Initiation: within 6 hours Duration: 24 hoursTherapeutic Hypothermia
    44. 44. Prevention
    45. 45.  Toddlers: ◦ Four-sided fence, 4 ft high, self latching and opens outward ◦ Remove toys in pool. ◦ Constant supervision. Children: ◦ Responsible adult present Adolescents: ◦ Avoid drinking alcohol ◦ Life jackets for recreational boating.CDC: Preventative Measures
    46. 46.  Children: Constant supervision of all children Infants and toddlers: ◦ “Touch supervision” ◦ Four-sided fence Swimming lessons okay >4 yrs ◦ Doesn’t replace other measures Resuscitation Education: ◦ Bystander CPR training ◦ EMS Education ◦ ED resuscitationAAP Preventative Measures
    47. 47.  Lifeguards present: ◦ 6% of all rescued persons needed medical attention ◦ 0.5% needed CPR Bystanders present: ◦ 30% required CPRLifeguard v. Bystander Study
    48. 48.  Terminology and Definitions Epidemiology Unique characteristics of the pediatric drowning patient, including: ◦ Mechanisms of injury. ◦ Physiology and response to injury. ◦ Social and family issues in pediatric trauma. The Treatment Paradigm Modes of PreventionSummary
    49. 49.  Avarello, J. Pediatric Major Trauma: An Approach to Evaluation and Management. Emerg Med Clin N Am 25 (2007) 803-806. Day, Coral et al. Diving-Related Injuries in Children <20 Years Old Treated in Emergency Departments in the United States; 1990-2006. Shepherd, S.M. and Shoff, W.H. Drowning. Updated June 9, 2009. eMedicine.medscape.com Fink, E. et al. A tertiary care center’s experience with therapeutic hypothermia after pediatric cardiac arrest. Pediatr Crit Care Med, Vol. 11, No. 1, 2010. Hutchison, J.S. et al. Hypothermia Therapy for Cardiac Arrest Patients. Pediatric Clin N Am 55 (2008) 529- 544. Layon, A.J. and Modell, J. H. Drowning. Update 2009. Anesthesiology 2009; 110: 1390-401. Mao, Shengyi et al. Injuries Associated with Bathtubs and Showers Among Children in the United States. Pediatrics 2009; 124; 541-547. Nelson’s Pediatrics. Policy Statement: Prevention of Drowning in Infants, Children, and Adolescents. Committee on Injury, Violence, and Poison Prevention. Pediatrics. 2003; 112; 437-439. Rafaat, K.T., et al. Cranial computed tomographic findings in a large group of children with drowning: Diagnostic, prognostic, and forensic implications. Pediatr Crit Care Med 2008, Vol. 9., No. 6. Swimming Programs for Infants and Toddlers. Committee on Sports Medicine and Fitness and Committee on Injury and Poison Prevention. Pediatrics 2000; 105; 868-870. The Pediatric Emergency Medicine Resource. 4th Ed. American Academy of Pediatrics, 2004. Topjian, A. et al. Pediatric Cardiopulmonary Resuscitation: Advances in Science, Techniques, and outcomes. Pediatrics, 2008; 122; 1086-1098. Wagner, C. Pediatric Submersion Injuries. Air Medical Journal, Vol. 28, Issue 3 (May 2009).References

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