Pediatrics notes about "Pediatric Drowning". These notes were published in 2018. You can download them from - Telegram: https://t.me/pediatric_notes_2018 - Mediafire: http://www.mediafire.com/folder/u5u60m184t9z7/Pediatric_Notes_2018

1. Pediatric Drowning
P a g e | 1
Emergency 2018
Kareem Alnakeeb
Pediatric Drowning
- Drowning is the process of experiencing respiratory impairment from submersion/
immersion in liquid ( WHO 2005 )
• Drowning vs near-drowning
• Near-fatal drowning
• Secondary drowning
• Wet drowning
• Dry drowning
“ World report on child injury prevention “
 Q1 : What is the most common injury Presenting to the ER?
A: Falls
 Q2 : What is the most common fatal Preventable Childhood Injury?
A : Road Traffic Accidents Then Drowning
 Scope of the report :
- Children under 18 years old
 Leading causes of unintentional injuries :
1. Road traffic injuries
2. Drowning
3. Burns
4. Falls
5. Poisoning
 Injuries represent a large proportion of child
deaths, in particular for older children
• With ↑ in age , children have
-  Communicable diseases
- ↑ Non-communicable diseases
- ↑ Injuries
Abandoned terminology:
Definition:
Epidemiology:

2. Pediatric Drowning
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Emergency 2018
Kareem Alnakeeb
 Child injuries are strongly related to social determinants;
- Low Income Countries → higher rate of unintentional injuries
- High Income Countries → lower rate of unintentional injuries
 Child injury prevention is cost effective;
Financial savings from selected injury prevention interventions
Expenditure of US$ 1 each on Savings (US$)
Smoke alarms 65
Child restraints 29
Bicycle helmets 29
Prevention counseling by pediatricians 10
Poison control services 7
Road safety improvements 3
 Facts:
- 480 children die from drowning every day
- For every 1 death, 4 others hospitalized & 14 seen in the ER
- Each year 2-3 million children come close to drowning.
- Most common in children under 5 years
- Socioeconomic status
o Low Income Countries : open waters
o High Income Countries : swimming pools
 The type of water:
- Freshwater:
• Natural bodies of water : ( Rivers - Lakes – Ponds )
• Domestic sites : ( Pools - Spas - Bathtubs – Toilets )
- Saltwater
 Temperature:
- Warm-water drowning: temperatures ≥ 20°C
- Cold-water drowning: temperatures < 20°C
(  energy expenditure with  demands →  tissue injury )
 Outcome:
- Fatal drowning: any death related to drowning
- Non-fatal drowning: those not ending in mortality.
Classification:

3. Pediatric Drowning
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Emergency 2018
Kareem Alnakeeb
- Males more than females beyond infancy
- Young age and adolescents
- Epilepsy
- Cardiac arrhythmias especially with Long QT syndrome (LQTS)
- Hypoglycemia prior to swimming
- Drug abuse, alcohol
 Asphyxia is the most important pathophysiology.
- Aspiration → Coughing and laryngospasm → Hypoxia, hypercarbia, and acidosis.
- With further hypoxia → laryngospasm abates → More aspiration → Cerebral hypoxemia →
Loss of consciousness and apnea.
I. Pulmonary pathology  Hypoxia
a. Intrapulmonary shunting due to
- Bronchospasm
- Aspirated fluid in the alveolar space
- Atelectasis
- Surfactant washout
- Surfactant inactivation
- Surfactant decreased production due to alveolar damage.
b. Raised pulmonary vascular resistance
c. Pulmonary edema
d. Chemical pneumonitis
e. Acute Lung Injury (ALI)
f. ARDS
Risk Factors:
Pathophysiology:
 No clinically significant differences in pulmonary injury between freshwater and saltwater

4. Pediatric Drowning
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Emergency 2018
Kareem Alnakeeb
II. Cardiovascular pathology
- Decreased myocardial contractility
- Increased peripheral VR: initially high BP
- Low COP
- Congestion of central veins
- Reduced ADH
- Diuresis
- Hypotension
- Hypovolemia ; Capillary leak
- Tachycardia, bradycardia, pulseless electrical activity, and finally asystole ;
Hypoxia, acidosis, and/or hypothermia
- Ventricular fibrillation is not as common ; Hypothermia → NO DC shock
III. Brain Injury
- Energy failure “Mismatch () demand & supply i.e. H2o & O2 “
- Lipid peroxidation
- Production of free radicals
- Inflammatory responses
- Release of excitotoxic neurotransmitters.
- Disruption of neuronal and glial functions.
- Neuronal losses
IV. Other systems
a. Metabolic acidosis
b. Renal insufficiency
 Anoxia
 Shock
 Myoglobinuria, or hemoglobinuria.
c. SIRS, sepsis
d. DIC
e. Infection e.g. Acanthamoeba causes Meningitis ( ttt: Metronidazole )

5. Pediatric Drowning
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Emergency 2018
Kareem Alnakeeb
( Lay person rescue - Pre-Hospital by EMS - ER Management - PICU Management )
I. Pre-Hospital
a) Mouth to mouth breathing ; ( For oxygenation & lung inflation )
- Immediate
- Better performed while still in water
- Not waiting for by attempting to drain water from the lungs
- May be all that is needed if there is some spontaneous circulation
b) Chest compressions;
- Once on solid ground, should be initiated if signs of life are absent.
c) Cervical spine immobilization;
- should be performed in cases with a history of diving.
II. ER Management ( For oxygenation )
 A and B
If No intubation If Intubation
• Spontaneously breathing
• Maintaining SaO2 > 90% on Fio2 < 50%
• CPAP
• Non-invasive bi-level ventilation
• Secure airway, prevents aspiration
• Rapid sequence induction (RSI);
Sellick maneuver : firm pressure over the Cricoid to
collapse the esophagus & prevent gastric aspiration
• NG tube
• High PEEP “Positive end-expiratory pressure “
 C
- Aggressive fluid therapy → NS 20 ml/kg boluses
- Dobutamine is preferred → Inotrope + Vasodilator
- Maintain normal BP
Management :

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Emergency 2018
Kareem Alnakeeb
 Warming
 Passive external rewarming
- Remove wet clothing
- Insulate with warm blankets/forced air warming blankets
 Active external rewarming
- Hot packs and heat lamps to trunk of body only
- Heated air blower
 Active internal rewarming (if core temperature ≤ 30°C)
- Warmed intravenous fluids (40°C-44°C)
- Warmed humidified oxygen (42°C-46°C)
- Peritoneal lavage (potassium chloride free fluid)
- Bladder wash with warm fluids
 Hypothermia
- If child remains unconscious, Keep moderate hypothermia (temp. 320C- 340C)
for 12-72 hours by Cool blanket / cool cap to  brain demand
 ER Investigations – monitoring
- Pulse oximetry
- NG tube
- ABG only if there is severe hypoxemia
- Check blood sugar
- Check electrolytes
- No need for CXR
- CT only if suspecting traumatic brain injury

7. Pediatric Drowning
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Emergency 2018
Kareem Alnakeeb
III. PICU
 Neuro-intensive Care (Brain Resuscitation)
- Aggressive management of seizures .. Continuous EEG monitoring
- Aggressive management of fever
- Moderate hypothermia (temp. 320
C- 340
C )
- Moderate fluid restriction
- Controlled hyperventilation
- Barbiturate coma ±
- Corticosteroids ±
- Continuous muscular paralysis ±
- Mannitol ±
 ALI - ARDS
- Lung protective ventilation
• PIP < 25 torr
• Vte 6-8 mL/kg
• FiO2 <0.60
• High PEEP
- Caveats
• High PEEP may increase ICP.
• High PEEP may reduce venous return
• Permissive hypercapnia is UNSUITABLE
- Continue MV for at least 24 hours
• Avoid re-emerging pulmonary oedema (secondary drowning)
• Adequate chance for pneumocyte regeneration
- Reduce FiO2 to < 50% as soon as possible
• Avoid Oxygen toxicity
- Exogenous surfactant (case reports only)
- Prone positioning due to VQ mismatch (cycles of supination & pronation)
- Nitric oxide (NO)
- ECMO “ Extracorporeal membrane oxygenation “
- No need for prophylactic antibiotics
- Treatment of pneumonia (>24 hours)

8. Pediatric Drowning
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Emergency 2018
Kareem Alnakeeb
 Continued CVS support
- Rarely needed
- Aim at normal BP and organ perfusion
 Metabolism
- Tight glycemic control
- Monitoring of electrolytes
- Fluid shifts
• Fresh water: hyponatremia and hypotonic hemolysis
• Sea water: hypernatremia, hyperchloremia and volume contraction
• These shifts are RARELY of clinical significance
 Poor prognostic signs ;
- Unwitnessed event
- Prolonged time to resuscitation
- The need for CPR at the scene
- The need for continued CPR in the ED,
- Prolonged coma
Outcome :