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1. Pediatric Drowning
Carlo Reyes, MD, JD, FACEP, FAAP
ZUMA BEACH
OCTOBER 25, 2012

2.  Terminology Objectives
 Epidemiology
 Pediatric
Characteristics:
◦ Mechanisms of injury
◦ Physiology
◦ Social and family
issues
 Treatment
Paradigm
 Prevention

3. Terminology

4.  Drowning vs. Near drowning
 Cold water (<20°C) vs. Warm water
(>20°C) vs. “Very-cold-water” (<5°C)
 Freshwater vs. salt-water
Terminology – Old Classifications

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. Epidemiology

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. 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 medications
Epidemiology: QUIZ

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 medications
Epidemiology: QUIZ

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 drowning
Epidemiology: Gender

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 higher
Epidemiology: Cultural

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 her
e) All of the above.
Epidemiology: Cultural Quiz

13.  1970: 3.87
 1980: 2.67
 1990: 1.60
 2000: 1.24
 2010: (projected) 1.19
Epidemiology: Deaths per 100,000
Population

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.  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 fence
Mechanisms of Injury by Age

16.  Bathtubs: location of non-pool drowning
 Other injuries:
◦ Slip and fall: Lacerations (most common)
◦ Burns (scald)
◦ Head and facial injuries most common < 4 yrs
Bathtub and shower injuries (Mao,
2009)

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.  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 drowning
Toddler Typical Patient Scenario

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:
◦ Suicidality
Adolescent Typical Patient
Scenario

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 mortis
Presentation Types (Shepherd,
2009)

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.  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 fluid
Pathophysiology:
Effects of Drowning

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 demand
Pathophysiology – CNS Injury

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
prognosis
Role of CT in Drownings

25. CT findings (Rafaat
 Early: et al., 2008)
◦ cerebral edema; loss
of grey-white matter
diff.
 Later:
◦ Injury to hippocampi,
thalami, basal ganglia

26. Pathophysiology- Brain injury
(Hutchison, 2008)

27.  Myocardial ischemia
◦ Arrhythmia
◦ Cardiac arrest
 “Diencephalic –hypothalamaic storm”
◦ Late effect due to severe CNS hypoxic injury
◦ Hypertension, tachycardia diaphoresis,
agitation
Hypoxic injury: Autonomic
Dysfunciton

28. Shallow Water Blackout

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 Blackout
What is it?

30. SHALLOW WATER BLACKOUT

31. http://www.youtube.com/watch?feature=pl
ayer_detailpage&v=qLe81lUbPNg
Youtube- Deep Water Blackout

32. Pre-Hospital Care

33. 3. What is the appropriate sequence in
resuscitation for laypersons after a
drowning?
a) A-B-C
b) C-A-B
c) B-A-C
d) C-B-A
e) None of the above.
Pre-Hospital Care- QUIZ

34. 3. What is the appropriate sequence in
resuscitation for laypersons after a
drowning?
a) A-B-C
b) C-A-B
c) B-A-C
d) C-B-A
e) None of the above.
Pre-Hospital Care- QUIZ

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.  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. The Trauma Evaluation

38.  Airway – Maintain C spine
 Breathing
 Circulation
 IV-O2-Monitor
 Disability – GCS, AVPU
 Exposure – Remove clothes, secondary
survey
The Trauma Evaluation

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.  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.  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 PICU
Appropriate Disposition

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.  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 hours
Therapeutic Hypothermia

44. Prevention

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.  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 resuscitation
AAP Preventative Measures

47.  Lifeguards present:
◦ 6% of all rescued persons needed medical
attention
◦ 0.5% needed CPR
 Bystanders present:
◦ 30% required CPR
Lifeguard v. Bystander Study

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 Prevention
Summary

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