Case # 00832989Case # 00832989

Mary PalomakiSt. Barnabas Hospital30 September 2009

Mary PalomakiSt. Barnabas Hospital30 September 2009

11 month old male

• Brought in by EMS as medical notification

What happened?

• Baby boy was in the bathtub with his cousin.• His aunt was supervising.• His aunt removed his cousin from the bathtub

and brought him into another room• She left the patient unattended.• The aunt then told the patient’s 15 y/o mother

to go take the patient out of the bathtub.

In the bathroom…

• The patient was left alone in the bathtub:

• 3/4 full adult size bathtub

• Warm water

• Water not running, not draining

• Mother and Aunt estimate patient was left alone for 2-3 minutes

When Mom entered the bathroom,• She found the patient:

– unresponsive – floating face up– a large, distended abdomen

• Mom called the aunt• His aunt gave rescue breaths and pumped on the

chest• The patient responded by vomiting, crying/gurgling,

and defecating• 4-5 minutes of “CPR” was given and 911 was

called

Upon EMS Arrival

• Baby boy found to have spontaneous respiration with RR 30 and HR 130

• He was wrapped in towels and actively vomiting

• He did not cry until he was en route to the hospital

Past Medical History:

• Birth History: Term, NSVD, no complications• No hospitalizations• No surgeries• No known drug allergies• Immunizations: Up to date• Social: Patient lives with mother,

grandmother, care for by his aunt during daytime

Physical Exam 17:00

• Initial Vital Signs: T:97.0 F, P:127, RR: 35 O2 Sat: 98% on 100% ventimask

• Weight estimated at 10 kg on broselow tape• Gen: Acute distress, GCS: 8 (1;no eye opening

+3;infant consistently inconsolable + 4;infant withdrew from pain)

• Heent: NC/AT, Pupils 3 mm bilaterally, sluggish reaction to light, eyes closed, lips pink

• Skin: cold, clammy, pink, no bruising, no old scars

Physical Exam Continued

• CVS: s1/s2, no murmur, distal pulses 2 +• Resp: + nasal flaring, + subcostal, + suprasternal

retractions, B/L air entry, + crackles B/L, R>L• Abd: + distention, + tympanic to percussion, firm

to palpation• Extremities: cap refill < 2 sec., no cyanosis• Neuro: No response to mother’s voice,

withdrawal and cry to pain, 3+ patellar reflexes, + B/L clonus of ankles 2-3 beats after forced flexion

Initial intervention

• Patient was placed on 100% ventimask initially

• Placed on monitor• IV inserted• 250 mL bolus of NS given• NG tube placed to decompress

stomach• Foley placed

Initial Labs:

• ABG (17:05): 7.237 /30.6/ 240/ 99.2/ -13.4 (on 100% FIO2)– Na: 123, K:3.7, Cl:103, Glu: 243, LA: 5.5

• CBC (17:15): 12.5>12.1/37.9<315 N:17.8%, L: 78%

• CMP: (17:15): 124|97|16 / 127 4.0|11|0.5 \ 8.5Mg 1.6 Pho 5.3 AST 75 ALT 31Alk phos 215 Alb 3.5 Pro 5.5

Chest X-ray

• Distended stomach

ED course• Patient declined in mental status, with decreased

response to pain, and no cry• Patient had two short episodes of tonic-clonic activity

about 5 seconds each, which responded to ativan 0.5 mg IVP

• A second 250mL bolus of NS given• Patient became increasingly tachypneaic with RR 54,

and O2 sat 85%• Patient was placed on NCPAP with peep of 5 with long

nasal prongs• Ceftriaxone 500 mg IV given for prophylaxis of aspiration

pneumonia

Vital Signs

• 17:20 – HR 163 BP 165/93 RR 38 O2 sat 95%

• 17:30– T 99.4 HR 174 RR 54 BP 137/93 O2 sat

85% (CPAP initiated at this time)

Repeat Labs (18:25):

• ABG: 7.33/ 33.2/ 125/ 98.6/ -7.7 (on 100% FiO2)– Na: 121, K:3.1, Cl:103, Glu: 181, LA: 2.4

• CMP: 125|101|15 / 174

3.5|15 |0.4\ 8

Alb: 3.1 Pro 4.9

Overview

• Definition

• Epidemiology

• Accidental vs. Non-accidental drowning

• Pathophysiology

• Management

• Prevention

Definition

• 2002 World congress on drowning defined drowning as

• “a process resulting in primary respiratory impairment from submersion in a liquid medium”

Shepard, Suzanne et al. Drowning. Emedicine.medscape.com/article/772753-overview. Updated 6/9/2009.

Fatal Drowning Statistics

• In 2005, 3,582 fatal unintentional drownings in U.S.• 1 in 4 drownings were children < 14 years old• Drowning is the second-leading cause of

unintentional injury-related death for children ages 1 to 14 years

• Fatal drowning rate of African American children ages 5 to 14 is 3.2 times that of white children in the same age range.

• Fatal drowning rate is 2.4 times higher for American Indian and Alaskan Native children than for white children in the same age range.

Water Injuries-Fact Sheet. www .cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet Accessed 25 Sept 2009.

Location of Drowning

• Brenner et al. looked at death certificates from victims of unintentional drownings in 1995

• Infant drownings: 55% in bathtubs• Age 1-4 years, 56% in artificial pools

and 26% in other bodies of freshwater• Children 63% of drownings were in

natural bodies of freshwaterBrenner RA, Trumble AC, Smith GS, Kessler EP, Overpeck MD. Where children drown, United States, 1995. Pediatrics 2001;108(1):85 ﾐ

Features which differentiate between accidental, non-accidental, and homicidal submersion injuries to children

• Accidental submersion: – Typically a baby momentarily left alone or with a sibling in the bath– Majority of children 8-15 months of age – Child the youngest in the family – No features suggesting child abuse

• Epilepsy related: – Child with history of epilepsy– Bathing alone– A child older than 24 months

• Non-accidental submersion: – Atypical submersion description, with inconsistent details– Late referral to hospital– Associated history of child abuse– Child outside 8-24 month age span– Child left with unsuitable carer

• Homicidal drowning: – Maternal history of mental illness– Child outside the 8-24 month age range– Previous history of child abuse

Kemp, Alison et al. Accidents and child abuse in bathtub submersions. Archives of Disease in Childhood 1994; 70: 435-438.

“Hypoxic March of Drowning”A pathophysiology summary

1. Involuntary submersion– Voluntary apnea, tachycardia, hypoxia, hypercarbia

2. Involuntary inspiration– Triggered by hypercarbia and hypoxia– arterial hypoxemia, tissue hypoxia, tissue acidosis,

and tachycardia

3. Water enters lungs– Increased peripheral airway resistance, pulmonary

vessel vasoconstriction/hypertension with shunting of blood, decreased lung compliance, decreased surfactant

Pearn, John. The management of near drowning. BMJ 1995. (291) 1447-1452

“Hypoxic March of Drowning” continued

4. Decompensation-gasping with further inhalation-swallowing with emesis-loss of consciousness

5. Neuronal dysfunction-blood brain barrier breaks down

4. Cardiac dysfunction-bradycardia, arrhythmias, asystole

7. Brain Death8. Somatic Death

Diving Reflex

• Infants and young children• Sudden contact with water less than 20

degrees Celsius• Causes:

– Bradycardia– vasoconstriction of nonessential vascular beds– shunting of blood to the coronary and cerebral

circulation

– Shepard, Suzanne et al. Drowning. Emedicine.medscape.com/article/772753-overview. Updated

6/9/2009.

Dry Drowning

• 10-20% of patients experience a laryngospasm that prevents aspiration of fluid into the lungs

• Tight spasm often persists until cardiac arrest• Lungs remain dry• Large volumes of fluid ingested into stomach• Major cause for electrolyte abnormalities in

children (hyponatremia from fresh water, hypernatremia from salt water)

Wet Drowning• 1-3 mL/kg water aspirated hinders gas exchange• When fluid is in the lungs, vagus nerve stimulates

vasoconstriction pulmonary vessels and pulmonary hypertension

• Freshwater diffuses rapidly across alveolar-capillary membrane and saltwater damages the membrane

• Surfactant is denatured by freshwater and washed away by salt water

• In both salt water and freshwater aspiration, compliance is decreased

What happens in the brain during drowning?

What is cerebral perfusion pressure?

• The pressure gradient driving cerebral blood flow

• CPP = MAP- ICP

• How can one calculate cerebral blood flow (CBF)?

• CBF=CPP/CVR

• CVR=cerebral vascular resistance

Cerebral Auto-regulationSystemic hypoxia

Increase in CBF

Redistribution of cardiac output

Epinephrine released

Increase in systemic BP

Cerebral blood flow increased

If systemic BP not able to maintain CBF:

• Decreased blood (02) supply to brain

• Intracellular energy failure

• Decreased brain temperature– Release of neurotransmitters

• G-aminobutyric acid transaminase (GABA)

– Decreased cerebral 02 demand

Hypoxic-Ischemic Encephalopathy

• Initial phase– Energy failure from hypoxia/ischemia

• Reperfusion Injury– 6-24 hours later– Cerebral edema, apoptosis

Mechanism of Hypoxic-Ischemic Encephalopathy

• Excitatory amino acids, glutamate and aspartate, are released in response to hypoxia/ischemia

• Activation receptors, NMDA, AMPA, Kainate– Ion channels open– Influx of calcium into cells– Cell death

• Lipid peroxidation of cell membranes– Destruction of Na+/K+ ATPase– Cerebral edema, neuron death

• Increased rate of apoptosis– Related to influx of calcium into cell and nucleus

Complications of hypoxic-Ischemic Encephalopathy

• Autonomic instability– Hypertension– Tachycardia– Diaphoresis– Agitation– Muscle rigidity

Aspiration

• Chemical Pneumonia– pH less than 2.5– Volume greater than 0.3mL/Kg – Inflammatory reaction by cytokines

• TNF-alpha, IL-8

• Bacterial Pneumonia– Anaerobic organisms

Other organ involvement

• Occur 24-72 hours after initial insult• Heart: decreased contractility, dilation,

tricuspid regurgitation, “tako-tsubo stress induced cardiomyopathy

• Renal: acute tubular necrosis, oliguria, anuria• Hepatic: increased LFT’s, hypoalbuminemia,

coagulopathy, hyperbilirubinemia• Rhabdomyolysis

Management: CPR• Bystander resuscitation necessary• 30% pediatric cardiac arrest patients receive

bystander CPR• PUSH HARD, PUSH FAST• Minimize interruptions• Some bystander CPR, better than none• Heimlich maneuver contraindicated because it can

cause emesis, aspiration• Rescue breaths at rates > 20 breaths/min

contraindicated because venous return can be obstructed

Arrival to the hospital• General Assessment:

• Appearance• Work of Breathing• Circulation

• Primary Assessment:• Airway• Breathing• Circulation• Disability• Exposure

Pediatric Advanced Life Support Provider Manual

Management• ET intubation:

– Cannot maintain PaO2 > 80 mm Hg on 100% O2 by face mask

– Inability to protect airway or handle secretions– Respiratory failure - PaCO2 >45 mm Hg– Worsening ABG results

• Peep:– shifts interstitial pulmonary water into the capillaries– increases lung volume by preventing of alveolar collapse– provides better alveolar ventilation and decreases

capillary blood flow

Management• ECMO

– If despite intubation, cannot oxygenate

• Broncoscopy– Removal of vomit, debris in lungs

• Albuterol– For bronchospasm

• Aspiration Pneumonia– Clindamycin for bacterial pneumonia is drug of choice

• Manage electrolyte abnormalities– hypoglycemia

Management of Hypothermia

• Two types:– 1. Rapid immersion in cold water, rapid onset of

hypothermia, core temperature < 86 degrees F• Neuroprotective, preferential shunting of blood to heart,

brain

– 2. Gradual onset of hypothermia

• Rapidly re-warm patients with gradual onset of hypothermia– patients at risk for ventricular fibrillation and

neuronal injury

Management

• Do not stop resuscitation of a patient until their core temperature is at least 30 degrees Celsius!

Prognosis

• Related to duration of submersion– Time greater than 25 min, prognosis is poor

• Indicators of poor outcome:– Fixed, dilated pupils– Low GCS– coma

• Survivors of resuscitation have good neurological outcomes if they show purposeful movement within 24 hours

Prevention• Designate a responsible adult to supervise water

related activities– Adults should not be doing other tasks at the same

time as supervision, no alcohol while supervising

• Swim with a buddy• No alcohol before, during swimming• Learn to swim

– AAP does not recommend swimming lessons as a primary prevention method for children under 4 years old

• Learn CPR

Water Injuries-Fact Sheet. www .cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet Accessed 25 Sept 2009

Prevention

• Fence swimming pools on 4 sides, at least 4 feet tall

• Do not use air or foam filled water toys in place of life-jackets

References:

Brenner RA, Trumble AC, Smith GS, Kessler EP, Overpeck MD. Where children drown, United States, 1995. Pediatrics 2001;108(1):85 ﾐ

Kemp, Alison et al. Accidents and child abuse in bathtub submersions. Archives of Disease in Childhood 1994; 70: 435-438.

Meyer, Robin et al. Childhood Drowning. 2006. Peds In Rev 27: 163-166

Pearn, John. The management of near drowning. BMJ 1995. (291) 1447-1452

Pediatric Advanced Life Support Provider Manual

Shepard, Suzanne et al. Drowning. Emedicine.medscape.com/article/772753-overview Updated 15 Jun 2009

Water Injuries-Fact Sheet. www .cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet Accessed 25 Sept 2009

Zanelli, Santina. Hypoxic-Ischemic Encephalopathy. emedicine.medscape.com/article/973501-overview. Updated 15 Dec 2008