Pediatric DrowningCarlo Reyes, MD, JD, FACEP, FAAP

ZUMA BEACHOCTOBER 25, 2012

ObjectivesTerminologyEpidemiologyPediatric

Characteristics:◦Mechanisms of injury ◦Physiology◦Social and family issues

Treatment ParadigmPrevention

Terminology

Terminology – Old Classifications

Drowning vs. Near drowningCold water (<20°C) vs. Warm water

(>20°C) vs. “Very-cold-water” (<5°C)Freshwater vs. salt-water

Terminology–WHO 2002

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.

Epidemiology

Epidemiology: Pediatric Drowning

500,000 deaths each year worldwideLeading cause of death worldwide in boys

5-142nd 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: QUIZ

1. What is the leading cause of accidental death in the U.S. today?

a) Heart attackb) Diabetesc) Drowningd) Car accidente) Prescription pain medications

Epidemiology: QUIZ

1. What is the leading cause of accidental death in the U.S. today?

a) Heart attackb) Diabetesc) Drowningd) Car accidente) Prescription pain medications

Epidemiology: Gender

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: Cultural

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 Quiz

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: Deaths per 100,000 Population

1970: 3.871980: 2.671990: 1.602000: 1.242010: (projected) 1.19

Epidemiology - Cost

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.

Mechanisms of Injury by Age

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

Bathtub and shower injuries (Mao, 2009)

Bathtubs: location of non-pool drowningOther injuries:

◦Slip and fall: Lacerations (most common)◦Burns (scald)◦Head and facial injuries most common < 4 yrs

Diving injuries (Day, 2006)

Aged 10-14 most common to have injuryHead, 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)

Toddler Typical Patient Scenario

Contributing factors: Unattended; no fence

Location: Pool (bathtub in <1 year)Unique characteristics: Silent drowningInjuries: cardiopulmonary arrestCo-morbidities: seizure (post-ictal state)Unique characteristics:

◦Child abuse/neglect◦Silent drowning

Adolescent Typical Patient Scenario

Contributing factors: Male, alcohol, drugs Location: Pool, ocean, or lake

Scenario: Diving, or boating accidentInjuries: HEENT injuries, overdose.Co-morbidities: seizure (post-ictal),

arrhythmia, hypoglycemia/diabetes, Unique characteristics:◦Suicidality

Presentation Types (Shepherd, 2009)

AsymptomaticSymptomatic:

◦Abnormal vitals◦Respiratory distress or hypoxia◦Alert or altered; Neurologic deficit

Cardiopulmonary arrest:◦Apnea◦Asystole, Vtach/Vfib, Bradycardia

Obviously dead: asystole, rigor mortis

Pathophysiology: Wet vs Dry Drowning

“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: Effects of Drowning

Hypoxemia shunts off pulmonary circ.Hypercarbia acidosisPulmonary hypertension ARDS Electrolyte Disturbances – usually from

ingestion of large amounts of fluid, minor effect from aspiration of fluid

Pathophysiology – CNS Injury

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

Role of CT in Drownings

Rule out accidental and non-accidental trauma◦Intracranial hemorrhage◦Maxillofacial injuries ◦Cervical injuries

Identify signs of anoxic brain injuryIf CT show signs of anoxic injury bad

prognosis

CT findings (Rafaat et al., 2008)Early:

◦cerebral edema; loss of grey-white matter diff.

Later: ◦Injury to hippocampi, thalami, basal ganglia

Pathophysiology- Brain injury (Hutchison, 2008)

Hypoxic injury: Autonomic Dysfunciton

Myocardial ischemia◦Arrhythmia◦Cardiac arrest

“Diencephalic –hypothalamaic storm”◦Late effect due to severe CNS hypoxic injury◦Hypertension, tachycardia diaphoresis,

agitation

Shallow Water Blackout

Shallow Water BlackoutWhat is it?

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

Youtube- Deep Water Blackout

http://www.youtube.com/watch?feature=player_detailpage&v=qLe81lUbPNg

Pre-Hospital Care

Pre-Hospital Care- QUIZ

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

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 CareRemove from waterMaintain airway and C

spine precautions100% FIO2 by mask BVM; don’t delay CPR with

intubationUse traditional ABC

sequence (not CAB)

Pre-Hospital Care- Poor Prognostic Factors

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.

The Trauma Evaluation

The Trauma Evaluation

Airway – Maintain C spineBreathingCirculationIV-O2-MonitorDisability – GCS, AVPUExposure – Remove clothes, secondary

survey

Initial Interventions- Airway

100% FIO2 by facemask if hypoxicBIPAP if awake and facemask not effectiveIntubation/RSI and immobilize neckBronchoscopy- consider if hypoxic despite

mechanical ventilation.ECMO – tertiary care center PICUs may

consider.

Initial Trauma Interventions

Fluid resuscitation with NS PRNAccucheck, Istats, trauma labsEKG and telemetryRewarming if hypothermic.

If Vfib- single defibrillation, then resume CPR and rewarmTrauma films: CXR +/- 3 v CspineEvacuate gastric contents Consider Utox, BALCT brain, C spine if altered or comatoseConsults: Trauma, Critical Care, Neurology,

Suicidality?

Appropriate Disposition

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

Therapeutic Hypothermia

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

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 itTarget: 32°CInitiation: within 6 hoursDuration: 24 hours

Prevention

CDC: Preventative Measures

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.

AAP Preventative Measures

Children: Constant supervision of all childrenInfants 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

Lifeguard v. Bystander Study

Lifeguards present: ◦6% of all rescued persons needed medical

attention◦0.5% needed CPR

Bystanders present:◦30% required CPR

Summary

Terminology and DefinitionsEpidemiologyUnique characteristics of the pediatric

drowning patient, including:◦Mechanisms of injury. ◦Physiology and response to injury.◦Social and family issues in pediatric trauma.

The Treatment ParadigmModes of Prevention

References

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).