Fellows conference Fellows conference

July 19, 2007July 19, 2007

Pediatric Near Pediatric Near DrowningDrowning

Question 1Question 1

• True or False?True or False?– Near drowning is the accounts for the highest Near drowning is the accounts for the highest

unintentional death in children?unintentional death in children?

Question 2Question 2

• Aspiration of ____ cc/kg is required before Aspiration of ____ cc/kg is required before altered blood volumealtered blood volume

• Aspiration of ____ cc/kg is required before Aspiration of ____ cc/kg is required before electrolyte abnormalitieselectrolyte abnormalities

• Most near drowning victims aspirate ____ Most near drowning victims aspirate ____ cc/kgcc/kg

Question 3Question 3

• True or false?True or false?– Increased intracranial hypertension is the Increased intracranial hypertension is the

most significant contribution to CNS injury in most significant contribution to CNS injury in the first 24 hours?the first 24 hours?

Question 4Question 4

• Children with seizure disorders are more Children with seizure disorders are more likely to drown where?likely to drown where?

Question 5Question 5

• True or false ?True or false ?– If there is a family history of near drowning If there is a family history of near drowning

one can do genetic testing which may further one can do genetic testing which may further identify family members at risk?identify family members at risk?

– There is a clinical test which may also be There is a clinical test which may also be helpful?helpful?

Near DrowningNear Drowning• ObjectivesObjectives

– Define near drowningDefine near drowning– DiscussDiscuss

• incidenceincidence

•epidemiologyepidemiology

•causescauses

– Review prognostic indicatorsReview prognostic indicators– Discuss therapeutic interventionsDiscuss therapeutic interventions– Discuss opportunities that impact Discuss opportunities that impact

outcomeoutcome

Near DrowningNear DrowningDefinitionsDefinitions

•Drowning: Drowning: To die within 24 hours To die within 24 hours of a submersion incident of a submersion incident

•Near Drowning: Near Drowning: To survive at least To survive at least 24 hours after a 24 hours after a submersion submersion incident incident (submersion)(submersion)

Near DrowningNear DrowningIncidenceIncidence

•140,000 annual submersion deaths worldwide 140,000 annual submersion deaths worldwide

•6-8,000 deaths in USA6-8,000 deaths in USA

•> 7000 additional pts. require medical > 7000 additional pts. require medical attentionattention

• incidence: holidays, warm weatherincidence: holidays, warm weather

•Leading cause of injury in toddlersLeading cause of injury in toddlers

•3rd3rd leading cause of all death < 15 yr. leading cause of all death < 15 yr.

•2nd2nd leading cause of all accidental deaths leading cause of all accidental deaths

Near Drowning Near Drowning

•““Tragically 90% of all fatal Tragically 90% of all fatal submersion incidents occur submersion incidents occur within ten yards of safety.”within ten yards of safety.”

Robinson, Ped Emer Care; 1987Robinson, Ped Emer Care; 1987

Relative Contribution of Various Relative Contribution of Various Submersion Media to Drowning AccidentsSubmersion Media to Drowning Accidents

Salt Water 1 - 2%

Fresh Water swimming pools: public swimming pools: private lakes, rivers, streams, storm drains bathtubs buckets of water fish tanks or pools toilets washing machines

50% 3% 20% 15% 4% 4% 1% 1%

98%

Near DrowningNear DrowningGroups at RiskGroups at Risk• Toddlers (40% of deaths < 5 y.o.)Toddlers (40% of deaths < 5 y.o.)• School age boysSchool age boys• TeenagersTeenagers• Males > females (5:1)Males > females (5:1)• African-American childrenAfrican-American children• Children with:Children with:

– seizuresseizures– cardiac dysrhythmiascardiac dysrhythmias

Near DrowningNear DrowningRisk Factors: AgeRisk Factors: Age

0

100

200

300

400

500

600

0-4 yr 5-9 yr 10-14 yr 15-19

Male

Female

Toddler DrowningsToddler Drownings

• Tend to occur because of lapse in Tend to occur because of lapse in supervisionsupervision

• Majority in afternoon/early evening-meal Majority in afternoon/early evening-meal timetime

• Responsible supervising adult in 84% of Responsible supervising adult in 84% of casescases

• Only 18% of cases actually witnessedOnly 18% of cases actually witnessed

Causes of Near DrowningCauses of Near DrowningRecreational BoatingRecreational Boating

•90% of deaths due to drowning90% of deaths due to drowning

•1,200/year1,200/year

•Small, open boatsSmall, open boats

•20% of deaths20% of deaths– too few or no floatation devices !too few or no floatation devices !

Other CausesOther CausesDiving InjuriesDiving Injuries

•700-800 per year700-800 per year

•Peak incidence 18-31 Peak incidence 18-31 yearsyears– No formal trainingNo formal training– 1st dive in unfamiliar 1st dive in unfamiliar

waterwater– 40-50% alcohol related40-50% alcohol related

Other CausesOther CausesSpas, Hot TubsSpas, Hot Tubs

•EntrapmentEntrapment– drainsdrains

•hair, body parts, clothinghair, body parts, clothing

– winter pool/spa coverswinter pool/spa covers

Bucket Drowning 1984-Bucket Drowning 1984-19891989RisksRisks

•Males > femalesMales > females

•African-Americans > CaucasiansAfrican-Americans > Caucasians

•Warm months > coldWarm months > cold– Peak = OctoberPeak = October

Near-Drowning Near-Drowning EpilepsyEpilepsy

• 2.5-4.6% of drowning victims had pre-existing 2.5-4.6% of drowning victims had pre-existing seizure disorderseizure disorder

• Drowned children with epilepsy more likely to: Drowned children with epilepsy more likely to: be older than 5, drown in bathtub, not be be older than 5, drown in bathtub, not be supervisedsupervised

• Relative risk of drowning for children with Relative risk of drowning for children with epilepsy:epilepsy:– 96 in bathtub (95% CI 33-275)96 in bathtub (95% CI 33-275)– 23 in pool (95% CI 7.1-77.1) 23 in pool (95% CI 7.1-77.1)

-Diekema et al., Pediatrics 1993

Near-Drowning Near-Drowning Long QT Syndrome (LQTS)Long QT Syndrome (LQTS)

• Swimming may be a trigger for LQTS eventSwimming may be a trigger for LQTS event

• Near-drowning event may be first presentation Near-drowning event may be first presentation of LQTS (15% of 1st LQTS syncopal events)of LQTS (15% of 1st LQTS syncopal events)

• Gene-specific KVLQT1 mutation associated with Gene-specific KVLQT1 mutation associated with swimming trigger and submersion eventswimming trigger and submersion event

• Can test with cold water face immersion Can test with cold water face immersion

• Importance: early diagnosis of survivor, or of Importance: early diagnosis of survivor, or of family members; consider with unexplained family members; consider with unexplained submersionsubmersion

-Ackerman et al., NEJM 1999

laryngospasmlaryngospasmrecursrecurs

Unexpected Unexpected SubmersionSubmersion

aspirationaspirationandand

laryngospasmlaryngospasm

anoxia, seizuresanoxia, seizuresand deathand death withoutwithout

aspiration (10%)aspiration (10%)

laryngospasmlaryngospasmabortedaborted

aspirationaspirationofof

water (90%)water (90%)

Stage IStage I(0-2 minutes)(0-2 minutes)

Stage IIStage II(1-2 minutes)(1-2 minutes)

swallows swallows waterwater

Stage IIIStage III

Pathophysiology of AnoxiaPathophysiology of AnoxiaPulmonaryPulmonary HemeHeme CNS CNSHypercapneaHypercapnea DICDIC Anoxic damageAnoxic damage

Cerebral edemaCerebral edema

Defective Defective

autoregulationautoregulation

Increased ICPIncreased ICP

GIGI

Hypercapnea Hypercapnea Mucosal sloughingMucosal sloughing

CardiacCardiacMyocardial ischemiaMyocardial ischemia

FibrillationFibrillation

RenalRenalATNATN

AsphyxiaAsphyxia

Near DrowningNear DrowningMulti-Organ EffectsMulti-Organ Effects

•Hypoxic/ischemic cerebral injuryHypoxic/ischemic cerebral injury

•Fluid overloadFluid overload

•Pulmonary injuryPulmonary injury

•HypothermiaHypothermia

Near DrowningNear Drowning Multi-Organ EffectsMulti-Organ Effects

•Cerebral hypoxia is Cerebral hypoxia is the final common the final common pathway in all pathway in all drowning victimsdrowning victims

Near DrowningNear DrowningCNS InjuryCNS Injury

• Initial HypoxiaInitial Hypoxia

• Post resuscitation cerebral hypoperfusionPost resuscitation cerebral hypoperfusion– Increased ICP (doubtful)Increased ICP (doubtful)– Cytotoxic cerebral edemaCytotoxic cerebral edema– Excessive accumulation of cytosolic calcium Excessive accumulation of cytosolic calcium

causing cerebral arteriolar spasmcausing cerebral arteriolar spasm– Increased free radicalsIncreased free radicals

Near DrowningNear DrowningCNS InjuryCNS Injury

• With significant hypoxia can have Lance-With significant hypoxia can have Lance-Adams syndrome Adams syndrome – Post hypoxic (action) myoclonusPost hypoxic (action) myoclonus– Often mistaken for seizuresOften mistaken for seizures– Happens more often when coming out of Happens more often when coming out of

sedationsedation– Must be differentiated from myoclonic status Must be differentiated from myoclonic status

which has poor prognosis which has poor prognosis

Near DrowningNear DrowningPulmonary InjuryPulmonary Injury

• Aspiration as little as 1-3 cc/kg can cause Aspiration as little as 1-3 cc/kg can cause significant effect on gas exchangesignificant effect on gas exchange– Increased permeabilityIncreased permeability– Exudation of proteinaceous material in alveoliExudation of proteinaceous material in alveoli– Pulmonary edemaPulmonary edema– decreased compliancedecreased compliance

Near DrowningNear DrowningPulmonary Injury:Pulmonary Injury:Fresh Water vs. Salt WaterFresh Water vs. Salt Water

• Theoretical changes not supported clinicallyTheoretical changes not supported clinically– Salt water: hypertonic pulmonary edemaSalt water: hypertonic pulmonary edema– Fresh water: plasma hypervolemia, hyponatremiaFresh water: plasma hypervolemia, hyponatremia– Unless in Dead SeaUnless in Dead Sea

• Humans (most aspirate 3-4cc/kg) Humans (most aspirate 3-4cc/kg) – Aspirate > 20cc/ kg before significant electrolyte Aspirate > 20cc/ kg before significant electrolyte

changeschanges– Aspirate > 11cc/kg before fluid changesAspirate > 11cc/kg before fluid changes

The Bottom LineThe Bottom LineFresh Water and Salt WaterFresh Water and Salt Water

•Both forms wash out surfactantBoth forms wash out surfactant

•Damaged alveolar basement Damaged alveolar basement membranemembrane– Pulmonary edemaPulmonary edema– ARDSARDS

Effect of Immediate Effect of Immediate Resuscitation on OutcomeResuscitation on Outcome

• Review of 166 near-drowning children in Review of 166 near-drowning children in CaliforniaCalifornia

• Children with good outcome 4.75 times Children with good outcome 4.75 times more likely to have had immediate more likely to have had immediate bystander CPR than poor outcome bystander CPR than poor outcome patientspatients

-Kyriacou et al., Pediatrics, 1994

TreatmentTreatmentPre-HospitalPre-Hospital

• Immediate, effective CPRImmediate, effective CPR– Oxygenation, ventilation ASAPOxygenation, ventilation ASAP– Chest compressionsChest compressions– C-spine stabilizationC-spine stabilization

•Avoid drainage proceduresAvoid drainage procedures

C-Spine Injuries Among C-Spine Injuries Among Submersion VictimsSubmersion Victims• ““Immobilize all near-drowning patients”Immobilize all near-drowning patients”

• 2244 submersion victims - Washington2244 submersion victims - Washington

• 11 C-spine injuries (0.5%)11 C-spine injuries (0.5%)

• All 11 in open bodies of water; all had history All 11 in open bodies of water; all had history of diving (RR 229), MVC, fall; witnessed, of diving (RR 229), MVC, fall; witnessed, >> 15 15

• No C-spine injury in 880 low-impact eventsNo C-spine injury in 880 low-impact events

• ““Routine immobilization does not appear to Routine immobilization does not appear to be warranted”be warranted”

-Watson et al., J Trauma 2001

TreatmentTreatmentTransportTransport

•Continue CPRContinue CPR

•Establish airwayEstablish airway

•Remove wet clothesRemove wet clothes

•Hospital evaluationHospital evaluation

TreatmentTreatmentEmergency DepartmentEmergency Department

• Continue established therapiesContinue established therapies

• History, physical, labsHistory, physical, labs

• Admit if: CNS or respiratory symptomsAdmit if: CNS or respiratory symptoms

• Observe in ED for minimum 4-6 hours if:Observe in ED for minimum 4-6 hours if:– Submersion > 1 min.Submersion > 1 min.– Cyanosis on extractionCyanosis on extraction– CPR requiredCPR required

Predicting Ability for ED Predicting Ability for ED DischargeDischarge

• Several studies support selected ED Several studies support selected ED dischargedischarge

• Child can safely be discharged home if at Child can safely be discharged home if at 6 hours after ED presentation:6 hours after ED presentation:– GCS GCS >> 13 13– Normal physical exam/respiratory effortNormal physical exam/respiratory effort– Room air pulse oximetry oxygen saturation > Room air pulse oximetry oxygen saturation >

95%95%

-Causey et al., Am J Emerg Med, 2000

ICU Management ICU Management StrategiesStrategiesNon-invasive VentilationNon-invasive Ventilation

•Nasal /face maskNasal /face mask

• Increase in small increments to Increase in small increments to maintain:maintain:– FIOFIO22 < 0.40 < 0.40

– QQSS/Q/QTT < 20% < 20%

– PaOPaO22/FIO/FIO22 > 300 > 300

•Wean slowlyWean slowly

ICU Management ICU Management StrategiesStrategiesIntubation/VentilationIntubation/VentilationIndicationsIndications

•SpOSpO22 < 90% on FIO < 90% on FIO22 > 0.6 > 0.6

•PaCOPaCO2 2 > 50 with pH < 7.3> 50 with pH < 7.3

• Increased work of breathingIncreased work of breathing

•Abnormal CNS examAbnormal CNS exam

ICU Management ICU Management StrategiesStrategiesRespiratoryRespiratory

•Oxygenate - avoid hypoxemiaOxygenate - avoid hypoxemia

•Ventilate - avoid significant Ventilate - avoid significant hyperventilationhyperventilation

•PEEP may be beneficial but is not PEEP may be beneficial but is not prophylacticprophylactic

•Exogenous surfactantExogenous surfactant

Management Management StrategiesStrategiesCardiovascularCardiovascular•Re-warming ( to a degree ? benefit Re-warming ( to a degree ? benefit

hypothermia)hypothermia)– LOC 34 CLOC 34 C– Pupils dialate 30 CPupils dialate 30 C– V Fib 28 CV Fib 28 C– EEG iso-electric 20CEEG iso-electric 20C

•CBF decrease 6-7% per degree C dropCBF decrease 6-7% per degree C drop

Management Management StrategiesStrategiesCentral Nervous SystemCentral Nervous System•Protect against 2Protect against 20 0 injuryinjury

– Perfuse it or lose it !!Perfuse it or lose it !!

• ICP monitoring not beneficial or ICP monitoring not beneficial or recommendedrecommended

•Some still monitor if:Some still monitor if:– Successful CPR followed by comaSuccessful CPR followed by coma– Sudden, unexplained deteriorationSudden, unexplained deterioration

Management Management Strategies Strategies Problem:Problem:

““Studies evaluating results of cerebral Studies evaluating results of cerebral resuscitation measures have resuscitation measures have failedfailed to to demonstrate that treatment directed at demonstrate that treatment directed at controlling increased intracranial pressure controlling increased intracranial pressure and maintaining normal cerebral perfusion and maintaining normal cerebral perfusion pressure pressure improves outcomeimproves outcome””

Orlowski, Orlowski, PCNAPCNA 34:85, 1987 34:85, 1987

Historical Therapy: Historical Therapy: HYPER-Directed TherapyHYPER-Directed Therapy

• Hyper-hydration: diureticsHyper-hydration: diuretics

• Hyperventilation: hypocarbia via Hyperventilation: hypocarbia via controlled ventilationcontrolled ventilation

• Hyperpyrexia: aggressive hypothermia to Hyperpyrexia: aggressive hypothermia to 30 degrees C30 degrees C

• Hyperexcitability: pentobarbital comaHyperexcitability: pentobarbital coma

• Hyperrigidity: neuromuscular blockade Hyperrigidity: neuromuscular blockade

-Conn et al., Can J Anesth 1979

CONN (Toronto) - HYPER TherapyCONN (Toronto) - HYPER Therapy Normal Severe CNS

Deficit Death

Awake upon ER arrival

n = 34

100%

-

-

Blunted n = 12

100% - -

Comatose n = 18

44% 24% 32%

-Conn et al., Can J Anesth 1979

MODELL (FL) - NO HYPER TherapyMODELL (FL) - NO HYPER Therapy Normal Severe CNS

Deficit Death

Awake upon ER arrival

n = 34

100%

-

-

Blunted n = 12

92% - 8%

Comatose n = 18

44% 17% 39%

-Modell et al, Crit Care Med, 1984

Management Management StrategiesStrategiesCentral Nervous SystemCentral Nervous System• ICP monitoring may not change ICP monitoring may not change

outcome, just predict itoutcome, just predict it

•Low ICP Better outcomeLow ICP Better outcome

•High ICP Poor outcomeHigh ICP Poor outcome

-Sarnaik et al., Crit Care Med, 1985

ICU Management ICU Management StrategiesStrategiesOther IssuesOther Issues

•Antibiotics - no benefit of prophylaxis, Antibiotics - no benefit of prophylaxis, may increase super-infectionmay increase super-infection

•Fulminant Strep pneumoniae sepsis Fulminant Strep pneumoniae sepsis has been described after severe has been described after severe submersionsubmersion

•Steroids - no demonstrated benefitSteroids - no demonstrated benefit

Factors Considered Predictive Factors Considered Predictive of Poor Submersion Outcomeof Poor Submersion Outcome

•Submersion timeSubmersion time

•Serum pHSerum pH

•Need for CPR in the E.D.Need for CPR in the E.D.

•Time to first gaspTime to first gasp

•Neuro evaluationNeuro evaluation

Survive Survive or not?or not?

Near DrowningNear DrowningPrognostic IndicatorsPrognostic Indicators

Peterson 1977Peterson 1977 Anoxic encephalopathy if: Anoxic encephalopathy if:

CPR in ERCPR in ER Submersion > 5 minutesSubmersion > 5 minutes

Seizures, flaccidity, Seizures, flaccidity, fixed/dilated pupils, coma fixed/dilated pupils, coma in E.D.in E.D.

Near DrowningNear DrowningPrognostic IndicatorsPrognostic Indicators

Pearn 1979Pearn 1979 Time to first spontaneous gasp:Time to first spontaneous gasp: < 5 minutes - most survive< 5 minutes - most survive > 60 minutes -CNS injury > 60 minutes -CNS injury inevitableinevitable

Allman 1986Allman 1986 GCS = 3 in ICU: GCS = 3 in ICU: Death or vegetative stateDeath or vegetative state

Near DrowningNear DrowningOrlowski Prognostic Orlowski Prognostic CriteriaCriteria

•Age < 3 yearsAge < 3 years

•Estimated submersion > 5 min.Estimated submersion > 5 min.

•No CPR > 10 min.No CPR > 10 min.

•Coma in EDComa in ED

•pH < 7.10pH < 7.10

Outcome and Predictors of Outcome and Predictors of Outcome in Pediatric Outcome in Pediatric Submersion VictimsSubmersion Victims

•Two pre-hospital risk factorsTwo pre-hospital risk factors– length of submersionlength of submersion– length of CPRlength of CPR

Quan et al, Quan et al, PediatricsPediatrics, , Oct 1990Oct 1990

Outcome and Predictors of Outcome and Predictors of Outcome in Pediatric Outcome in Pediatric Submersion VictimsSubmersion Victims•SURVIVAL:SURVIVAL:

– 0/20 with CPR > 25 minutes0/20 with CPR > 25 minutes

Quan et al, Quan et al, PediatricsPediatrics, Oct 1990, Oct 1990

Outcome and Predictors of Outcome and Predictors of Outcome in Pediatric Outcome in Pediatric Submersion VictimsSubmersion VictimsSubmersion

0 - 5 minutes 6 - 9 minutes 10 - 25 minutes > 25 minutes

7/67 5/9

21/25 4/4

10% 56% 88%

100%

Near Drowning Near Drowning ConcernConcern

•Prolonged resuscitation in the Prolonged resuscitation in the Emergency Department may increase Emergency Department may increase the proportion of “successful” the proportion of “successful” resuscitations resuscitations withoutwithout normal normal neurologic recovery!!neurologic recovery!!

Near DrowningNear DrowningTherefore:Therefore:

• Initiate full, immediate resuscitationInitiate full, immediate resuscitation

•Elicit circumstances of eventElicit circumstances of event

•After 25 min... of full but unsuccessful After 25 min... of full but unsuccessful resuscitation think resuscitation think ““PROGNOSISPROGNOSIS” ” before continuing to resuscitatebefore continuing to resuscitate

Near DrowningNear DrowningSocial and Economic Social and Economic EffectsEffects

• DivorceDivorce

• Sibling psychosocial maladjustmentSibling psychosocial maladjustment

• 100,000 years of productive life lost100,000 years of productive life lost

• $4.4 million/year in direct health care $4.4 million/year in direct health care costscosts

• $350-450 million/year in indirect costs$350-450 million/year in indirect costs– $100,000/year to care for the neurologically $100,000/year to care for the neurologically

impaired survivor of a near drowningimpaired survivor of a near drowning

Near Drowning: Near Drowning: Pediatrician Anticipatory Pediatrician Anticipatory GuidanceGuidance• Survey to 800 pediatriciansSurvey to 800 pediatricians

• 85% believe community involvement in 85% believe community involvement in legislation importantlegislation important

• 4% actually involved4% actually involved

• 40% gave written water safety materials40% gave written water safety materials

• 50% gave anticipatory guidance50% gave anticipatory guidance

-O’Flaherty et al., Pediatrics, 1997

Near Drowning Near Drowning Keeping Your Child SafeKeeping Your Child Safe

•Never leave a child alone Never leave a child alone in or near water, even for in or near water, even for a minutea minute

•Limit pool access.Limit pool access.

•Remove potential hazardsRemove potential hazards

Children with Epilepsy: Children with Epilepsy: Safety RecommendationsSafety Recommendations

• Child can swim in lifeguard-supervised Child can swim in lifeguard-supervised swimming pool - no open waterswimming pool - no open water

• Older child should shower in a non-glass Older child should shower in a non-glass cubicle - no bathcubicle - no bath

• Leave bathroom unlockedLeave bathroom unlocked

• Supervision!Supervision!

Near DrowningNear DrowningSwimming Pool LoreSwimming Pool Lore

•My Child is My Child is “Water “Water Safe” Safe” because he/she because he/she has taken swimming has taken swimming lessonslessons..

Near DrowningNear DrowningKeeping Your Child SafeKeeping Your Child Safe

•Learn CPRLearn CPR

•Use approved personal Use approved personal flotation devicesflotation devices

•Teach safe water behaviorTeach safe water behavior

Near DrowningNear DrowningSummarySummary

•Frequently preventableFrequently preventable

•Mortality & morbidity 2Mortality & morbidity 20 0 to:to:– Hypoxic ischemic injuryHypoxic ischemic injury– Multisystem organ dysfunctionMultisystem organ dysfunction

•CPR is most important therapyCPR is most important therapy– Prolonged Poor prognosisProlonged Poor prognosis

Near DrowningNear DrowningSummarySummary

•Submersion timeSubmersion time– Prolonged Poor prognosisProlonged Poor prognosis

•Prevention through:Prevention through:– Education Education – SupervisionSupervision– BarriersBarriers

Near Drowning Near Drowning The Best Approach The Best Approach Therefore:Therefore:

•P P revention ! revention !

•P P revention !revention !

•P P revention !revention !

Near Drowning Near Drowning What can you do?What can you do?

•P P revention ! revention ! – Get parents involved in support groupsGet parents involved in support groups

•P P revention !revention !– Support legislative actions that require fencing Support legislative actions that require fencing

etc.etc.

•P P revention !revention !– Promote SAFEKIDS and other safety movementsPromote SAFEKIDS and other safety movements

Questions????Questions????

Pulmonary SystemPulmonary System 1. secondary apnea,1. secondary apnea, aspirationaspiration 2. hypercapnea2. hypercapnea

RenalRenal1. acute tubular necrosis1. acute tubular necrosis2. acute cortical necrosis2. acute cortical necrosis

CardiacCardiac1. myocardial ischemia1. myocardial ischemia2. fibrillation2. fibrillation

Central Nervous SystemCentral Nervous System1. anoxic damage1. anoxic damage2. defective autoregulation2. defective autoregulation3. cerebral edema 3. cerebral edema 4. increased ICP4. increased ICP

AsphyxiaAsphyxia

low low BPBP

Pulmonary SystemPulmonary System1. alveolar fluid1. alveolar fluid2. “ARDS”2. “ARDS”3. hypoventilation3. hypoventilation

Dilution EffectsDilution Effects1. hypokalemia1. hypokalemia2. hemodilution2. hemodilution3. hemolysis3. hemolysis

GastrointestinalGastrointestinal1. gastric distension1. gastric distension2. vomiting, aspiration2. vomiting, aspiration3. ileus3. ileus

Central Nervous SystemCentral Nervous System1. cerebral edema1. cerebral edema2. intracranial hypertension2. intracranial hypertension

Water OverloadWater Overload

HypothermiaHypothermia

CARDIACCARDIACdysrhythmiadysrhythmia

VASODILATIONVASODILATIONdecreased ICPdecreased ICPdecreased BPdecreased BP

CENTRALCENTRALNERVOUSNERVOUS1. reduced metabolism1. reduced metabolism2. reduced ICP2. reduced ICP3. ?protection?3. ?protection?4. may produce picture4. may produce picture of clinical death of clinical death

RENAL RENAL FAILUREFAILURE

DEATHDEATH

--- Rogers, Pediatric Critical Care--- Rogers, Pediatric Critical Care