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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).