NEAR DROWNING

Pediatric Critical Care Medicine

Emory University
Childrens Healthcare of Atlanta

Objectives

Definition
Incidence, epidemiology, causes
Prognosis
Interventions/managements
Opportunities that impact outcome

Definition
Drowning: die within 24 hours of a submersion incident
Near Drowning: survive at least 24 hrsafter a submersion
incident

2002 World Congress: all victims to be labeled as drowning

Incidence/Epidemiology
CDC 2012 for 2005-2009 for US

~3,880 fatal drowning, 2X treated in ER for non-fatal drowning

Leading cause of injury death among children 1-4 yrs, highest rate
2nd leading cause of all accidental deaths <14 yr (MVC 1st)
Fatality: male>female (42.07:0.54/100,000
African-American
1.3X higher than Caucasian
3.4X higher in 5-14 yo age group

Incidence
For every 1 death
4 others hospitalized a
14 seen in the ER

incidence: holidays, weekends and warm weather

Children <5 pools; older kids and adults in open water
Fatality: 35%; 33% with neurological impairment; 11% severe
neurologic sequelae

Causes
Salt Water

1-2%

Fresh water

98%

swimming pools: public

50%

swimming pools: private

3%

lakes, rivers, streams, storm drains

20%

bathtubs

15%

buckets of water

4%

fish tanks or pools

4%

toilets

1%

washing machines

1%

Causes
Toddlers:

Lapse of supervision
Afternoon/early evening-meal time
84% with responsible supervising adults
Only 18% of cases actually witnessed

Causes
Recreational boating
90% of deaths due to drowning
Vast majority are not wearing life jackets

1,200/yr
Small, open boats
20% of deaths
Too few or no floatation devices!

Diving
700-800/yr
1st drive in unfamiliar water
40-50% alcohol related
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Causes
Spas, hot tubs
Entrapment in drains, covers

Buckets drowning
males/>females
African-Americans>caucasians
Warm months>cold

Causes
Epilepsy:
1.5-4.6 % had pre-existing seizure disorder
>5 yr, drown in bathtub, not be supervised

Long QT syndrome:
Swimming may be a trigger for LQTS
Near drowning may be first presentation
Specific gene KVLQT1 mutation associated w/swimming trigger &
submersion

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Laryngospasm
aborted
Unexpected
Submersion

Aspiration &
Laryngospasm

Swallows
water
Laryngospasm
recurs

Stage I
(0-2 minutes)

aspiration
of
water (90%)

Stage II
(1-2 minutes)

anoxia, seizures
and death
without
aspiration (10%)

Stage III

Pathophysiology
Part I

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Voluntary breath-holding
Aspiration of small amounts into larynx
Involuntary laryngospasm
Swallow large amounts
Laryngospasm abates (due to hypoxia)
Aspiration into lungs

Pathophysiology
Part II

13

Decrease in sats
Decrease in cardiac output
Intense peripheral vasoconstriction
Hypothermia
Bradycardia
Circulatory arrest, while VF rare
Extravascular fluid shifts, diuresis

Pathophysiology
Diving reflex
Bradycardia, apnea, vasoconstriction
Relatively quite weak in humans
better in kids

Occurs when the face is submerged in very cold water (<20C)

Extent of neurologic protection in humans due to diving reflex is likely
very minimal

14

Pathophysiology
Asphyxia, hypoxemia, hypercarbia, & metabolic acidosis
Fresh water vs salt water - little difference (except for
drowning in water with very high mineral content, like the
Dead Sea)
Hypoxemia

15

Occlusion of airways with water & particulate debris

Changes in surfactant activity
Bronchospasm
Right-to-left shunting increased
Physiologic dead space increased

Pathophysiology

16

Cardiac arrhythmias
Hypoxic encephalopathy
Renal insufficiency
Pulmonary injury
Global brain anoxia & potential diffuse cerebral edema

Pathophysiology Cerebral edema

Initial hypoxia
Post resuscitation cerebral hypoperfusion
Increased ICP
Cytoxic cerebral edema:
BBB remains intact: derangement in cellular metabolism resulting in
inadequate functioning of the Na & K pump

Excessive accumulation of cytosolic calcium causing cerebral arterial

spasm

Lance-Adams syndrome with sign hypoxia

Post hypoxic (action) myoclonus, often mistaken for sz
Happens more often with coming out of sedation
Must be differentiated from myoclonic status (poor prognosis)
17

Pathophysiology Pulmonary Injury

Aspiration as little as 1-3 cc/kg can cause significant effect on
gas exchange

18

Increased permeability
Exudation of proteinaceous material in alveoli
Pulmonary edema
decreased compliance

Pathophysiology fresh vs. salt

Both forms wash out surfactant
Damaged alveolar basement membrane pulmonary edema, ARDS

Theoretical changes not supported clinically

Salt water: hypertonic pulmonary edema
Fresh water: plasma hypervolemia, hyponatremia
Unless in Dead Sea

Humans (most aspirate 3-4cc/kg)

Aspirate > 20cc/ kg before significant electrolyte changes
Aspirate > 11cc/kg before fluid changes

19

Pathophysiology
Findings at autopsy

Wet, heavy lungs

Varying amounts of hemorrhage and edema
Disruption of alveolar walls
~70% of victims had aspirated vomitus, sand, mud, and aquatic
vegetation
Cerebral edema and diffuse neuronal injury
Acute tubular necrosis

20

Pathophysiology Pulmonary edema

Findings at autopsy

Wet, heavy lungs

Varying amounts of hemorrhage and edema
Disruption of alveolar walls
~70% of victims had aspirated vomitus, sand, mud, and aquatic
vegetation
Cerebral edema and diffuse neuronal injury
Acute tubular necrosis

21

Signs & Symptoms

22

70% develops sxs within 7 hrs

Alertness agitation coma
Cyanosis, coughing & pink frothy sputum (pulm edema)
Tachypnea, tachycardia
Low grade fever
Rales, rhonchi & less often wheezes
Signs of associated trauma to the head & neck should be
sought

Prognosis
Better outcomes associated with early CPR (bystander)
C-spine protection:
Transport

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Continue effective CPR

Establish airway
Remove wet clothes
Hospital evaluation

Labs & Tests

Min electrolyte changes
Increase WBC
Hct & HgB normal initially
Fresh water: Hct falls due to
hemolysis
Inc. in free HgB w/o a change
in Hct

DIC occasionally
ABG metabolic acidosis &
hypoxemia
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EKG
Sinus tach, non spec STsegment & T-wave changes
Resolved within hrs
Ominous- vent arrhythmias,
complete heart block

CXR
May be nl initially
Patchy infiltrate
Pulm edema

Treatment
ED eval
Admit if: CNS or respiratory symptoms
Observe for 4-6 hours if
Submersion >1min
Cyanosis on extraction
CPR required

25

Treatment: ED discharge
ED eval
Admit if: CNS or respiratory symptoms
Observe for 4-6 hours if
Submersion >1min
Cyanosis on extraction
CPR required

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Predicting Ability for ED Discharge

Several studies support selected ED discharge
Child can safely be discharged home if at 6 hours after ED
presentation:
GCS > 13
Normal physical exam/respiratory effort
Room air pulse oximetry oxygen saturation > 95%

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

ICU treatment: Respiratory

PPV
Treatment of bronchospasm
Steroids: no benefits
Bronchoscopy
Prophylactic abx: no benefits
Surfactant: no beneficial

ICU treatment: Cardiovascular

Re-warming
CBF decrease 6-7% / C drop

LOC 34C
Pupil dilate at 30C
V-fib 28C
EEG isoelectris 20C

ICU treatment: CNS

ICP monitoring - not indicated, typically irreversible hypoxic
cellular injury
Brain CT not indicated, unless TBI suspected
Mild hyperventilation?
Osmotherapy not indicated
Corticosteroids (dexamethasone) - no proven benefit
Seizures - treat aggressively
Shivering or random, purposeless movements can increase ICP
Hypothermia and barbiturate coma - highly controversial &
unlikely to benefit the patient (31 comatose kids, J Modell, NEJM 1993)
-

ICU treatment: Others

Antibiotics: no benefit or prophylaxis, may increase
superinfection
Fulminant strep pneumo sepsis has been described after severe
submersion
Steroids no demonstrated benefit

Prognosis predictors
Poor outcomes

Age < 3yrs

Submersion time: >10 min
Time to BLS >10 min
Serum pH: <7.0
CPR >25 min
Initial core temp <33C
GCS <5

Prognosis predictors

Prognosis predictors
Submersion time

survival

Fatality

0-5 min

7/67

10%

6-9 min

5/9

56%

21/25

88%

4/4

100%

10-25 min
>25 min

Prolonged resuscitation may increase the success of

resuscitation w/o normal neurologic recovery
After 25 min of full but unsuccessful resuscitation, thin
PROGNOSIS

Effects of near drowning

Divorce
Sibling psychosocial maladjustment
100,000 yrs of productive life lost
$4.4 million/yr in direct health care costs
$350-450 million/yr in direct costs
$100,000/yr to care for the neurologically impaired survivor of a near
drowing