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48. Pediatric Drowning: The Cold Water Blues
Keywords
CDCPediatric drowningLife jacketsSwimmingCPRPool fencesCase
Pertinent History
This 8-year-old male presented to the Emergency Department (ED) in full cardiac arrest. The patient had been waiting to be picked up for school and fell through an iced retaining pond. Time from fall to retrieval from the water was estimated at about 25 minutes. Cardiopulmonary resuscitation (CPR) was initiated and he arrived at the ED about 25 minutes after retrieval. He was intubated and had received 4 doses of epinephrine by Emergency Medical Services (EMS) en route to the ED.
Pertinent Physical Exam
Active CPR, Temperature 31.6 °C (88.9 °F)
Except as noted below, the findings of a complete physician exam are within normal limits.
Primary Survey
Airway – Intubated with 5.0 cuffed endotracheal tube (ETT) at 22 cm at the teeth.
Breathing – Breath sounds bilaterally with bagging, positive color change noted on colorimeter. Circulation – no palpable pulses, CPR ongoing.
Secondary Survey.
Head – abrasion to the right forehead. Bilateral pupils fixed and dilated.
Neck – in c-collar.
Chest – Right with clear breath sounds, Left diminished breath sounds – ETT pulled back to 18 cm at the teeth with improved breath sounds bilaterally.
Abdomen – soft, distended.
Pelvis – stable, normal rectal tone, no rectal blood.
Extremities – no pulses, no deformities.
Pertinent Diagnostic Testing
Test | Result | Units | Normal range |
|---|---|---|---|
pH (arterial) | 6.7 ↓ | – | 7.35–7.45 |
pCO2 (arterial) | 113 ↑ | mmHg | 35–45 mmHg |
Base excess | −22 ↓ | mmol/L | −3.0–3.0 mmol/L |
Bicarbonate | 15 ↓ | mEq/L | 21–34 mEq/L |
Hgb | 10.9 ↓ | g/dL | (Male) 14–18 g/dL |
(Female) 11–16 g/dL | |||
Hematocrit | 32 ↓ | % | 34.9–44.3% |
Plan
Continue Pediatric Advanced Life Support (PALS) and rewarming
Update 1/Resuscitation Efforts
Resuscitation efforts continued following PALS algorithms. Two intraosseous (IO) catheters were placed in the patient’s bilateral tibias. The patient received a total of 6 doses of epinephrine and was then started on an epinephrine drip. As noted above, the ET tube was pulled back with improved breath sounds. The patient received 40 ml/kg of warmed IV fluids and 10 mL/kg of pRBCs. Return of spontaneous circulation (ROSC) was achieved about 15 minutes after his arrival to the ED. His temperature at the time of ROSC was 28.8 °C (83.8 °F), which was lower than his initial presenting temperature.
Update 2/Rewarming Efforts
Removal of wet clothing
Application of warm blankets
Ceiling warmers (convection heating)
Forced-air blanket placed on the patient
Warmed saline via IV boluses
Foley catheter placed with bladder lavage with warmed fluid (10 mL NS/kg ×3)
Chest tubes were placed. 2 chest tubes were placed on the right side, a lower argyle chest tube and an upper pigtail. 3 L of warmed saline, in 1 L increments, were placed via the pigtail and drained through the argyle chest tube. One chest tube was placed on the left and approximately 150 mL of warmed fluid was instilled via the left chest tube.
Update 3
The patient was transferred to the Pediatric Intensive Care Unit (PICU). In the PICU, a femoral central line was placed. The patient was placed on temperature-regulating equipment through his femoral line which can allow for controlled rewarming. The patient’s temperature gradually improved.
Learning Points: Pediatric Drowning
Priming Questions
- 1.
What are some of the complications of drowning that you have to worry about in the ED?
- 2.
How is this diagnosis made, and what roles do laboratory and imaging studies play (blood gas, CXR, decision to admit/transfer)?
- 3.
What variables have shown to affect patient outcomes in drowning?
- 4.
What are some of the treatments for hypothermia that can be initiated in the Emergency Department?
Introduction/Background
- 1.
There has been a national campaign in part through the CDC and American Academy of Pediatrics to increase awareness of pediatric drowning. Much has been publicized on drowning prevention strategies such as increased supervision, CPR teaching to parents, installing pool fences, and wearing life jackets around lakes or the ocean even for experienced swimmers [1, 2].
- 2.
Across the United States approximately 3 children die every day from unintentional drowning, and drownings are a leading cause of death for children age 1–14. For every death, 5 more children are treated in EDs for non-fatal drowning injuries [1].
- 3.
Drowning is defined as “a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium.” This is the term that should be used regardless of outcome and regardless of chronicity of symptoms. “Drowning” should be broadly applied and should replace other terms such as “near drowning,” “wet drowning,” “dry drowning,” and “secondary drowning.” [3]
Physiology/Pathophysiology
- 1.
Drowning is first and foremost a hypoxic event. This can be secondary to a few processes such as laryngospasm, apnea, and/or aspiration. Those who suffer cardiac arrest at the primary event of drowning likely have suffered a fatal arrhythmia as a result of the hypoxia, hypercarbia, and acidosis.
- 2.
Many of the complications from drowning are due to both the initial hypoxic-ischemic insult and reperfusion injuries after rescue [3].
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Lung injury – often caused by abnormal surfactant function and increased capillary endothelial permeability [3].
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This can lead to pulmonary edema, ventilation/perfusion mismatch, atelectasis, poor compliance, and acute respiratory distress syndrome (ARDS) [3].
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Aspiration of fresh water vs salt water was classically taught to result in varying electrolyte abnormalities; however, this has recently been questioned and the salinity of the water is now thought to be of little to any clinical significance [3].
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Shock – This can be caused by a combination of decreased oxygenation of the blood and severe myocardial dysfunction [4]. Hypothermia can also contribute to this state of poor tissue perfusion.
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Hypoxic brain injury – irreversible central nervous system (CNS) damage begins after 4–6 minutes of hypoxia [4].
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- 3.
Patients should also be evaluated for traumatic injuries, as these can be the inciting event which caused the drowning to occur.
Making the Diagnosis
Differential Diagnosis
Pneumonia
ARDS
Asthma Attack
Heart Failure
Flash Pulmonary Edema
- 1.
This diagnosis is generally readily apparent from the history, but identifying the degree of injury from a drowning relies heavily on the physical exam.
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Respiratory rate, respiratory effort, oxygen saturation, pulmonary exam, and mental status are going to provide key information about whether or not the patient has suffered injury from an aspiration event. Vital sign values and mental status should be analyzed in the context of age-appropriate parameters.
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