Question 25

College Answer

Assess for signs of life and if absent commence CPR, check underlying rhythm and treat appropriately following APLS guidelines

Airway and breathing Administer 100% oxygen

Intubation for airway protection and suction with ETT cuffed size 7 (ILCOR guidelines – cuffed ETT’s acceptable in children) (age/4 +4) (half size bigger and smaller available) with C spine precautions

Ventilate with appropriate settings (Vt 6-8ml/kg, RR 15-20, PEEP > 5cm H2O) SpO2 and ETCO2 monitoring, ABG and CXR 
May get some discussion re management of ARDS

Circulation

Assess pulse rate and volume, blood pressure and capillary return, Doppler may be helpful if hypothermic 
Secure IV access

If inadequate circulation fluid bolus of 20 ml/kg 0.9% Saline – avoid hypotonic intravenous fluids

Consider inotrope support early Blood glucose, FBE, U & E

Cerebral support 
Avoid any further episodes of hypoxia and hypercarbia

Optimise circulation

Temperature

Actively rewarm to core temperature of 34oC Passively rewarm over 34oC

If post cardiac arrest – maintain hypothermia 32.5 – 33.5oC for > 24 hours

Other

Primary and secondary survey for associated trauma

Look for precipitating cause (hypoglycaemia, epilepsy, drug/alcohol ingestion, marine envenomation) 
Antibiotics not indicated routinely

Collateral history – immersion time, resuscitation at scene, medical history Admit to ICU with appropriate paediatric expertise

Counsel family regarding likely outcomes

Discussion

This question would benefit from a systematic answer. The college answer is already quite systematic; there is little that can be added to it without this turning into an unmanageably long discussion.

First step: assess for signs of life/confirm cardiac arrest.

If cardiac arrest is confirmed, follow the pediatric ALS algorithm.

Next step: Primary survey;

Important pre-hospital issues

• Unskilled rescuers should avoid drowning themselves.
• Do not start CPR while still in the water (one should not need to say this)
• CPR should not be of the compression-only variety (you really need the breaths)
• Avoid all active attempts to "force" the water out by placing the person face-down or any sort of abdominal thrusting, as this will only lead to the aspiration of stomach contents.
• Do not stop the resuscitation of the hypothermic drowning victim (the ICU doctors might want to publish another case report of miraculous ECMO-aided survival).

Emergency management issues

1. Assessment of the airway and of the need for immediate intubation.
   Drowning is associated with a high risk of aspiration (and not just of lake water).
2. Ventilation with high FiO₂
   High PEEP, 12-15
   Investigation of possible aspiration with CXR and ABG
3. Establishment of IV access and correction of hypovolemia;
   drowning victims may become hypovolemic following prolonged immersion due to the hydrostatic effects of water (particularly salt water)
4. Investigate causes of drowning related to intracranial events, eg. ICH, or trauma resulting from a fall into submerged obstacles
5. Assessment of temperature, and rewarming (the immersed patient is invariably hypothermic, as it is rare to drown in a body of water with an ambient temperature higher than human core body temperature).

ICU management issues

1. Assessment of the airway device effectiveness (i.e. is it in the right main bronchus?)
   Bronchoscopy and suction as indicated by copious aspirated material.
2. Lung protective ventilation; open lung strategy
   No benefit in corticosteroids
3. Assess the effectiveness of volume resuscitation; give more.
4. Sedation as required: no specific recommendations can be made.
   If the patient has had a cardiac arrest, therapeutic hypothermia might be worthwhile.
5. Electrolytes are unlikely to be deranged by this stage.
6. Renal function is unlikely to be impaired
7. There is no reason to omit normal nasogastric feeds
8. Monitor Hb, and satisfy yourself that there is no haemolysis.
9. There is no need for antibiotics.

The ARC ALS2 manual (2011) has a section on drowning (pp. 127). This was my main source of information.

Pearn, John. "The management of near drowning." British medical journal (Clinical research ed.) 291.6507 (1985): 1447.