Question 25

College Answer

Difficult to give exact template, as style may vary, but should include:

Initial Assessment/Primary Survey

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 ETTs 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 and arterial access

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

Blood glucose, FBE, U & E

Cerebral support

Avoid any further episodes of hypoxia and hypercarbia. Avoid hyperoxia

Optimise circulation

BSL control

Temperature

Actively rewarm to core temperature of 34^oC

Passively rewarm over 34^oC

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

Could allow a normothermia strategy, but fever must be controlled

Other

Primary and secondary survey for associated trauma

Look for precipitating cause (hypoglycaemia, epilepsy, toxin 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

Generic issues in the resuscitation of drowning, from the chapter on immersion submersion and drowning:

• Drowning is the process of experiencing respiratory impairment from submersion or immersion in a liquid
• Common complications of drowning include death from hypoxic arrest, laryngospasm, aspiration of water and gastric contents, ARDS and pulmonary oedema due to loss of surfactant, hypothermia and cerebral hypoxia which is the main determinant of long-term morbidity.
• Uncommon complications of drowning include electrolyte derangement, haemolysis, renal failure due to haemoglobinuria, and infection (due to aspiration of unclean water).
• Predictors of poor neurological outcome following drowning include immersion for more than 5 minutes, a delay in CPR longer than 10 minutes, GCS of 3 and fixed dilated pupils on admission, severe acidosis (pH < 7.00) and abnormal neurology during admission (eg. GCS less than 6 and abnormal brainstem function after 48 hours).

Resuscitation of the drowned patient

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.

Uniquely paediatric issues in the resuscitation of drowning, from the chapter on resuscitation of the drowned child

Need to search for predisposing conditions and risk factors:

• Young age (high centre of gravity)
• Adolescence (alcohol, drugs, poor judgement)
• Epilepsy (risk increased up to 14 fold)
• Developmental delay
• Long QT (arrhythmias triggered by cold water)

Unique paediatric issues:

• C-spine immobilisation in the very young (under 5) age group is usually unnecessary
• Transfer to paediatric ICU is required
• Hypothermia is usually a poor prognostic indicator
• Asphyxia is more common than immersion phenomena, unlike in adult swimmers
• Family needs to be councelled: emotional response to the accidental drowning of a child is typically guilt and self-accusation

Non-accidental drowning needs to be considered as the cause

• Unfortunately, by itself abusive drowning leaves no pathognomonic stigmata
• Evidence of other physical abuse may be present
• Child may have been left with an unsuitable carer (eg. an alcoholic relative)
• History of mental illness or substance abuse in the carer
• Presentation may be late
• Story may be inconsistent with the findings
• Age group of the child outside of the usual range for bathtub immersion (i.e. older than 24 months).
• Care must be taken not to add stigma of culpability and accusation to an already emotionally difficult situation for the parent

Prognostication

• 30%-50% will die
• 10% survive with severe neurological sequelae
• The rest may recover unremarkably

Features which favour non-survival or severe disability:

• Apnoea on presentation to ED
• Coma (GCS < 8) on presentation to ED
• pH < 7.00 
• Need for CPR in the ED
• CPR for longer than 10 minutes
  (data from Christensen et al, 1997)

Fandel, Ivar, and Eduardo Bancalari. "Near-drowning in children: clinical aspects." Pediatrics 58.4 (1976): 573-579.

Pearn, John H. "Secondary drowning in children." Br Med J 281.6248 (1980): 1103-1105.

Burford, Amy E., et al. "Drowning and near-drowning in children and adolescents: a succinct review for emergency physicians and nurses." Pediatric emergency care 21.9 (2005): 610-616.

Austin, Sébastien, and Iain Macintosh. "Management of drowning in children." Paediatrics and Child Health 23.9 (2013): 397-401.

Watson, R. Scott, et al. "Cervical spine injuries among submersion victims." Journal of Trauma and Acute Care Surgery 51.4 (2001): 658-662.

Nixon, James, and John Pearn. "Non-accidental immersion in bathwater: another aspect of child abuse." British medical journal 1.6056 (1977): 271.

Nixon, James, and John Pearn. "Emotional sequelae of parents and sibs following the drowning or near-drowning of a child." Australian and New Zealand Journal of Psychiatry 11.4 (1977): 265-268.

Kemp, Alison M., A. M. Mott, and Jonathan Richard Sibert. "Accidents and child abuse in bathtub submersions." Archives of disease in childhood 70.5 (1994): 435-438.

Coryell, Jason, and Laura M. Ibsen. "Pediatric Drowning." Pediatric Critical Care Medicine. Springer London, 2014. 665-676.

Biggart, Matthew J., and Desmond J. Boh. "Effect of hypothermia and cardiac arrest on outcome of near-drowning accidents in children." The Journal of pediatrics 117.2 (1990): 179-183.

Moler, Frank W., et al. "Multicenter cohort study of out-of-hospital pediatric cardiac arrest." Critical care medicine 39.1 (2011): 141.

Christensen, David W., Paul Jansen, and Ronald M. Perkin. "Outcome and acute care hospital costs after warm water near drowning in children." Pediatrics 99.5 (1997): 715-721.