Drowning in children

Question 25 from the second paper of 2016 presents a case of near-drowning in a twelve year old child. The specific scenario is one of submersion in sea water. The college wanted to hear about immediate management, which excludes much of the ICU-level care (as that fun stuff would be non-immediate). Judging by the college answer, the examiners wanted to see what the candidate would do if they somehow inexplicably found themselves in charge of the Emergency department.

The best short-form literature resource for such an ACEM-centric answer is probably this 2005 CME review article by Burford et al (2005), the target audience for which seems to be ED medical and nursing staff from the United States.  "Management of drowning in children" by Austin et al (2013) is a similar article, but slightly longer and more British. Ultimately, if one is able to get a hold of the 2014 copy of Pediatric Critical Care Medicine from Springer, one may explore Chapter 48 ("Paediatric drowning") by Coryell and Ibsen. Locally, a longform introduction to the intensive care issues surrounding drowning can be explored in one of the chapters from the required reading section on trauma. 

The college answer for Question 25 from the second paper of 2016 begins with "Difficult to give exact template, as style may vary". This suggests that there might have been some sort of merit in an approach which deviated from the standard A-B-C-D mantra of resuscitation. In the humble opinion of the author, the style of the answer to such a question should never vary, and should always include the primary survey series.​

Generic issues in resuscitation of paediatric drowning

Because of the fact that the college has presented us with a 12-year-old (who might be anatomically suitable for adult ICU in terms of mass and height), the standard adult approach to resuscitation can be applied. The chapter on immersion submersion and drowning from the "required reading" section on trauma contains such an algorithm; in the interest of simplifying revision it is reproduced below with zero modification. The basic definitions and known complications of drowning are also similar across age groups.

• 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.

The twelve year old in the SAQ is probably non-representative. The Burford paper reports that of the children presenting with submersion injuries, 70% of the cases are under five years old. Bathtubs, buckets and toilets are implicated (children can tip themselves in but cannot get themselves out, or tip the objet over). In short, in addition to the generic approach one needs add issues which are uniquely paediatric:

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)

Unique issues in resuscitation of paediatric drowning

C-spine immobilisation in the very young (under 5) age group is likely an unnecessary encumbrance on the airway management. Few of the children under 5 will present with C-spine  injury. Watson et al (2001) found that in a series of 2288 patients only 11 had significant C-spine injuries.  These drowning victims are invariably older (over 15) and present with a clear history of high-speed impact, for example from diving or a motor vehicle accident. 

The surface area to weight ratio of infants and toddlers favours rapid hypothermia, which might appear protective from miraculous case reports. Biggart et al (1990) reported on a case series where hypothermia (<33.0°C) was the main predictor which separated children who died or survived with severe disability from those who went on to make a recovery. However, that was the 90s. A more up to date multicentre cohort study (Moler et al, 2011) found that non-survivors of post-submersion cardiac arrest were more lijkely to be colder (on average, 33.5°C).

Transfer to a paediatric ICU is something that needs to be mentioned as a part of any complete answer. So does the councelling of the family. In accidental paediatric drowning, the shadow of negloigence hangs over the parents. Social stigma of guilt and responsibility compounds the emotional injury of losing a child, and channels normal grieving into pathological avenues, giving rise to parental PTSD, depression and substance abuse.

Non-accidental injury needs to be considered, as it does in all traumatic paediatric presentations. As an 1977 article by Nixon and Pearn puts it,

"An older infant or toddler is usually bathed at the end of the day, when a mother is tired and when stress and frustration are usually maximal. It is not surprising that this scenario is the occasion when a disturbed parent finally acts out the temptation and impulses that are usually chronically present, but barely submerged, in this group of families at risk."

The features which identify non-accidental injury are usually absent in drowning, as it leaves no physical marks to act as evidence. Usually, the incident is not isolated, and other physical marks from previous incidents of abuse will be present. A 1994 article by Kemp et al identified several cases of infant or toddler homicide by drowning; in the majority a single mother under psychological or financial stress was the murderer. In a minority, an estranged father was guilty, the abuse occurring during a scheduled access visit. Therefore, one feature which raises suspicion might be a social history suggestive of ... for lack of a better word, "unwantedness". Other characteristic feature seems to be inconsistency of story with presentation or a delayed presentation. For instance, Kemp et al offer the story of a 6 week old girl who was being bathed by her father: "the baby was put to bed and not brought to the hospital until some time later that evening when breathing problems were noted".