Get a free sample article on ED Assessment and Management of Pediatric Acute Mild Traumatic Brain Injury and Concussion
Enter your email to get your copy today!
About This Issue
Drowning and submersion injuries are highly prevalent, yet preventable, causes of pediatric mortality and morbidity. Prehospital care should focus on restoring normal ventilation and circulation as quickly as possible to limit the extent of hypoxic insult. In this review, passive external, active external, and active internal rewarming techniques for treatment of hypothermic patients are discussed. A systematic approach to treatment and disposition of pediatric drowning victims is provided, and risk factors, caveats in pediatric care, and factors affecting prognosis are also discussed.
What are the risk factors for pediatric drowning, and what factors affect prognosis?
How does the clinical scenario affect the choice of rewarming strategy for the hypothermic drowning patient?
What criteria should be met to determine when resuscitation should be terminated?
Does the evidence support “dry drowning” and “secondary drowning”?
Drowning and submersion injuries are highly prevalent, yet preventable, causes of pediatric mortality and morbidity. Prehospital care should focus on restoring normal ventilation and circulation as quickly as possible to limit the extent of hypoxic insult. Diagnostic testing for symptomatic patients may include blood glucose level, arterial blood gas level, complete blood count, electrolyte levels, chest radiography, and cardiorespiratory monitoring with pulse oximetry and a rhythm strip. In this review, passive external, active external, and active internal rewarming techniques for treatment of hypothermic patients are discussed. A systematic approach to treatment and disposition of pediatric drowning victims is provided, and risk factors, caveats in pediatric care, and factors affecting prognosis are also discussed.
A 10-month-old girl is brought to the ED after she had been missing for 15 minutes and was finally located at the bottom of the pool. Rescue breaths were given by bystanders, but on arrival to the ED, she is in full cardiorespiratory arrest with a GCS score of 3. She is intubated, and passive rewarming measures are initiated. After intraosseous access is obtained, 2 doses of epinephrine are given with a return of spontaneous circulation after 10 minutes. What additional care should be provided while awaiting admission of this patient?
An 8-year-old boy sustained a submersion injury at a pool party, and had spontaneous return of respiration when rescued by adults at the party. However, 3 hours later, he is brought to the ED by his parents, as he is in respiratory distress. Pulse oximetry is 89%, and diffuse crackles and rales with retractions are noted on chest examination. His GCS score is 15 with a normal neurologic examination. You consider any diagnostic tests that may be necessary for this patient and what management should be undertaken...
During the spring, a 2-year-old girl is transported to the ED after being pulled from a fast-moving river by the swift-water rescue team following 45 minutes of submersion. She was apneic and pulseless when pulled from the river. After a 20-minute helicopter transport, she arrives to the ED in full cardiorespiratory arrest, with CPR in progress. Her GCS score is 3, her pupils are fixed and dilated, and her rectal temperature is 34°C. When she is intubated, pulmonary edema is evident. Intraosseous access and central line access are obtained. While examining the patient, you consider your management options...
How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.
Clinical Pathway for Pediatric Submersion Injuries
Subscribe to access the complete flowchart to guide your clinical decision making.
26. *Idris AH, Berg RA, Bierens J, et al. Recommended guidelines for uniform reporting of data from drowning: the “Utstein style”. Resuscitation. 2003;59(1):45-57. (Guidelines) DOI: 10.1016/j.resuscitation.2003.09.003
32. *Szpilman D, Bierens JJ, Handley AJ, et al. Drowning. N Engl J Med. 2012;366(22):2102-2110. (Review) DOI: 10.1056/NEJMra1013317
35. *Burford AE, Ryan LM, Stone BJ, et al. Drowning and near-drowning in children and adolescents: a succinct review for emergency physicians and nurses. Pediatr Emerg Care. 2005;21(9):610-616. (Review) DOI: 10.1097/01.pec.0000177204.21774.35
54. *Vanden Hoek TL, Morrison LJ, Shuster M, et al. Part 12.11: Cardiac arrest in special situations: 2010 American Heart Association Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010(122):S829-S861. (Clinical practice guidelines) DOI: 10.1161/CIRCULATIONAHA.110.971069
64. *Topjian AA, de Caen A, Wainwright MS, et al. Pediatric post-cardiac arrest care: a scientific statement from the American Heart Association. Circulation. 2019;140(6):e194-e233. (Guidelines) DOI: 10.1161/CIR.0000000000000697
73. *Van de Voorde P, Turner NM, Djakow J, et al. European Resuscitation Council Guidelines 2021: Paediatric Life Support. Resuscitation. 2021;161:327-387. (Guidelines) DOI: 10.1016/j.resuscitation.2021.02.015
Subscribe to get the full list of 127 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.
Drowning may be defined by the type of water (eg, freshwater, saltwater) and the temperature of the water. In general, warm-water drowning refers to temperatures >20°C (68°F). Cold-water drowning is defined as occurring in water temperatures <20°C (68°F).
It is estimated that children can only struggle for 20 to 30 seconds before final submersion.
The primary objective of prehospital management is to restore normal ventilation and circulation as quickly as possible after prompt removal from the water. Initial evaluation should include assessment of airway, breathing, and circulation. If the assessment is unclear or if there is no response from the victim, then the person should be assumed to be in cardiac arrest and CPR should be initiated immediately.
Date of Original Release: June 15, 2022. Date of most recent review: June 10, 2022. Termination date: June 15, 2025.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 Credits™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 4 Trauma credits, subject to your state and institutional requirements.
Needs Assessment: The need for this educational activity was determined by a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; thorough review of current literature on the topic and practice gap assessment; and evaluation of prior activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) identify areas in practice that require modification to be consistent with current evidence in order to improve competence and performance; (2) develop strategies to accurately diagnose and treat both common and critical ED presentations; and (3) demonstrate informed medical decision-making based on the strongest clinical evidence.
CME Objectives: Upon completion of this activity, you should be able to: (1) identify risk factors for pediatric drowning, caveats in the care of the pediatric patient, and factors affecting prognosis; (2) initiate appropriate management of the drowning patient, including initial resuscitation and diagnostic testing and monitoring; (3) utilize targeted rewarming strategies in the hypothermic drowning patient; and (4) determine appropriate disposition and follow-up for pediatric drowning patients.
Discussion of Investigational Information: As part of the activity, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration–approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME activities. All faculty participating in the planning or implementation of a CME activity are expected to disclose to the participants any relevant financial relationships and to assist in mitigating the relationships. In compliance with all ACCME accreditation requirements and policies, all faculty for this CME activity were asked to complete a full disclosure statement. The in-formation received is as follows: Update Contributors (June 2022): Dr. Janet Semple-Hess, author, Dr. Rachel Long, peer reviewer, and Dr. Lara Zibners, editor-in-chief, report no relevant financial relationships with ineligible companies. Original Contributors (June 2014): Dr. Semple-Hess, Dr. Campwala, Dr. Quan, Dr. Waltzman, Dr. Vella, Dr. Wang, Dr. Damilini, and their related parties reported no relevant financial relationship with the manufacturer(s) of any commercial product(s) discussed in this educational presentation.
Commercial Support: This supplement to Pediatric Emergency Medicine Practice did not receive any commercial support.
Earning Credit: Read the PDF and complete the CME test online.
Hardware/Software Requirements: You will need a computer, tablet, or smartphone to access the online archived article and CME test.
Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit www.ebmedicine.net/policies