Pediatric Submersion Injuries: Emergency Department Management
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Pediatric Submersion Injuries: Emergency Care and Resuscitation - Trauma EXTRA Supplement (Trauma CME)

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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”?

Table of Contents
  1. About This Issue
  2. Abstract
  3. Case Presentations
  4. Introduction
  5. Critical Appraisal of the Literature
  6. Definitions and Demographics of Pediatric Drowning
  7. Risk Factors for Pediatric Drowning
    1. Epilepsy
    2. Cardiac Conditions
    3. Metabolic Factors
    4. Environmental and Other Factors
  8. Pathophysiology
    1. The Drowning Process
    2. Pulmonary Factors
    3. Cardiovascular Factors
    4. Neurologic Factors
    5. Other Body Systems
    6. “Dry Drowning”
    7. The Autonomic Conflict in Cold Water Immersion
  9. Differential Diagnosis
  10. Prehospital Care
  11. Emergency Department Evaluation
  12. Diagnostic Testing
  13. Treatment
    1. Management of Hypothermia
      1. External Rewarming
      2. Internal Rewarming
      3. Other Physiologic Considerations for Hypothermia
    2. Referral to the Pediatric Intensive Care Unit
  14. Disposition
  15. Predictors of Outcomes in the Pediatric Drowning Patient
    1. Resuscitation in the Field and Duration of Cardiopulmonary Resuscitation
    2. Glasgow Coma Scale Score and Pediatric Risk of Mortality Score
    3. Other Predictors of Morbidity and Mortality
      1. State of Hypothermia
      2. Water Temperature
      3. Age of Drowning Victim
      4. Other Predictors
    4. Summary of Outcome Predictors
  16. Special Circumstances
    1. Pediatric Drowning In Bathtubs, Buckets, And Spas
      1. Bucket Drowning
      2. Bathtub Drowning
      3. Hot Tub and Spa Drowning
    2. Stagnant or Contaminated Water
    3. Drowning and Nonaccidental Trauma
  17. Controversies and Cutting Edge
    1. Recovery for Hypothermic Drowning Victims
    2. Extracorporeal Circulation Versus Extracorporeal Membrane Oxygenation
    3. “Secondary Drowning”
  18. Prevention of Submersion Incidents
  19. Time- and Cost-Effective Strategies
  20. Risk Management Pitfalls to Avoid for Pediatric Drowning Victims
  21. Case Conclusions
  22. Clinical Pathways
    1. Clinical Pathway for Pediatric Submersion Injuries
    2. Clinical Pathway for the Hypothermic Pediatric Drowning Victim
  23. Tables
  24. References

Abstract

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.

Case Presentations

CASE 1
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?
CASE 2
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...
CASE 3
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...

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Clinical Pathway for Pediatric Submersion Injuries

Clinical Pathway for Pediatric Submersion Injuries

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Tables

Table 1. Methods of Rewarming a Hypothermic Patient After a Submersion Incident

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. United States Centers for Disease Control and Prevention. 10 Leading Causes of Death, United States: 2019, Both Sexes, All Ages, All Races. Accessed June 1, 2022. (Statistical data visualization)

24. *Orlowski JP, Szpilman D. Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am. 2001;48(3):627-646. DOI: 10.1016/s0031-3955(05)70331-x

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.

Keywords: drowning, submersion, pediatric, hypothermia, ACLS, PALS, freshwater, saltwater, pools, spas, bathtubs, buckets, NAT, nonaccidental trauma, autonomic conflict, ventilation, circulation, CPR, resuscitation, oxygen, pulse oximetry, internal rewarming, external rewarming, PICU, GCS, PRISM, ECMO, ECC

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Publication Information
Authors

Janet Semple-Hess, MD

Peer Reviewed By

Rachel Long, DO

Publication Date

June 15, 2022

CME Expiration Date

June 15, 2025

Pub Med ID: 35737684

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CME Information

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