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Jana Stockwell, MD
Statistics
1995 data:
2000 CDC data:
>1000 kids <14 years old drown 60% <4 years old 3,281 unintentional drownings in USA (adults & kids) averaging 9 people/day - not including boatingrelated incidents For every child who drowns, 3 need ED care for nonfatal submersion injuries >40% of these children require hospitalization
>75%ile of National avg 50-75%ile of National avg 25-50%ile of National avg <25%ile of National avg
the hospital As many as 20% of drowning survivors suffer severe, permanent neurological disability
Drowning modalities
Infants (age <1)
bathtubs, buckets & toilets Children ages 1-4 years swimming pools, hot tubs & spas Children ages 5-14 years - swimming pools & open water sites
(Brenner 2001)
Bucket drownings
~300 children in the US since
1984 7-15 months of age 24 to 31 inches tall Bucket may contain water or nasty cleaning fluid
Tub drownings
Approximately 10% of childhood drownings Typically lacking adult supervision Do tub seats help?
Bathtub seats - ? or ?
Not intended or marketed as safety devices Bathtub drowning deaths of infants aged 6-10 mo
from 1994-1998 40 infant drowning deaths associated with bath seats 78 deaths not associated with bath seats ~45% of infants in this age group use bath seats Data suggests seats either have no effect or they may provide some slight protection against unintentional bathtub drowning risks Odds ratio 0.6 [95% CI 0.4-0.9]
Data: US Consumer Product Safety Commission & National Center for Health Statistics for US resident infants (1994-1998)
Pool/Spa drownings
Most residential pool drownings are in kids <4 yo 3,000 pool drownings require hospital ED treatment
each year
last seen inside the home missing from sight <5 minutes in the care of one or both parents at the time of the drowning
>50% occur in the child's home pool 1/3 occur at homes of friends, neighbors or family Since 1980, ~230 kids <4 yrs in spas & hot tubs
(Present 1987, Brenner 2001)
Odds ratio (OR) for the risk of drowning or near drowning in a fenced pool
compared to an unfenced pool is 0.27 (95% CI 0.16 0.47)
Isolation fencing (enclosing pool only) is superior to perimeter fencing (enclosing property and pool)
sided isolation fencing are 60% more likely to be involved in drownings than those with 4-sided isolation fencing
Boat-related drownings
2002 Coast Guard data, all ages:
5,705 boating incidents: 4,062 injured, 750 killed 70% of fatalities due to drowning 30% of fatalities due to trauma, hypothermia, CO poisoning, or other causes Alcohol was involved in 39% of fatalities Open motor boats - 41% Personal watercraft 28%
Alcohol
Involved in 25-50% of teen and adult deaths
Hingson 1988)
judgment, and its effects are heightened by sun exposure and heat (Smith and Kraus 1988) Relative risk of drowning was 31.8 in persons with a markedly elevated alcohol level (>21.7 mmol/L) and 4.6 for levels <21.6 mmol/L
(Cummmings JAMA 281:2198, 1999)
vasoconstriction Hypothermia Bradycardia Circulatory arrest, while VF rare Extravascular fluid shifts, diuresis
Diving reflex
Bradycardia, apnea, vasoconstriction Relatively quite weak in humans
better in kids
water (<20C) Extent of neurologic protection in humans due to diving reflex is likely very minimal
Pathogenesis 1
Asphyxia, hypoxemia, hypercarbia, & metabolic
acidosis Fresh water vs salt water - little difference (except for drowning in water with very high mineral content, like the Dead Sea) Hypoxemia
Occlusion of airways with water & particulate debris Changes in surfactant activity Bronchospasm Right-to-left shunting increased Physiologic dead space increased
Pathogenesis 2
Cardiac arrhythmias Hypoxic encephalopathy Renal insufficiency Global brain anoxia & potential diffuse cerebral edema
Findings at autopsy
Wet, heavy lungs Varying amounts of hemorrhage and edema Disruption of alveolar walls ~70% of victims had aspirated vomitus, sand, mud, and aquatic vegetation Cerebral edema and diffuse neuronal injury Acute tubular necrosis
kids Median age 3.8 years (1 mo 18.7 yrs) 30% with pre-existing disease
CHD, sz, MR/CP, DD
EKG
CXR
Sinus tachycardia & nonspecific ST-segment and T-wave changes Reverts to normal within hours Ominous - ventricular arrhythmias, complete heart block May be normal initially despite severe respiratory disturbances Patchy infiltrates Pulmonary edema
CPAP or PEEP Aerosolized -agonists for bronchospasm Bronchoscopy Prophylactic antibiotics have not been shown to be beneficial Steroids:
No controlled human studies to support use Animal models and retrospective studies in humans have failed to demonstrate benefit
Surfactant
Beneficial
Porcine surfactant (Curosurf) 0.5 ml/kg (40 mg/kg) IT for ARDS 8h after freshwater neardrowning in a 12yo
Not beneficial
Submerged rabbits
(A Anker, Acad Emerg Med 1995)
Kids
(F Perez-Benavides, Ped Emerg Care 1995)
Brain therapy
ICP monitoring - not indicated, typically irreversible
hypoxic cellular injury Brain CT not indicated, unless TBI suspected Mild hyperventilation? Osmotherapy not indicated Corticosteroids (dexamethasone) - no proven benefit Seizures - treat aggressively Shivering or random, purposeless movements can increase ICP Hypothermia and barbiturate coma - highly controversial & unlikely to benefit the patient (31 comatose kids, J Modell, NEJM
1993)
Age <3 years CPR in ER Initial ABG pH <7.1 Initial core temp <33o
Neurologic prognosis
Absence of spontaneous respiration is an
ominous sign associated with severe neurologic sequelae Permanent neurologic sequelae persist in ~20% of victims who present comatose
Minimal brain dysfunction, spastic quadriplegia, extrapyramidal syndromes, optic and cerebral atrophy, and peripheral neuromuscular damage
body temperature must fall rapidly, decreasing cellular metabolic rate, before significant hypoxemia begins
Finnish study:
Hypothermic protection has not been observed 92% of good survivors had initial core temp of >34C 61% of those who died or had severe neurologic injury had core temp <34C Median water temp 16C Submersion duration <10 minutes had greatest sensitivity in predicting good outcome, even in kids
Re-warming
Re-warm 1-2oC per hour to range 33-36oC Mild (32-35o) passive rewarming Moderate (28-32o)
Shivering fails J wave Active internal/external rewarming (not extremities) Appears dead, pupils dilated/NR VFib, extreme brady, pulseless Deep rectal or esophageal temps Maintain CPR until core temp >32o
Severe (<28o)
Paramedic CPR - 87/89 children 18 (20% of those w/ CPR) no longer needed CPR in ED Paramedics intubated 19 children Epinephrine in 30 patients
Respiratory
submersion victims can be predicted with 4 measures: coma, absence of pupillary light reflex, admission blood glucose concentration (high) and sex
Recommendations
Pre-hospital resuscitation, including early
intubation, ventilation, vascular access, and administration of advanced life support medications Continued resuscitation and stabilization in the ED Full supportive care in the ICU for a minimum of 48 hrs Consider withdrawal of support if no neurologic improvement is detected after 48 hours
Ancillary testing such as brainstem evoked responses, EEG, and MRI (not CT) may prove helpful to corroborate the neurologic Pediatrics, 1997 Christenson, Jansen, Perkins examination
67 year old with pulmonary fibrosis S/P lung resection On ward, with O2 POD#2 developed distress, to ICU, intubated, ARDS Finally extubates