Pediatric submersion injuries: emergency care and resuscitation

Drowning and submersion injuries are highly prevalent, yet preventable, causes of childhood mortality and morbidity. Although much of the resuscitation of the drowning pediatric victim is basic to all respiratory and cardiac arrest situations, there are some caveats for treatment of this type of injury. Risk factors for drowning victims include epilepsy, underlying cardiac dysrhythmias, hyperventilation, hypoglycemia, hypothermia, and alcohol and illicit drug use. 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, electrolytes 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 or admission of pediatric drowning victims is also included, with extensive clinical pathways for quick reference.

Swimming-triggered aborted sudden cardiac death in a patient with Andersen–Tawil syndrome

In this report we describe the case of a 42-year-old woman who experienced an episode of near drowning during recreational swimming. A diagnosis of Andersen-Tawil syndrome was made based on the patient's dysmorphic features, characteristic T-U-wave patterns and ventricular arrhythmias. To our knowledge, this is the first report of a swimming-triggered cardiac event in a patient with Andersen-Tawil syndrome.

Buoyancy of synthetic cast and its implications to young patients

One of the authors' young patients suffered near-drowning while being treated with a synthetic below-knee cast, and this intrigued them into examining the buoyancy of waterproof casts and their use in small children. Synthetic and fiberglass casts were fabricated and subjected to immersion testing using lead pellets. Fiberglass casts sank immediately, while synthetic casts stayed afloat. With the addition of weights averaging 221 g, the synthetic casts finally sank. When supine, the casts stayed afloat with more weights. This study shows that synthetic liners are buoyant. Although the weight necessary to sink the casts was small, the weights were lead pellets, which is different from a human limb. Enhanced buoyancy of synthetic casts may pose a potential danger to a small child when not properly supervised in water. The initial buoyant force may be too startling and may place them at a higher risk for near-drowning.

Usual water-related behaviour and 'near-drowning' incidents in young adults

OBJECTIVE

To describe usual water-related behaviour and 'near-drowning' incidents in a cohort of young New Zealand adults.

METHOD

This was a cross-sectional study based on data collected as part of the Dunedin Multidisciplinary Health and Development Study, which is the study of a cohort (n = 1,037) born between 1 April 1972 and 31 March 1973 in Dunedin, New Zealand. The data analysed were collected at age 21 (1993/94). Each study member was given a face-to-face interview using a structured questionnaire.

RESULTS

Males reported a higher level of water confidence, exposure to risk behaviours, and exposure to unsafe locations, and more 'near-drowning' incidents, than the females, but protective behaviour did not differ. Males and females who were 'confident' in the water were more likely to be exposed to unsafe water locations, and water-confident males were more likely to drink alcohol before water activities, but not boating. A total of 169 'near-drowning' incidents were reported by 141 study members (63% males). 'Near-drowning' incidents were associated with unsafe swimming environments for males (p < 0.001) and boating within two hours of consuming alcohol for females (p = 0.002).

CONCLUSIONS

This study described usual water-related behaviour and has provided preliminary evidence of the factors associated with 'near-drowning' incidents among a high-risk age group. Larger case-control studies are required to further investigate risk factors for 'near-drowning'. IMPLICATIONS FOR PRACTITIONERS: Further investigation is required to determine the effectiveness of providing water skills acquisition in both safe and unsafe environments on 'near-drowning' experience.

Infant bath seats, drowning and near-drowning

OBJECTIVE

To investigate the possible role of infant bathtub seats in drowning and near-drowning episodes in infants.

METHODS

A review was conducted of the files of the Forensic Science Centre and Child Protection Unit, Women's and Children's Hospital, Adelaide, South Australia, for significant immersion incidents in infants involving bathtub seats from January 1998 to December 2003.

RESULTS

A total of six cases of drowning occurred over the 6-year period of the study in children under 2 years of age, including two infants. One of these cases, a 7-month-old boy, had been left unattended for some time in an adult bath in a bathtub seat. He was found drowned, having submerged after slipping down and becoming trapped in the seat. Three near-drowning episodes occurred in children under the age of 2 years, including two boys aged 7 and 8 months, both of whom had been left for some time in adult baths in bath seats. Both were successfully resuscitated and treated in hospital.

CONCLUSIONS

These cases demonstrate the vulnerability of infants to immersion incidents when left unattended in bathtubs. Bathtubs are particularly dangerous for infants as the slippery and smooth surfaces predispose to loss of balance and make escape from water difficult. Infant bathtub seats may give parents and child carers a false sense of security leading to infants being left unattended. Unfortunately, however, infants may fall out of, or slip and become trapped in, such seats. Infants and young children cannot be left unsupervised in water, and devices used as bathing aids such as bathtub seats may contribute to immersion incidents.

Alcohol involvement in burn, submersion, spinal cord, and brain injuries

BACKGROUND

Alcohol is involved in many injuries, but estimates of this involvement vary considerably. Most information pertains to deaths although most injuries are nonfatal.

MATERIAL/METHODS

The portion of fatal and nonfatal injuries involving alcohol was determined from a comprehensive Oklahoma surveillance system that tracks persons killed or hospitalized due to burns, submersions, spinal cord injuries (SCIs), and traumatic brain injuries (TBIs). Logistic regression was used to determine factors that explain the percentage of alcohol involvement in fatal versus nonfatal cases.

RESULTS

The victim was alcohol involved in 17% of fire burns, 4% of scald burns, 24% of submersions, 34% of SCIs, and 41% of TBIs where involvement was known. Large differences existed in total alcohol involvement between age and gender groups and between fatal and nonfatal cases of fire burns (31% vs.11%) and submersions (33% vs. 6%). Large differences also existed in victim alcohol involvement between fatal and nonfatal cases of intentional SCIs (0% vs. 48%) and TBIs (38% vs. 70%). Those who imbibed during the day were not at excess risk of scald injury, but they were twice as likely to suffer a serious fire burn, 3 times as likely to suffer a spinal cord injury, 3.5 times as likely to suffer a submersion injury, and 2 to 4 times as likely to suffer a TBI. These excess risks persisted for all age groups between 15 and 64, with the excess risk especially high for underage drinkers aged 15 to 20. In contrast, people aged 65 and older did not appear to be at excess risk on days that they imbibed.

CONCLUSIONS

A large percentage of fatal and nonfatal injuries as classified by diagnosis group involve alcohol. People who had been drinking were substantially more likely to suffer serious nonfatal and fatal injuries other than scald burns.

Injuries Associated With Whitewater Rafting and Kayaking

Whitewater rafting and kayaking are growing exponentially in popularity, with almost 10 million rafters and 2 to 3 million kayakers, yet little has been published concerning the safety or hazards of these activities. This article reviews the demographics of such injuries and the types of injuries commonly encountered. Fortunately, fatalities are uncommon in these activities, with rafting and kayaking fatalities occurring at a rate of 0.55 and 2.9 per 100000 user days, respectively. Injury rates for kayaking and rafting are 3 to 6 and 0.26 to 2.1 per 100000 boating days, respectively. Acute injuries in kayaking are usually due to the transferred force of the water on the upper extremity, most often the shoulder, or the impact on an object while "swimming." Acute rafting injuries are more often due to contact with another rafter's paddle or other equipment; the next most common injury is the rafter hitting an object while "swimming." Chronic injuries are very uncommon in rafting but account for 25% to 40% of all kayaking injuries and are most often either shoulder or wrist complaints.

Unusual freshwater near-drowning syndrome in a hospitalized postlobectomy patient

Near-drowning syndrome depends on the duration of submersion, the amount of fluid aspirated, and the severity of hypoxia. We report a case in which a patient developed ARDS shortly after undergoing a left upper lobectomy and a chest wall resection for a lung carcinoma. On further investigation, the ARDS was caused by near-drowning in a basin of freshwater: the patient's face was submerged by the patient's companion as part of a cultural tradition of trying to clean his lung. We believe that this case presents the etiology of freshwater near-drowning syndrome due to an ethnogenic practice not previously reported.

Near drowning in cold water

Drowning and near drowning is a common cause of accidental death all over the world; specially in road traffic accidents over bridges, swimming pool and boat tragedies. Cold water drowning resulting in hypothermia can lead to instant death before actual drowning. Five cases of near drowning (ND) in cold water, who presented with varied clinical picture like coma with decerebrate rigidity and fixed dilated pupils, hypertension with coma and delayed pulmonary oedema (Secondary drowning) are reported. Energetic management with continuous positive airway pressure was very rewarding in all patients with ND except in one who had transient organic psychosis persisting for two weeks followed by minimal cognitive defect in the form of slow mentation, lack of drive and mild irritability (Bender Gestald Test Score of 53). We have tried to analyse some of the clinical features of ND and the sequel associated with it. The management as well as recent developments in the field are also discussed.

Unexplained fainting, near drowning and unusual seizures in childhood: screening for long QT syndrome in New Zealand families

AIMS

To construct detailed pedigrees of five New Zealand families with autosomal dominant long QT syndrome (LQTS) and screen selected individuals based on initial symptomatic and ECG data.

METHODS

Clinical data were collected using a questionnaire and relevant medical record review. Participants were then classified according to ECG diagnostic criteria based on the presence or absence of symptoms and the rate-corrected QT interval (QTc) into three groups: affected, uncertain or unaffected. Blood samples were also collected from each participant and DNA extracted for genetic testing.

RESULTS

Seventy-eight family members were screened. The majority of the 35 symptomatic family members, who were affected on these criteria, had presented with symptoms in childhood. Of the remaining 43 asymptomatic family members, the majority were in the uncertain diagnostic group based on these ECG criteria.

CONCLUSIONS

Autosomal dominant long QT syndrome (Romano Ward syndrome) is being increasingly recognised and must be considered in the investigation of children who present with unexplained fainting, near drowning, unusual seizures and sudden death. Screening long QT syndrome families based on ECG criteria remains difficult leaving a number of family members with an uncertain diagnosis. It is hoped that genetic testing will become useful for diagnosis of presymptomatic carriers of long QT syndrome in New Zealand in the future.

Kerosene-induced severe acute respiratory failure in near drowning: reports on four cases and review of the literature

OBJECTIVE

The purpose of this study is to present an unusual respiratory and cardiovascular course after intoxication and near drowning in a river contaminated with kerosene.

DESIGN

Case reports and review of the literature.

SETTING

Intensive care unit of a university-affiliated hospital.

PATIENTS

Four patients after near drowning.

INTERVENTION

Supportive only.

RESULTS

The four patients developed acute respiratory failure. Cardiomyopathy was present in three patients and a persistent hypokalemia in two patients. The onset of the symptoms was delayed, which led to underestimation of the severity of their illness. Two of the four patients died. The diagnosis of hydrocarbon intoxication was based on bronchoalveolar lavage results, neutrophilic alveolitis with the presence of lipid-laden macrophages, and evidence of lipoid pneumonia from the autopsy performed on one victim. One patient who clinically deteriorated and another who developed a severe restrictive pulmonary disorder were treated with corticosteroids, which were effective only in the latter patient.

CONCLUSIONS

Acute kerosene intoxication in a near-drowning event often results in severe respiratory and cardiac failure, with a high fatality rate. Treatment with corticosteroids may lead to a rapid improvement in lung function.

Drowning and near-drowning--some lessons learnt

Over a period of sixteen months, 17 cases of submersion injury (encompassing victims of drowning and near-drowning) were attended to at our Accident and Emergency Department at Changi General Hospital. Most of the victims were inexperienced recreational swimmers, and in 6 of them, early bystander cardiopulmonary resuscitation enabled them to recover without severe morbidity. Non-cardiogenic pulmonary oedema with resulting chest infection was the commonest complication in survivors. Most of the episodes occurred in an urban setting in swimming pools without supervision by lifeguards. About two-thirds of the cases were adults over the age of fifteen years. In addition, there were patients in whom submersion injury was associated with more sinister conditions (fits, traumatic cervical spine injury, dysbarism, intoxication from alcohol or drugs), some of which were unsuspected by the doctors initially. Apart from the immediate threats of hypoxia and pulmonary injury, active search for any possible precipitating causes and associated occult injury should be made. In this study, the determinants of survival from near-drowning were early institution of cardiopulmonary resuscitation, presence of pupil reactivity, and presence of a palpable pulse and cardiac sinus rhythm.

Near drowning. Rescuing patients through education as well as treatment

Optimal prehospital care of near-drowning victims requires bystanders and emergency-response personnel who are knowledgeable in CPR and proper rescue techniques. Primary care physicians can play an important role when asked to teach CPR, first-responder, or emergency-care classes or to serve as medical director for a local ambulance group. Rapid response and appropriate ventilation and airway protection by prehospitalization providers can improve the condition of near-drowning victims on arrival in the emergency department and their chances for neurologically intact survival. With knowledge of the local risks of drowning, proper emergency treatment, appropriate referral, and conscientious efforts at prevention conducted in the office and the community, primary care physicians can have maximum impact on this summer-time killer.

Inflicted submersion in childhood

OBJECTIVE

To improve characterization and recognition of inflicted pediatric submersions.

DESIGN

Retrospective case series, records review.

SETTING

A regional children's hospital and the King County (Washington) Medical Examiner's office.

PATIENTS

Children younger than 19 years who sustained submersion injury between 1983 and 1991 and were hospitalized or autopsied.

OUTCOME MEASURES

Two pediatricians, using preestablished criteria, categorized abstracted case scenarios as either inflicted or unintentional events. The two groups were compared.

RESULTS

Of 205 submersions, 16 (8%) were judged to have been inflicted. Objective physical signs of abuse and incompatibilities between the history and the child's stage of development or physical findings were common (69% and 50%, respectively). Inflicted submersion victims were likely to be young (median age, 2.1 years). They tended to be the youngest sibling in a large (three or more children) household. Social and demographic attributes of inflicted and unintentional submersion victims did not differ significantly. Bathtubs were the most common site for inflicted submersions (9/16 [56%]), and submersions in bathtubs were frequently inflicted (9/34 [26%]). Compared with unintentional submersion victims, children who were inflicted submersion victims were less likely to be revived by bystanders (relative risk, 0.10; confidence interval, 0.01 to 0.72) and were more likely to die (relative risk, 4.32; confidence interval, 1.40 to 21.43).

CONCLUSIONS

Enough childhood submersions are inflicted to warrant careful case evaluation. Bathtub submersion victims and children with physical and historical findings common to other forms of abuse are most likely to be the victims of inflicted submersion.

Ten-year review of pediatric bathtub near-drownings: evaluation for child abuse and neglect

STUDY OBJECTIVE

To evaluate the risk factors associated with bathtub submersion injury and their relationship to child abuse and neglect.

DESIGN

Retrospective chart review.

SETTING

An urban children's hospital.

PARTICIPANTS

Any child sustaining a bathtub near-drowning over the 10-year period from 1982 to 1992.

INTERVENTIONS

None.

RESULTS

Twenty-one patients were treated for bathtub near-drownings during the 10-year period, accounting for 24% of all submersion injuries. A significant number (67%) had historic and/or physical findings suspicious for abuse or neglect, including incompatible history for the injury, other physical injuries, previous child abuse reports, psychiatric history of the caretaker, and/or psychosocial concerns noted in the chart. The mortality rate of 42% was significant. No demographic characteristics identified the children at risk.

CONCLUSION

Many children who are injured in the bathtub suffer from abuse or neglect. Medical evaluation should include social work consultation and a search for other accompanying injuries.

Accidents and child abuse in bathtub submersions

Non-accidental bath drowning is an infrequently reported form of child abuse. Details of 44 children who suffered from drowning or near drowning in the bath were analysed from a two year (1988-9) UK study to investigate factors that might point to abuse. Cases of near drowning were notified through the British Paediatric Surveillance Unit inquiry system and drowning cases from the Office of Population Censuses and Surveys, the Scottish Government Record Office, and the Northern Ireland Office. In 28 cases the story was of accidental submersion with a baby of modal age 9 months being left unsupervised in a bath. Two other neonates briefly slipped from the parents arms while having a bath. Four bathtub drownings were related to epilepsy. In contrast 10 cases (six drowning and four near drowning) had stories very suggestive of abuse with inconsistent histories, previous history of abuse, and late presentation for medical care. A diagnosis of abuse should be considered in the differential diagnosis of atypical bathtub immersions in the absence of epilepsy and developmental delay.

Aspiration emergencies

Aspiration of foreign material into the lungs can represent a medical emergency requiring timely interventions to assure a favorable outcome. Establishment of a patent airway and maintenance of adequate oxygenation are the initial requirements for successful treatment of all types of aspiration emergencies. The nature of the aspirated material dictates further interventions and potential outcome.

[The pulmonary manifestations of diving accidents]

Scuba diving is associated with risks of drowning, lung barotrauma and decompression sickness. In case of near-drowning, irreversible neurologic lesions or death may follow an acute hypoxemia or a cardiopulmonary arrest. Therefore, victims of drowning should benefit from an immediate and prolonged cardiopulmonary resuscitation. Lung barotrauma are due to the failure of expanding lung gases to escape during ascent; they are likely to be complicated by arterial gas embolism. They can follow a panic ascent even from a shallow depth. Most of decompression procedures induce the formation of asymptomatic venous gas bubbles, normally filtrated and eliminated by the lungs. In case of massive intravenous bubbling, the filtering capacity of the lungs can be overwhelmed and the lung microcirculation damaged up to the point of provoking a cardio-respiratory failure.

Epilepsy in children and the risk of drowning

To clarify the risks of drowning for children with epilepsy we have studied the records of the 306 children who drowned or nearly drowned in the UK in 1988 and 1989. Ten children with incidents related to epilepsy presented over the study period, four of whom drowned. Children with epilepsy had a higher incidence of submersion accidents but no child participating in supervised swimming drowned. Two children died in the bath. Five children had special needs. We conclude that children with epilepsy can enjoy swimming with a friend in a lifeguard supervised swimming pool. They should be encouraged to shower in a non-glass cubicle rather than have a bath. The bathroom should remain unlocked. Children with poorly controlled epilepsy or associated learning difficulties are at a higher risk from all accident trauma. They need a very high level of supervision while swimming and advice should be given on an individual basis according to what is considered realistic for that child.

Epilepsy as a risk factor for submersion injury in children

The purpose of this study was to determine the risk of submersion injury and drowning among children with epilepsy and to define further specific risk factors. In a population-based retrospective cohort study the authors identified and reviewed records of all 0-through 19-year-old residents of King County, Washington, who suffered a submersion incident between 1974 and 1990. Children with epilepsy were compared with those without epilepsy with regard to age, sex, site of incident, supervision, outcome, and presence of preexisting handicap. Relative risks were determined using population-based estimates of epilepsy prevalence. Of 336 submersions, 21 (6%) occurred among children with epilepsy. Children with epilepsy were more likely to be greater than 5 years old (86% vs 47%) and more likely to submerge in a bathtub (38% vs 11%). The relative risk of submersion for children with epilepsy was 47 (95% confidence interval [CI] 22 to 100) in the bathtub and 18.7 (95% CI 9.8 to 35.6) in the pool. The relative risk of drowning for children with epilepsy was 96 (95% CI 33 to 275) in the bathtub and 23.4 (95% CI 7.1 to 77.1) in the pool. These data support an increased risk of submersion and drowning among children with epilepsy.

Submersion injuries in children younger than 5 years in urban Utah

Submersion injuries of children younger than 5 years in 4 urban Utah counties from 1984 through 1988 were studied retrospectively to identify associated risk factors. Infants younger than 1 year had the highest rates of both submersion injuries and deaths. The incidence of bathtub drownings was 2 to 3 times higher than reported national rates. All bathtub drownings occurred while the victim was bathing with a young sibling (10 months to 7 years of age) without adult supervision. All drownings in pools and moving bodies of water (rivers, irrigation ditches) resulted from unintentional falls into the water rather than from swimming and wading activities. Drowning prevention strategies should focus on educating parents about the risk of young children bathing with siblings in the absence of adult supervision and fencing regulations for pools and open bodies of moving water.

Immersion events in residential swimming pools. Evidence for an experience effect

BACKGROUND

--Drowning and near-drowning in residential swimming pools are leading causes of morbidity and mortality for young children. We tested the hypothesis that the period immediately after a pool is acquired is a time of high risk for these events. This study was also designed to provide population-based data on swimming pool immersion events, regardless of severity.

METHODS

--We conducted a mail survey of a probability sample of Sacramento County, California, households with in-ground swimming pools in January 1988; 80% of eligible subjects responded. Onset of exposure to a pool was defined as the month in which (1) the responding household had a pool installed, or (2) the responding household first occupied a residence with a pool. Exposures began in 1959 through 1987.

RESULTS

--The home swimming pool immersion event rate was 11 per 1000 pool-years. The rate per 1000 pool-years was higher for the first 6 months of exposure than thereafter (0 to 6 months, 44; 7 to 24 months, 14; greater than 24 months, seven), but 77% of events occurred outside the high-risk period. For households whose exposures began in 1984 through 1987, the immersion event rate was 51 per 1000 pool-years overall and 123 per 1000 pool-years for the first 6 months of pool exposure; these increases probably represent underreporting of earlier events. In this group, 48% of events occurred outside the high-risk period. The family swimming pool accounted for 91% of immersion events at the respondents' homes.

CONCLUSIONS

--The residential swimming pool is an important hazard for pool-owning households. The first 6 months of exposure constitute a high-risk period, but many immersion events occur later. Pool drowning prevention programs may focus on newly acquired swimming pools and their owners but should be as broad as possible to maximize their effectiveness.

[Near drowning of a child with severe epilepsy]

A case of near-drowning in an 11 year old child with severe epilepsy (myoclone-astatic) is described. The child was left alone in a indoor swimming-pool and was found lifeless on the bottom 1-2 minutes later presumably after an epileptic seizure. Resuscitation was instituted immediately and the child survived without sequelae. Leaving children with seizure phenomena without observation in the neighbourhood of swimming pools, is warned against.

Childhood drowning and near-drowning in the United States

More than 2000 children drown each year; in some states drowning is considered the leading cause of death for children under the age of 5 years. Many survivors of near-drowning have permanent neurologic disability. There are two distinct high risk groups: children under 5 years of age and boys aged 15 to 19 years. Most drownings in the former group occur in residential pools. Among survivors, the clinical course is bimodal; intact survival and survival with severe permanent disability are the most likely outcomes. The outcome of an immersion event is determined within a few minutes of the onset of immersion, mandating an emphasis on primary prevention. A requirement for pool fencing is the most promising such strategy and could be implemented soon. Training in cardiopulmonary resuscitation and (for older children) alcohol abuse prevention programs may be valuable adjuncts.