CASE

The overhead announcement goes off: “Team B to the trauma room”.  The report: EMS is bringing a 2-year-old female that was found unresponsive in the family swimming pool by her mother after being alerted by an older sibling. Unknown downtime. The patient is being bagged by bag-valve mask (BVM) and has slow, but palpable, femoral pulses, she is unresponsive, ETA 2 minutes.

Upon arrival, there is a 2-year-old female, being bagged, who is cyanotic and very wet. Primary survey is significant for unresponsiveness, spontaneous breaths with a rate of 5 breaths per minute, lung sounds are coarse throughout but present bilaterally. Palpable femoral pulses with a rate of 70, blood pressure 92/45, oxygen saturation of 73%. GCS calculated at 6 (E1V1M4). She is transferred to the ED stretcher and bagging is transferred to ED staff. There is vomitus in her mouth and covering her chest. Secondary survey is significant only for central and peripheral cyanosis, pupils are 4mm and sluggishly reactive, abdomen is distended, but no other signs of trauma.

DIAGNOSIS

Respiratory compromise secondary to submersion injury

DISCUSSION

Introduction

Drowning is defined as any injury occurring from water entering the airway. There are both submersion (airway below the water) and immersion (airway above the water) injuries. The terms “near, dry, wet, partial, and complete” should no longer be used as modifiers for the act of drowning, as they are not useful in discussing the common pathology of airway compromise due to water that leads to hypoxia.   

The highest risk age group for drowning worldwide is children 1-4 years old [1], which places the highest burden on the pediatric emergency medicine clinician. These injuries are also quite common with approximately 360,000 deaths globally each year [1]. The primary pathophysiologic driver of injury due to drowning is hypoxia.  Airway management and oxygenation is of the utmost importance. Pediatric patients tend to have better neurologic outcomes than adult victims of drowning, however morbidity and mortality are likely underreported.

Airway Management and Oxygenation

Positive pressure ventilation with the highest oxygen concentration available is the goal for resuscitation of a drowning victim who is obtunded. This can be achieved by mouth-to-mouth breathing in the prehospital environment, but ideally a BVM is available.  Establishing an airway, whether by airway adjuncts such as nasopharyngeal or oropharyngeal airway or by supraglottic device (SGA) should be the priority.  There are some concerns regarding pulmonary edema from aspiration causing high leak pressure for certain SGA’s [2], which could lead to air entering the stomach and increasing the risk of vomiting. Therefore, endotracheal intubation should be considered early.

Oxygenation should be optimized with the highest oxygen available during the acute resuscitation. The use of positive pressure ventilation, whether BVM or non-invasive positive pressure ventilation (NIPPV) is also suggested [1]. However, caution should be taken with NIPPV due to the significantly increased risk of vomiting due to drowning and therefore an increased risk of aspiration.

Circulation

Initial resuscitation should focus on airway control. if cardiac arrest ensues, then compressions should be started, with prioritization of a definitive airway and oxygenation. Cardiac arrest in the pediatric patient with a history of drowning is presumed to be due to hypoxia. If return of spontaneous circulation (ROSC) is obtained then standard post-ROSC measures should be taken.

Work-Up

After initial stabilization of the pediatric drowning patient some considerations for work-up include determining the cause of drowning. If there is concern for a possible cardiac or neurological event, then those workups can be undertaken. The same is true for toxic ingestion leading to drowning. In the true accidental drowning victim, there is little evidence for routine laboratory evaluations or chest radiograph, as these are neither diagnostic nor prognostic.

Computed tomography of the head and neck, as well as cervical spine immobilization, are only necessary if there is a history of head or neck trauma and should not be employed empirically.

Antibiotics can be considered; however, empiric antibiotics are not necessary in every drowning patient. Pneumonitis from aspiration can be seen on chest radiograph that can mimic pneumonia and leukocytosis can be seen due to demargination. Fever can also be present due to traumatic drowning, thus making the clinical diagnosis of pneumonia difficult.

Dexamethasone and other corticosteroids have been used in the past to treat inflammatory pneumonitis due to drowning and aspiration. However, there is insufficient evidence for the use of steroids empirically in drowning victims. [3]

Disposition

Any child with a drowning injury should be evaluated in the ED, particularly if there were prehospital interventions. In the ED, if the patient has normal mental status and oxygenation as well as a reassuring exam, observation and discharge may be warranted [4]. If any prehospital intervention or concern for respiratory decline, the patient should be admitted for observation. Signs of respiratory decline include hypoxia at any point, respiratory distress, or change in mental status. If cardiac arrest occurs, or if intubation is required ICU-level of care is warranted.

CASE RESOLUTION

The patient was optimized with BVM and 100% FiO2 as well as placement of a nasogastric tube for gastric decompression. She was not intubated, but with appropriate airway adjuncts and BVM her oxygen saturation rose to 95%. Her mental status improved to a GCS of 11 (E3V3M5) prior to transport to the PICU. Her chest radiograph showed diffuse pulmonary infiltrates, likely due to aspiration pneumonitis. She was admitted to the PICU and continued to improve over the coming days. She started interacting with her mother the evening of admission and made a full neurologic recovery.

TAKE-AWAYS

-       Pediatric drownings are most common in the 1–4-year-old age group

-       Airway, airway, airway.

-       Respirations before compressions if in cardiac arrest

-       Empiric treatment with antibiotics and corticosteroids are not indicated

Author:Sean Bilodeau, DO is a 2nd year Emergency Medicine Resident at Brown University

Faculty Reviewers: Meaghan Beucher, MD & Heather Rybasack-Smith, MD 

REFERENCES

1.     Schmidt, A. C., Sempsrott, J. R., Hawkins, S. C., Arastu, A. S., Cushing, T. A., & Auerbach, P. S. (2019). Wilderness Medical Society Clinical Practice Guidelines for the treatment and prevention of drowning: 2019 update. Wilderness & Environmental Medicine, 30(4). https://doi.org/10.1016/j.wem.2019.06.007

2.     Baker PA, Webber JB. Failure to ventilate with supraglottic airways after drowning. Anaesth Intensive Care. 2011;39: 675e7.

3.     Foex BA, Boyd R. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Corticosteroids in the management of near-drowning. Emerg Med J. 2001;18(6):465e6.

4.     Cantu, R. M., Pruitt, C. M., Samuy, N., & Wu, C. L. (2018). Predictors of emergency department discharge following pediatric drowning. The American Journal of Emergency Medicine, 36(3), 446–449. https://doi.org/10.1016/j.ajem.2017.08.057

5.     Auerbach, P. S., Cushing, T. A., & Harris, N. S. (2017). Drowning and Submersion Injuries. In Auerbach's wilderness medicine. essay, Elsevier.

6.     Wagner, C. (2009). Pediatric submersion injuries. Air Medical Journal, 28(3), 116–119. https://doi.org/10.1016/j.amj.2009.02.009

7.     Shenoi, R. P., Allahabadi, S., Rubalcava, D. M., & Camp, E. A. (2017). The pediatric submersion score predicts children at low risk for injury following submersions. Academic Emergency Medicine, 24(12), 1491–1500. https://doi.org/10.1111/acem.13278