Paediatrics: Drowning

Drowning

Drowning is caused by submersion in water. When water has been aspi-rated into the lungs it is usually a small amount (<22mL/kg). In 10% there has been laryngospasm without aspiration of water. The location—sea, freshwater, brackish water—is of little consequence. However, the tem-perature of the water is important, and the incident is classified as warm, cold, and very cold when the water temperature is 20°C, 6–19°C, and = <  5°C, respectively.

Symptoms

Respiratory acidosis occurs with inadequate ventilation.

·  If there has been a hypoxic–ischaemic insult, brain swelling, and raised intracranial pressure (ICP) may develop.

·  Hypoxaemia and inadequate perfusion will cause acidosis, arrhythmia, and shock.

Aetiology

Children under 3yrs old and teenagers are most at risk. Young children may have accidents in pools and bathtubs if left unattended. Assess the duration of submersion, water temperature, and presence of cyanosis or apnoea. Emergency staff should provide details of resuscitation and the time taken to establish a pulse and cardiac output. Consider:

·  head and neck injuries from diving;

·  pre-existing cardiac arrhythmia;

·  pre-existing seizure disorder;

·  drug and alcohol abuse.

Initial treatment

Follow a standard protocol.

·  AB: the neck may be injured and the airway may be obstructed by material from the water. Clear the mouth and immobilize the neck. If there is no gagging, hypoxaemia, or apnoea, then endotracheal intubation is needed. At the time of intubation use in-line traction.

·  C: poor perfusion occurs in children with severe hypoxic–ischaemic injury or pulmonary oedema.

·  Temperature: remove all wet clothing in order to avoid cooling. Warm the child to achieve a core temperature >35°C (use a heating blanket). In profound hypothermia, more invasive methods of warming may be used on the intensive care unit (e.g. heart–lung bypass or internal bladder and gastric lavage).

After resuscitation

·  Assess: vital signs, chest, heart, and the central nervous system.

·  Start: pulse oximetry and cardiac monitoring.

·  ECG.

·  Look closely for signs of lower respiratory tract involvement: use of accessory respiratory muscles, nasal flaring, tachypnoea, cough, wheeze, and crackles.