Drowning is a major cause of death in children. However, most children who present to emergency following “near drowning” will require nothing more than observation.
There is no clinical or therapeutically important difference between drowning in fresh or salt water
Water quality may influence the nature of acute lung injury due to secondary infection
Hypothermia is an important issue following submersion, especially in small children who have a large body surface area to weight ratio
Aspiration of water results in pulmonary oedema and wash out of surfactant causing acute respiratory distress syndrome (ARDS) with the consequence of hypoxaemia. Hypovolaemia may also occur as a result of tissue hypoxia and capillary leak.
Indicators of Poor Prognosis
Immersion time > 8 minutes
Initial serum pH < 7.0
Lack of initial effective CPR after rescue (delay longer than 10 minutes)
Lack of response to early resuscitation efforts
Comatose (GCS <5) on arrival in the ED
Important history points:
Need for basic life support
Mechanism of immersion – be aware of other injuries e.g. cervical spine or non accidental injury
Volume re-expansion is critical in the management of hypothermia – use saline rather than lactate containing fluids
Hypothermia is only neuro-protective if it occurs rapidly, prior to the onset of hypoxia (usually in water < 10ºC)
Effects of hypothermia:
Hypothermia substantially reduces effectiveness of defibrillation and resuscitation drugs. It is reasonable to attempt defibrillation, but if unsuccessful, continue cardiac compression until core temperature is > 30°C, when defibrillation / drugs are more likely to be effective.
Actively rewarm to 32oC then allow passive warming
Never diagnose death and thus stop resuscitation until the patient is rewarmed to at least 32°C, or cannot be rewarmed despite active measures
Children who are asymptomatic, or only suffered mild, transient symptoms on arrival following a brief submersion require a minimum of 8 hours of in-hospital observation (Emergency Observation Ward). Advise to see GP or return to ED if febrile or unwell after discharge.
If submerged for more than one minute, a period of cyanosis or apnoea, or required any CPR – admit for observation for 24 hours or at least overnight in Emergency Observation Ward, even if they are well in the emergency department. In children who are asymptomatic initially (even with normal CXR), cases of fulminant pulmonary oedema up to 12 hours after submersion have been reported. If any symptomatic deterioration, oxygen requirement or respiratory distress, for ICU admission.
Admit to ICU if:
required cardiopulmonary resuscitation
supplemental oxygen requirement
abnormal blood gases on arrival
altered level of consciousness
PMH ED Guideline: Immersion Injury. Last Updated November 2014