Fellows conference

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Pediatric Near Drowning

• Fellows conference
• July 19, 2007

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Question 1

• True or False?
• Near drowning is the accounts for the highest
  unintentional death in children?

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Question 2

• Aspiration of ____ cc/kg is required before
  altered blood volume
• Aspiration of ____ cc/kg is required before
  electrolyte abnormalities
• Most near drowning victims aspirate ____ cc/kg

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Question 3

• True or false?
• Increased intracranial hypertension is the most
  significant contribution to CNS injury in the
  first 24 hours?

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Question 4

• Children with seizure disorders are more likely
  to drown where?

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Question 5

• True or false ?
• If there is a family history of near drowning one
  can do genetic testing which may further identify
  family members at risk?
• There is a clinical test which may also be
  helpful?

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Near Drowning

• Objectives
• Define near drowning
• Discuss
• incidence
• epidemiology
• causes
• Review prognostic indicators
• Discuss therapeutic interventions
• Discuss opportunities that impact outcome

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Near DrowningDefinitions

• Drowning To die within 24 hours
  of a submersion incident
• Near Drowning To survive at least
  24 hours after a
  submersion
  incident (submersion)

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Near DrowningIncidence

• 140,000 annual submersion deaths worldwide
• 6-8,000 deaths in USA
• gt 7000 additional pts. require medical attention
• incidence holidays, warm weather
• Leading cause of injury in toddlers
• 3rd leading cause of all death lt 15 yr.
• 2nd leading cause of all accidental deaths

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Near Drowning

• Tragically 90 of all fatal submersion incidents
  occur within ten yards of safety.
• Robinson, Ped Emer Care 1987

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Relative Contribution of Various Submersion Media
to Drowning Accidents
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Near DrowningGroups at Risk

• Toddlers (40 of deaths lt 5 y.o.)
• School age boys
• Teenagers
• Males gt females (51)
• African-American children
• Children with
• seizures
• cardiac dysrhythmias

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Near DrowningRisk Factors Age
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Toddler Drownings

• Tend to occur because of lapse in supervision
• Majority in afternoon/early evening-meal time
• Responsible supervising adult in 84 of cases
• Only 18 of cases actually witnessed

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Causes of Near DrowningRecreational Boating

• 90 of deaths due to drowning
• 1,200/year
• Small, open boats
• 20 of deaths
• too few or no floatation devices !

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Other CausesDiving Injuries

• 700-800 per year
• Peak incidence 18-31 years
• No formal training
• 1st dive in unfamiliar water
• 40-50 alcohol related

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Other CausesSpas, Hot Tubs

• Entrapment
• drains
• hair, body parts, clothing
• winter pool/spa covers

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Bucket Drowning 1984-1989Risks

• Males gt females
• African-Americans gt Caucasians
• Warm months gt cold
• Peak October

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Near-Drowning Epilepsy

• 2.5-4.6 of drowning victims had pre-existing
  seizure disorder
• Drowned children with epilepsy more likely to be
  older than 5, drown in bathtub, not be supervised
• Relative risk of drowning for children with
  epilepsy
• 96 in bathtub (95 CI 33-275)
• 23 in pool (95 CI 7.1-77.1)

-Diekema et al., Pediatrics 1993
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Near-Drowning Long QT Syndrome (LQTS)

• Swimming may be a trigger for LQTS event
• Near-drowning event may be first presentation of
  LQTS (15 of 1st LQTS syncopal events)
• Gene-specific KVLQT1 mutation associated with
  swimming trigger and submersion event
• Can test with cold water face immersion
• Importance early diagnosis of survivor, or of
  family members consider with unexplained
  submersion

-Ackerman et al., NEJM 1999
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aspiration of water (90)
laryngospasm aborted
aspiration and laryngospasm
swallows water
Unexpected Submersion
anoxia, seizures and death without aspiration
(10)
laryngospasm recurs
Stage I (0-2 minutes)
Stage II (1-2 minutes)
Stage III
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Pathophysiology of Anoxia
Pulmonary Heme CNS
Hypercapnea
DIC
Anoxic damage Cerebral edema Defective
autoregulation Increased ICP
GI
Asphyxia
Hypercapnea Mucosal sloughing
Cardiac
Renal
Myocardial ischemia Fibrillation
ATN
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Near DrowningMulti-Organ Effects

• Hypoxic/ischemic cerebral injury
• Fluid overload
• Pulmonary injury
• Hypothermia

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Near Drowning Multi-Organ Effects

• Cerebral hypoxia is the final common pathway in
  all drowning victims

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Near DrowningCNS Injury

• Initial Hypoxia
• Post resuscitation cerebral hypoperfusion
• Increased ICP (doubtful)
• Cytotoxic cerebral edema
• Excessive accumulation of cytosolic calcium
  causing cerebral arteriolar spasm
• Increased free radicals

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Near DrowningCNS Injury

• With significant hypoxia can have Lance-Adams
  syndrome
• Post hypoxic (action) myoclonus
• Often mistaken for seizures
• Happens more often when coming out of sedation
• Must be differentiated from myoclonic status
  which has poor prognosis

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Near DrowningPulmonary Injury

• Aspiration as little as 1-3 cc/kg can cause
  significant effect on gas exchange
• Increased permeability
• Exudation of proteinaceous material in alveoli
• Pulmonary edema
• decreased compliance

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Near DrowningPulmonary InjuryFresh Water vs.
Salt Water

• Theoretical changes not supported clinically
• Salt water hypertonic pulmonary edema
• Fresh water plasma hypervolemia, hyponatremia
• Unless in Dead Sea
• Humans (most aspirate 3-4cc/kg)
• Aspirate gt 20cc/ kg before significant
  electrolyte changes
• Aspirate gt 11cc/kg before fluid changes

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The Bottom LineFresh Water and Salt Water

• Both forms wash out surfactant
• Damaged alveolar basement membrane
• Pulmonary edema
• ARDS

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Effect of Immediate Resuscitation on Outcome

• Review of 166 near-drowning children in
  California
• Children with good outcome 4.75 times more likely
  to have had immediate bystander CPR than poor
  outcome patients

-Kyriacou et al., Pediatrics, 1994
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TreatmentPre-Hospital

• Immediate, effective CPR
• Oxygenation, ventilation ASAP
• Chest compressions
• C-spine stabilization
• Avoid drainage procedures

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C-Spine Injuries Among Submersion Victims

• Immobilize all near-drowning patients
• 2244 submersion victims - Washington
• 11 C-spine injuries (0.5)
• All 11 in open bodies of water all had history
  of diving (RR 229), MVC, fall witnessed, gt 15
• No C-spine injury in 880 low-impact events
• Routine immobilization does not appear to be
  warranted

-Watson et al., J Trauma 2001
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TreatmentTransport

• Continue CPR
• Establish airway
• Remove wet clothes
• Hospital evaluation

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TreatmentEmergency Department

• Continue established therapies
• History, physical, labs
• Admit if CNS or respiratory symptoms
• Observe in ED for minimum 4-6 hours if
• Submersion gt 1 min.
• Cyanosis on extraction
• CPR required

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Predicting Ability for ED Discharge

• Several studies support selected ED discharge
• Child can safely be discharged home if at 6 hours
  after ED presentation
• GCS gt 13
• Normal physical exam/respiratory effort
• Room air pulse oximetry oxygen saturation gt 95

-Causey et al., Am J Emerg Med, 2000
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ICU Management StrategiesNon-invasive Ventilation

• Nasal /face mask
• Increase in small increments to maintain
• FIO2 lt 0.40
• QS/QT lt 20
• PaO2/FIO2 gt 300
• Wean slowly

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ICU Management StrategiesIntubation/VentilationI
ndications

• SpO2 lt 90 on FIO2 gt 0.6
• PaCO2 gt 50 with pH lt 7.3
• Increased work of breathing
• Abnormal CNS exam

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ICU Management StrategiesRespiratory

• Oxygenate - avoid hypoxemia
• Ventilate - avoid significant hyperventilation
• PEEP may be beneficial but is not prophylactic
• Exogenous surfactant

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Management StrategiesCardiovascular

• Re-warming ( to a degree ? benefit hypothermia)
• LOC 34 C
• Pupils dialate 30 C
• V Fib 28 C
• EEG iso-electric 20C
• CBF decrease 6-7 per degree C drop

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Management StrategiesCentral Nervous System

• Protect against 20 injury
• Perfuse it or lose it !!
• ICP monitoring not beneficial or recommended
• Some still monitor if
• Successful CPR followed by coma
• Sudden, unexplained deterioration

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Management Strategies Problem

• Studies evaluating results of cerebral
  resuscitation measures have failed to demonstrate
  that treatment directed at controlling increased
  intracranial pressure and maintaining normal
  cerebral perfusion pressure improves outcome
• Orlowski, PCNA 3485, 1987

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Historical Therapy HYPER-Directed Therapy

• Hyper-hydration diuretics
• Hyperventilation hypocarbia via controlled
  ventilation
• Hyperpyrexia aggressive hypothermia to 30
  degrees C
• Hyperexcitability pentobarbital coma
• Hyperrigidity neuromuscular blockade

-Conn et al., Can J Anesth 1979
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CONN (Toronto) - HYPER Therapy
-Conn et al., Can J Anesth 1979
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MODELL (FL) - NO HYPER Therapy
-Modell et al, Crit Care Med, 1984
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Management StrategiesCentral Nervous System

• ICP monitoring may not change outcome, just
  predict it
• Low ICP Better outcome
• High ICP Poor outcome

-Sarnaik et al., Crit Care Med, 1985
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ICU Management StrategiesOther Issues

• Antibiotics - no benefit of prophylaxis, may
  increase super-infection
• Fulminant Strep pneumoniae sepsis has been
  described after severe submersion
• Steroids - no demonstrated benefit

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Factors Considered Predictive of Poor Submersion
Outcome

• Submersion time
• Serum pH
• Need for CPR in the E.D.
• Time to first gasp
• Neuro evaluation

Survive or not?
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Near DrowningPrognostic Indicators
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Near DrowningPrognostic Indicators
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Near DrowningOrlowski Prognostic Criteria

• Age lt 3 years
• Estimated submersion gt 5 min.
• No CPR gt 10 min.
• Coma in ED
• pH lt 7.10

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Outcome and Predictors of Outcome in Pediatric
Submersion Victims

• Two pre-hospital risk factors
• length of submersion
• length of CPR
• Quan et al, Pediatrics, Oct 1990

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Outcome and Predictors of Outcome in Pediatric
Submersion Victims

• SURVIVAL
• 0/20 with CPR gt 25 minutes
• Quan et al, Pediatrics, Oct 1990

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Outcome and Predictors of Outcome in Pediatric
Submersion Victims
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Near Drowning Concern

• Prolonged resuscitation in the Emergency
  Department may increase the proportion of
  successful resuscitations without normal
  neurologic recovery!!

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Near DrowningTherefore

• Initiate full, immediate resuscitation
• Elicit circumstances of event
• After 25 min... of full but unsuccessful
  resuscitation think PROGNOSIS before continuing
  to resuscitate

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Near DrowningSocial and Economic Effects

• Divorce
• Sibling psychosocial maladjustment
• 100,000 years of productive life lost
• 4.4 million/year in direct health care costs
• 350-450 million/year in indirect costs
• 100,000/year to care for the neurologically
  impaired survivor of a near drowning

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Near Drowning Pediatrician Anticipatory Guidance

• Survey to 800 pediatricians
• 85 believe community involvement in legislation
  important
• 4 actually involved
• 40 gave written water safety materials
• 50 gave anticipatory guidance

-OFlaherty et al., Pediatrics, 1997
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Near Drowning Keeping Your Child Safe

• Never leave a child alone in or near water, even
  for a minute
• Limit pool access.
• Remove potential hazards

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Children with Epilepsy Safety Recommendations

• Child can swim in lifeguard-supervised swimming
  pool - no open water
• Older child should shower in a non-glass cubicle
  - no bath
• Leave bathroom unlocked
• Supervision!

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Near DrowningSwimming Pool Lore

• My Child is Water Safe because he/she has taken
  swimming lessons.

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Near DrowningKeeping Your Child Safe

• Learn CPR
• Use approved personal flotation devices
• Teach safe water behavior

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Near DrowningSummary

• Frequently preventable
• Mortality morbidity 20 to
• Hypoxic ischemic injury
• Multisystem organ dysfunction
• CPR is most important therapy
• Prolonged Poor prognosis

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Near DrowningSummary

• Submersion time
• Prolonged Poor prognosis
• Prevention through
• Education
• Supervision
• Barriers

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Near Drowning The Best Approach Therefore

• P revention !
• P revention !
• P revention !

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Near Drowning What can you do?

• P revention !
• Get parents involved in support groups
• P revention !
• Support legislative actions that require fencing
  etc.
• P revention !
• Promote SAFEKIDS and other safety movements

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Questions????
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Central Nervous System 1. anoxic damage 2.
defective autoregulation 3. cerebral edema 4.
increased ICP
Pulmonary System 1. secondary apnea,
aspiration 2. hypercapnea
Renal 1. acute tubular necrosis 2. acute
cortical necrosis
Cardiac 1. myocardial ischemia 2. fibrillation
low BP
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Pulmonary System 1. alveolar fluid 2. ARDS 3.
hypoventilation
Central Nervous System 1. cerebral edema 2.
intracranial hypertension
Dilution Effects 1. hypokalemia 2.
hemodilution 3. hemolysis
Gastrointestinal 1. gastric distension 2.
vomiting, aspiration 3. ileus
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Hypothermia
VASODILATION decreased ICP decreased BP
CENTRAL NERVOUS 1. reduced metabolism 2. reduced
ICP 3. ?protection? 4. may produce picture of
clinical death
CARDIAC dysrhythmia
RENAL FAILURE
DEATH
--- Rogers, Pediatric Critical Care