Submersion Injuries in Pediatric Population

Ashley Grigsby, MSIII

Disclosures

July 22, 2013

For most of the country, people are still putting on their winter jackets and mittens. But in Arizona, swimming pool season is fast approaching and unfortunately, an increase in submersion injuries (near drowning) comes with it.

The number of swimming pool deaths is highest in Arizona, Nevada, Mississippi, and Florida. Drowning is the second most common cause of death for children ages one-four, after congenital anomalies. It is also the third leading cause of accidental death in the United States. Children age 14 and under account for one in five deaths from drowning and for every child who dies, another five will need emergency care for nonfatal injuries.[1] For these reasons, it is critical that emergency physicians be familiar with the management of submersion injuries.

Signs and symptoms of near drowning include respiratory distress, tachypnea, rales, wheezing and possible hypothermia. Obviously, initial management includes the ABCs — Airway, Breathing and Circulation. The indications for intubation include: signs of neurologic deterioration, PaO2 less than 60mmHg or SpO2 less than 90% on high flow supplemental oxygen, or a PaCO2 above 50mmHg.[2] If the patient requires intubation an orogastric tube should be placed. This will help to reduce the amount of gastric distension caused by water intake in near drowning.[3] If intubation is not required supplemental oxygen should be given to maintain oxygen saturation at 94% or higher.[3]

A trauma evaluation should be done with imaging as needed. The cervical spine should not be immobilized in submersion injuries unless there is a mechanism of possible trauma. Cervical spinal cord injury is uncommon in near drowning patients; therefore, spine immobilization should not be done due to the possible interference with establishing an airway.[3]

Cardiac monitoring should also be conducted in all of these patients due to the high incidence of arrhythmias due to hypothermia, often encountered in submersion injuries. Arrhythmias should be treated according to ACLS guidelines. All wet clothes should be removed and rewarming initiated. Due to the neuroprotective effects of hypothermia, CPR should continue until the temperature reaches 32-35 ºC, even if CPR lasts for several hours.[3]

About 75% of drowning patients survive; however, there are several factors that indicate poor prognosis: submersion more than 10 minutes, time to BLS more than 10 minutes, resuscitation longer than 25 minutes, age less than three years, Glasgow coma scale less than five, arterial blood pH <7.1 on presentation, and water temperature greater than 50 ºF. The colder the water in which the injury occurs, the better the neurologic outcome seen. This is due to the protective effects of hypothermia.[3]

Symptomatic patients should be admitted until symptoms resolve. However, review of asymptomatic patients showed that pediatric patients developed symptoms within seven hours of submersion. Therefore, asymptomatic patients should be observed for eight hours and admitted if their clinical appearance worsens. If there is no change or decline in the patient's vitals, oxygen saturation or a chest radiograph obtained at the end of eight hours, then the patient may be discharged. However, adequate follow-up and a responsible adult are absolutely necessary for discharge.[3]

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