Management of Drowning in Pediatric Age

Topic Name Introduction Initial Assessment Resuscitation Critical Care Complications Prognostic Factors Prevention

Introduction to Pediatric Drowning Management

Definitions and Classification

• Drowning: Process of experiencing respiratory impairment from submersion/immersion in liquid
• Submersion Time:
  • Critical factor in outcome
  • Survival unlikely after >25-30 minutes
  • Exception: Cold water drowning
• Water Temperature Impact:
  • Warm water (>20°C): Rapid neurological deterioration
  • Cold water (<20°C): Possible protective effect
  • Ice-cold water (<5°C): Maximal protective effect

Epidemiology

• Risk Factors:
  • Age: Peak incidence 1-4 years
  • Gender: Males > Females
  • Location: Home pools, natural water bodies
  • Supervision gaps
  • Lack of barriers/safety measures
• Mortality Patterns:
  • Immediate deaths: 10-20%
  • Early deaths (<24h): 30-40%
  • Late deaths: 10-20%
  • Survival with sequelae: 20-30%

Initial Assessment

Scene Assessment

• Critical Information:
  • Submersion duration
  • Water temperature
  • Witnessed vs unwitnessed
  • Initial rescue attempts
  • Water type (fresh/salt)
• Safety Considerations:
  • Scene safety for rescuers
  • Multiple victim possibility
  • Environmental hazards

Primary Survey

• Airway:
  • Clear foreign material
  • Look for airway edema
  • Assess need for intubation
  • Cervical spine precautions if trauma
• Breathing:
  • Assess respiratory effort
  • Auscultate for crackles/wheezing
  • Check oxygen saturation
  • Look for signs of ARDS
• Circulation:
  • Check pulses and perfusion
  • Assess heart rate and rhythm
  • Look for signs of shock
  • Monitor blood pressure

Initial Vital Signs

Parameter	Severe	Moderate	Mild
GCS	≤8	9-12	13-15
SpO2	<85%	85-92%	>92%
Respiratory Rate	Apnea/Gasping	Tachypnea	Normal

Resuscitation Protocols

Immediate Actions

• Cardiac Arrest Management:
  • Begin high-quality CPR immediately
  • Use appropriate compression depth
  • Ensure adequate recoil
  • Minimize interruptions
• Airway Management:
  • Early intubation if GCS ≤8
  • Use cuffed ETT when indicated
  • Consider video laryngoscopy
  • Prepare for difficult airway

Ventilation Strategy

• Initial Settings:
  • PEEP: 5-10 cmH2O
  • Tidal Volume: 6-8 mL/kg
  • FiO2: Start 100%, titrate down
  • Target SpO2: 94-98%
• ARDS Protocol:
  • Higher PEEP strategy
  • Permissive hypercapnia
  • Prone positioning if severe
  • Consider HFOV in refractory cases

Medication Protocols

Medication	Indication	Dose	Notes
Epinephrine	Cardiac arrest	0.01 mg/kg	Q3-5 min
Midazolam	Sedation	0.1 mg/kg	Titrate to effect
Vecuronium	Paralysis	0.1 mg/kg	If indicated

Critical Care Management

Temperature Management

• Hypothermia Protocol:
  • Target temp: 32-34°C if indicated
  • Duration: 24-72 hours
  • Rewarming: 0.25-0.5°C/hour
  • Monitoring for complications
• Rewarming Techniques:
  • Passive external
  • Active external
  • Active internal
  • ECMO if indicated

Neurological Care

• Monitoring:
  • Continuous EEG
  • ICP monitoring if indicated
  • Serial neurological exams
  • Pupillary responses
• Management:
  • Maintain CPP >40 mmHg
  • Treat seizures aggressively
  • Control fever
  • Monitor electrolytes

Organ Support

• Respiratory:
  • Lung-protective ventilation
  • Regular recruitment
  • Surfactant if indicated
  • Consider ECMO
• Cardiovascular:
  • Maintain adequate BP
  • Support cardiac function
  • Monitor fluid balance
  • Treat arrhythmias
• Renal:
  • Monitor urine output
  • Check renal function
  • Consider CRRT if needed
  • Manage electrolytes

Complications and Management

Early Complications

• Respiratory:
  • ARDS (40-60% cases)
  • Pneumonia
  • Atelectasis
  • Pulmonary edema
• Neurological:
  • Cerebral edema
  • Seizures
  • Increased ICP
  • Brain death

Late Complications

• Neurological Sequelae:
  • Cognitive impairment
  • Motor deficits
  • Visual/hearing problems
  • Behavioral changes
• Systemic:
  • Chronic lung disease
  • Renal dysfunction
  • Psychological trauma
  • Growth issues

Prognostic Factors and Outcomes

Key Predictors

• Major Factors:
  • Submersion duration
  • Time to ROSC
  • Initial GCS
  • Water temperature
• Scoring Systems:

  Factor	Good Prognosis	Poor Prognosis
  Submersion Time	<5 minutes	>10 minutes
  CPR Duration	<10 minutes	>25 minutes
  Initial pH	>7.1	<6.8

Prevention Strategies

Primary Prevention

• Environmental:
  • Pool fencing (4-sided)
  • Self-closing gates
  • Pool covers
  • Drain covers
• Educational:
  • Swimming lessons
  • Water safety training
  • CPR training for caregivers
  • Public awareness

Secondary Prevention

• Supervision:
  • Constant adult supervision
  • Designated water watchers
  • No alcohol use while supervising
  • Emergency response training
• Safety Equipment:
  • Life jackets
  • Rescue equipment
  • Emergency phones
  • First aid kits