drowning Archives

drowning

July 12 2022

Drowning in Children

PME-Admin article, medical children, drowning, pediatric, pediatrics

Drowning in Children — Santa J. Bartholomew M.D.

Drowning

Drowning is defined as the submersion in liquid causing respiratory impairment. Terms such as near drowning, dry drowning, wet drowning, delayed drowning are all terms no longer used in the literature.

Fatal and non-fatal drownings are responsible for a significant cost to the US healthcare system. Estimated costs of drowning in 2015 were $68.5 million. Drowning is the one of the top 5 causes for death round the world in children 1 to 14 years old, so it is a substantial health risk worldwide.

RISKS FOR DROWNING

Age and location of fluid

10% of all fatal drowning incidents occur in bathtubs with the highest risk in children under 1 year old.
38% occur in pools in the 1- to 4-year-old age group.
43% occur in open water and with increasing risk as children grow older. Adolescents are the second only to toddlers in drowning death because of increased risk-taking behaviors in this age group.

Supervision

A study in Arizona, California and Florida found that 69% of children drowned during NON-SWIM times underscoring the need for appropriate barriers.
90% of parents in a survey by Safe Kids Worldwide attested that they consistently supervise children when they are in the water, meaning that most children drown under supervision.
If supervising adult is distracted talking on phone, texting, social media or impaired by alcohol of drugs children are at greater risk of drowning.

Medical Conditions

Medical conditions such as epilepsy increase risk of drowning. In fact children with epilepsy have a 10 fold higher risk of drowning than those without epilepsy.
Children with Autism, Prolonged QT syndrome, other arrythmias are also at increased risk.

Sex and Race

Boys are twice as likely to drown than girls and it is the leading cause of death in boys worldwide.
CDC also report a racial disparity in which African- American children ages 5 to 9 years drown in pools at a rate 5.5 times higher than white children of the same age.

Alcohol and environmental factors

Alcohol plays a significant role in teenage drownings.

Boys are twice as likely to drown than girls and it is the leading cause of death in boys worldwide.

90% of most children drown even under adult supervision.

Alcohol plays a significant role in teenage drownings.

PATHOGENESIS OF DROWNING

Children typically drown quickly and quietly, they may slip under the water without a splash or thrashing as depicted by the media. There is an “intrinsic drowning response” in which the autonomic nervous system is triggered making the victim incapable of yelling out or waving their arms. The arms instinctively move to the side to try to lift the body and bring the head out of the water to breathe but because of relatively poor upper body strength this is often not accomplished.

The drowning process generally occurs in 1 minute or less.

COMPLICATIONS OF DROWNING

Central nervous system

Hypoxic-ischemic injury to the brain
Cerebral edema
Permanent neurologic damage – directly related to the duration of submersion

Pulmonary

Hypoxemia
Pneumonia
Acute respiratory distress syndrome
Pneumonia
Non -cardiac pulmonary edema
Chemical pneumonitis due to aspiration of gastric contents

Renal and metabolic

Metabolic acidosis: most common metabolic consequence of drowning
Renal insufficiency

Hypothermia

Water temperature in which patient was submerged is NOT a factor

Infectious and hematologic

Sepsis
Systemic inflammatory response syndrome
Hemolysis (rare)
Disseminated intravascular coagulation (rare)

Misnomers for drowning

These are terms used by lay media but not supported by the literature:

Dry drowning – historically used in cases in which no water was found in lung at autopsy.
Secondary drowning – describes patients with severe pulmonary edema after insult.

Management

Initiation of bystander CPR immediately after drowning is the most significant factor in good neurologic outcome.
Generally recommended to observe patients for 4 to 8 hours monitoring for hypoxia and respiratory distress or altered mentation.

Suggestions for the management of drowning

Pre-hospital interventions

Bystander cardiopulmonary resuscitation, and
Initiation of advanced cardiac life support.

In-hospital asymptomatic patients

Evaluation – pulse oximetry monitoring
Disposition – discharge after 4 to 8 hours of monitoring

In-hospital symptomatic patients

Evaluation – may include blood gas, complete metabolic panel, complete blood cell count, chest x-radiography, cardiorespiratory monitoring, pulse oximetry, toxicology testing.
Resuscitation
- Respiratory support to prevent further hypoxia.
- Volume expansion with intravenous fluids and vasopressors if needed.
- Electrolyte disturbance correction if indicated; however, will likely improve with ventilation, oxygenation, and fluids.
- Remove cold, wet clothing and warm patient to 91.4ºF to 96.8ºF (33ºC to 36ºC.)
Disposition
- In-patient admission to intermediate care until or ICU for patients with persistent respiratory distress or altered mental status.

DROWNING PREVENTION

Barriers and fences on all 4 sides of pool.
Employing a touch supervisor while children are in water. This person is in the water within arm’s length of swimming children
Water watcher: an adult that is at the pool side without distraction watching swimming children
Formal swimming lessons beginning 1 year old
Having all adults (or able-bodied persons) in household learn CPR.
Some type of flotation device for all children under 6 years old
Blocking of drain covers so children to not get stuck in drains
Weight bearing pool covers.

Install barriers or fences around all four sides of the pool.

Floatation devices for all children under the age of six.

Having all able-bodied household members trained in CPR.

Disclaimer: This web site provides general information about pediatric health and related subjects. The information and other content provided on this website or in any linked materials are not intended and should not be considered, or used as a substitute for, medical advice, diagnosis or treatment. Never disregard professional medical advice or delay in seeking it because of something that you have read on this website or in any linked materials.

May 3 2022

Common Home Emergencies

PME-Admin article, medical burns, children, drowning, falls, household accidents, ingestions, pediatric, pediatrics, suffocation

Common Home Emergencies — Santa J. Bartholomew M.D.

Common Home Emergencies include:

DROWNING

Drowning accounts for 6,000 to 8,000 deaths in the United States and 450,000 worldwide. Most common drownings in the United States occur mostly in the backyard pool or in bodies of water close to the home. It frequently occurs in the summer months as one would expect and is more common in male children as many traumatic injuries. In young children drowning is usually secondary to inadequate supervision but in adolescents drowning events are usually associated with risk-taking behaviors such as diving in shallow pools causing severe spine injuries or hyperventilating before submersion for a high.

Critical to good neurologic survival is bystander CPR at the scene by laypersons. Hypoxia is the main issue in drowning so anything to decrease this risk improves mortality.
Submersions > 5 minutes usually portend poor prognosis
Hypothermia has long been thought to be protective, especially if the child drowns in very cold water and body temperature falls rapidly.
Return of spontaneous circulation in less than 10 minutes usually provides a favorable outcome.

SUFFOCATION

Suffocation is the leading cause of unintentional injury in deaths of children under 12 months. Despite massive efforts to educated about safe sleep environments for infants we continue to see 900-1000 deaths/annum of infants suffocated or strangled in bed clothing. Soft bedding like in an adult bed, co-sleeping and covering infants with blankets are among the most dangerous sleeping environments for infants and children up to a year old. Adults impaired by alcohol and/or drugs are also major hazards as they can overlay or wedge and infant into a corner without being aware of it because of their impaired state.

INGESTIONS

There are myriad dangerous substances in the home that can in ingested accidentally or intentionally by children of all different ages in the home: household cleaners, medications, lithium button batteries, magnets, toys, cosmetics. SAFE STORAGE IS KEY!!

Age and sex are the two main risk factors. Across all medications children <5 is at the highest risk given the explorative nature and curiosity of this age group. Boys account for most ingestions in the home. Locking up medications, corrosive cleaning supplies and laundry pods are the best method of preventing these injuries.

Laundry Pods are brightly colored and look like candy but cause severe toxicity when ingested. They cause severe esophageal burns that can last a lifetime, pneumonitis, and central nervous system injury

BURNS

300 children/day visit emergency rooms for burn related injuries. Burns account for 16% of all hospitalizations for children less than 12 months old. Mortality is 0.4 to 2.8% among burned children, burns are the third most common cause of unintentional death in children 5 to 9 years old. Toddlers and preshool-age children sustain mostly scald burns, chemical burns, intraoral burns and electrical burns. Toddlers are higher risk of burn because of their mobility and curiosity. These types of burns in children that are not mobile are highly suspicious for non-accidental injury. In adolescents flame injuries are most common, boys more than girls because of risk taking behavior.

Burn prevention centers on anticipating injuries and trying to prevent these for example scalds are usually hot liquids pulled from stove or spilled with child in arms. Placing children in play pen or other safe environment while cooking prevents such injuries.
The key is adult supervision and attentiveness.

FIREARMS

Approximately 4000 children a year die from firearms in the home. This number has been rising in the last years. One half the homes in America have at least one gun in their home and about 1 in 10 families admit to having loaded and unlocked guns in their home. Five percent of children in the United States have witnessed a shooting in the past year.

Children most at risk for a firearm injury are males or adolescent age, minority ethnicity, and mental illness and mental illness in conjunction with alcohol or drug abuse.
Deaths of young children with a firearm are more likely related to intimate partner violence and more likely shot as innocent bystander in domestic conflicts.
Prevention of gun related injury requires firearms to be always locked and unloaded. Ammunition kept separate from the firearm. Counseling parents about safe gun storage.

FALLS

Education is the key to preventing falls in the home. For instance, preventing infants 0-6 months from falling requires not placing these infants in situations where they can fall: placing the car seat or bouncy seat on the table, placing an infant on the couch. Starting at the age when children become mobile (around 9 months) then preventing falls down stairs and from windows or decks requires acute attention to detail: placing safety gates, furniture corner covers, window safety devices and avoiding infant walkers.

Source Article: Accidents Waiting to Happen: A Review of Unintentional Household Injuries in Children Erin P. O’Donnell, MD,* Therese L. Canares, MD* *Department of Pediatrics, Division of Pediatric Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD