Pediatric Drowning: Current Management Strategies for Immediate Care

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This review will introduce new universal terminology recommended for drowning, review the pathophysiology of drowning, and discuss current management strategies for treating the drowning victim. Drowning is a major burden of injury for children. The drowning process results in hypoxia, the degree of which ultimately determines clinical outcome. No single or combination of variables has proven to be reliably predictive of poor outcome. Initial care is focused on reversing the hypoxia and maintaining cardiovascular stability. Injuries associated with drowning can be complicated by hypothermia as well as predisposing medical and traumatic conditions, all of which will need to be addressed concomitantly. Posthypoxic cerebral encephalopathy is a delayed outcome of drowning associated with the greatest morbidity. Thus, early measures to prevent secondary brain injury are important.

Section snippets

Definitions

In 2002, the World Congress on Drowning published expert consensus recommendations regarding drowning definitions, prevention, rescue, and treatment. Two recent reviews have summarized some of the expert conclusions 4, 5. The final report, Handbook on Drowning, was published in 2004 [6].

Terminology describing drowning has varied for decades. Lack of uniformity has resulted in confusion among clinicians and difficulty in interpreting and comparing reported data. Thus, a major goal of the World

The Pathophysiology of the Drowning Process

Understanding the drowning process provides rationale for current rescue and treatment strategies. The drowning process begins when the victim's airway lies below the surface of a liquid medium (usually water). Typically, voluntary breath-holding ensues. Small amounts of water are aspirated from the oropharynx/larynx, which triggers involuntary laryngospasm resulting in hypoxia. Large amounts of water are subsequently swallowed. With prolonged hypoxia, laryngospasm abates and more water is

Predicting Outcomes

A great deal of research has focused on epidemiological, clinical, and laboratory predictors of outcome for drowning victims. Four outcomes can occur in pediatric drowning: (1) full recovery (neurologically intact), (2) neurological impairment, (3) persistent vegetative state, and (4) death [20]. Predictors studied to date include demographic characteristics (age and sex), historical factors (submersion time, time to resuscitation, and cardiopulmonary resuscitation [CPR] at the scene), and

Scene Interventions

The immediate care of the drowning victim begins at the scene (Table 1). The importance of bystander resuscitation to restore oxygenation cannot be overemphasized. Mouth-to-mouth breathing should be initiated immediately, even while the victim is still in the water [8]. Any delay in pulmonary resuscitation exacerbates the existing hypoxia and decreases the victim's chances of intact survival 22, 36, 37. In fact, some studies have shown survival only in those victims who received bystander

Prevention

Prevention is the key link in the chain of survival [40]. A recent review of unintentional drowning deaths in the United States found that 78% of drowning deaths among infants were in bathtubs. Of drowning injuries in children 1 to 4 years, 56% were in artificial pools, and among those occurring in children older than 5 years, 63% occurred in fresh bodies of water [65]. Most pool drowning episodes occurred in the child's own home. The use of 4-sided pool fencing has been shown to reduce the

Summary

The immediate care of drowning victims is challenging because of unique pathophysiological mechanisms and complex management issues. Current resuscitation strategies focus on restoring oxygenation and perfusion and preventing secondary pulmonary and neurological injury. Hypothermic patients should be rewarmed to more than 32°C, recognizing that rewarming may be difficult in the absence of normal circulation. Extracorporeal rewarming can be considered for victims with profound hypothermia or

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