Snapshot A 5-year-old previously healthy male is brought to the emergency department (ED) after falling into a freshwater lake while hiking with his father. He was unaccounted for 15 minutes until his body was found floating face down in the water. He is cyanotic, pulseless, and apneic with fixed and dilated pupils. Temporal temperature is 80.0°F (26.7°C). Passive and active rewarming protocols are employed. Cardiopulmonary resuscitation (CPR) has been ongoing since he was found. The patient is intubated and mechanically hyperventilated for reduction of intracranial pressure and with high positive end-expiratory pressure (PEEP) settings for maximal alveolar recruitment. Chest radiograph reflects no evidence of pulmonary edema. Arterial blood gas (ABG) measurements reflect gradually correcting hypoxemia but persistent lactic acidosis. Intraosseous access is established for fluid administration. The patient is admitted to the pediatric intensive care unity (PICU). Introduction Clinical definition process resulting in primary respiratory impairment from submersion or immersion in water or other liquid medium Epidemiology Demographics 3rd most common cause of accidental death in United States bimodal distribution: children < 5 years and teenagers/young adults Risk factors inability to swim/inadequate supervision substance use hypothermia seizure disorder known/unknown cardiac arrhythmia ETIOLOGY Pathogenesis reflex inspiratory efforts lead to hypoxemia by either aspiration or laryngospasm Presentation Symptoms shortness of breath altered mental status, unconscious Physical exam vital signs hypotension hypothermia may have hypoxemia lung rales acute respiratory distress syndrome (ARDS) pulmonary edema decreased breath sounds pneumothorax cardiovascular dysrhythmias neuro hypoxemia/ischemia can easily lead to hypoxic encephalopathy and cerebral edema low GCS score check pupil size for dilation/response and focal deficits cervical spine injuries (especially with history of diving into shallow water) scuba-related injuries barotrauma air emboli renal metabolic and/or respiratory acidosis, acute tubular necrosis (ATN) due to hypoxemia/shock studies Complete blood count Electrolytes Creatinine Arterial blood gas Urinalysis Electrocardiogram imaging Chest radiograph Differential Suicide/homicide Seizure Heart arrhythmia Hypoglycemia DIAGNOSIS Diagnostic approach should be performed after initial primary/secondary assessment and resuscitation Treatment Initial management approach (immediate, in the field) primary and secondary survey with resuscitation move person out of water (including standing water) and dry off shake for consciousness check for breathing (agonal breathing is not effective breathing) if spontaneously breathing, give high-flow supplemental oxygen and check pulse if not effectively breathing, give 2 rescue breaths (look for visible chest rise) if patient does not respond to rescue breaths, then check pulse of note, priorities of CPR differ from that of typical cardiac arrest patients, which normally emphasizes immediate uninterrupted chest compressions check pulse (for 5-10 seconds, no longer) start advanced cardiovascular life support (ACLS) protocol/CPR if pulseless if respiratory arrest (no breathing, but has pulse) open airway with jaw thrust maneuver and provide basic ventilation artificial airways, suction, and advanced airways may be necessary intubate and mechanically ventilate early in apneic/unconscious patient continue efforts until patient's core temperature reaches 32 to 35ºC (90 to 95ºF) Other treatments remove wet clothing and rewarm indicated if hypothermic correct hypoxemia and acidosis especially indicated if patient has dysrhythmia nasogastric (NG) suction indicated if vomiting prevents aspiration and relieves gastric distension seizure control indicated if convulsing usually corrected with oxygen support if refractory, aggressively control non-sedating anticonvulsants such as phenytoin preferred as do not depress consciousness no routine cervical spine immobilization unless concerning history (e.g., shallow dive, associated with motor vehicle crash) Complications Respiratory failure or infection Permanent neurologic disability Death Prognosis Survival rates vary Factors associated with poor prognosis duration of submersion > 5 minutes (most critical) age > 14 years time to basic life support > 10 minutes resuscitation duration > 25 minutes Glasgow coma scale (GCS) < 5 arterial blood pH < 7.1 upon presentation drug or alcohol abuse preceding drowning