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Updated: Dec 23 2021


  • 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
    • 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
    • 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
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