Drowning Management - Nelson's Textbook of Pediatrics

Definition (WHO / Nelson's)

Epidemiology

• Second most common cause of unintentional injury death in children (after MVAs)
• Peak ages: toddlers (1-4 years) in pools/bathtubs, and adolescents (15-19 years) in open water
• Males predominate (4:1 ratio)
• Children with epilepsy are at significantly higher risk
• Risk factors: lack of supervision, alcohol/drugs, underlying cardiac arrhythmias (LQTS, HCM), hyperventilation before breath-hold diving

Pathophysiology

1. Voluntary breath-holding on submersion
2. Laryngospasm - initially prevents aspiration ("dry drowning" - occurs in ~10-15%)
3. Hypoxia develops, leading to relaxation of laryngospasm
4. Aspiration of water occurs in ~85%
5. The CNS hypoxic-ischemic insult is the primary determinant of outcome

• Freshwater: hypotonic, absorbed rapidly → surfactant washout, atelectasis, V/Q mismatch
• Saltwater: hypertonic, draws fluid into alveoli → pulmonary edema
• Clinical distinction is NOT significant - the end result (hypoxemia) and management are the same

Clinical Features

Management

1. Prehospital Care

• Priority: Restore ventilation and oxygenation as quickly as possible
• Rescue victim from water safely; do NOT delay CPR to drain water
• Heimlich maneuver / abdominal thrusts are NOT recommended to expel water - they delay CPR and increase aspiration risk
• Cervical spine injury is rare (0.5%) - immobilize only if there is a history of diving, fall from height, or motorized vehicle crash
• Begin CPR immediately if apneic/pulseless - start with rescue breaths (5 initial breaths), then 30:2 compressions:ventilations
• Administer 100% high-flow O₂ by non-rebreather mask if breathing spontaneously
• In-water resuscitation: mouth-to-mouth ventilation in water by trained rescuer is beneficial
• All patients with loss of consciousness, amnesia, or observed apnea → transport to ED

2. Emergency Department Management

GCS ≥13 AND SpO₂ ≥95%

• Observe for 4-6 hours
• Monitor O₂ saturation continuously
• Laboratory tests and CXR usually NOT necessary (not predictive of outcome)
• If SpO₂ remains ≥95% and lung exam is normal (no rales/rhonchi/wheeze) → safe to discharge home
• Instruct to return for fever, mental status changes, or respiratory symptoms
• If deterioration occurs → treat as GCS <13

GCS <13 OR SpO₂ <95%

• Supplemental oxygen to maintain SpO₂ ≥95%
• If high-flow O₂ (FiO₂ 40-60%) fails to maintain PaO₂ >60 mmHg (>80 in children) → endotracheal intubation + positive-pressure ventilation
• CPAP/PEEP: use supernormal PEEP to recruit fluid-filled alveoli
• Investigations:
  • CXR, ABG, CBC, electrolytes, glucose, CK, urine myoglobin, urine drug screen
  • ECG (arrhythmias), PT/PTT
  • Troponin if cardiac dysfunction suspected
• Continuous cardiac monitoring + pulse oximetry + temperature monitoring
• Treat hypothermia (see below)
• Admit to ICU

3. Specific Management Issues

Hypothermia

• Remove wet clothing; dry the patient
• Mild (32-35°C): Passive rewarming (warm blankets, warm environment)
• Moderate (28-32°C): Active external rewarming (warm IV fluids at 40°C, warm humidified O₂)
• Severe (<28°C): Active internal rewarming - gastric/bladder irrigation with warm saline; consider ECMO if cardiac arrest persists
• "Not dead until warm and dead" - CPR must continue until core temp ≥32°C
• Complete neurologic recovery after icy-water submersion is possible even after prolonged arrest

Cardiovascular

• For post-arrest patients, epinephrine response is short-lived → start continuous dopamine or epinephrine infusion
• Hemodynamic recovery expected within 48 hours if it will occur
• Echocardiography useful for ventricular function assessment

Neurological / Cerebral Resuscitation

• Cerebral edema degree is set at time of anoxic insult
• Mannitol, loop diuretics, hypertonic saline, hyperventilation, ICP monitoring, barbiturate coma - NONE have shown outcome benefit
• Therapeutic hypothermia (targeted temperature management) - controversial; does not reliably improve outcome in pediatric drowning (unlike cardiac arrest from other causes)
• Treat seizures aggressively (benzodiazepines → phenobarbital)

Pulmonary

• ARDS may develop - manage with lung-protective ventilation (low tidal volume 6 mL/kg, high PEEP)
• Prophylactic antibiotics - NOT recommended (do not improve outcome; risk of resistant organisms)
• If pneumonia develops, consider unusual organisms: Aeromonas, Pseudomonas (especially freshwater/pond submersion)
• Bronchoscopy only if unexpected ventilation difficulty

Electrolytes

• Electrolyte abnormalities are seldom clinically significant in drowning
• May occur with massive aspiration, hemolysis, or renal injury from myoglobinuria

Prognosis

• Alert on arrival, GCS >13
• No CPR required at scene or ED
• Submersion <5 minutes
• Cold water (<20°C)
• Prompt resuscitation
• Age <14 (children have better neurological recovery)

• Bystander CPR required at the scene
• Submersion >10 minutes
• Resuscitation >25 minutes
• Coma on arrival (GCS <5)
• Asystole at ED arrival (if normothermic)
• Fixed dilated pupils
• pH <7.1 on ABG
• Apgar score <3 at 5 minutes

Flowchart (Tintinalli's / Standard of Care)

Prevention (Nelson's Emphasis)

• 4-sided pool fencing (most effective single intervention)
• Supervision within arm's reach for children <5 years
• Swim lessons for children ≥4 years (AAP recommendation)
• Life jackets in open water
• Never swim alone
• CPR training for parents/caregivers
• Drain buckets and bathtubs immediately after use

Key Nelson's Points Summary

• Thomas AA, Caglar D. Chapter 91: Drowning and Submersion Injury. In: Nelson Textbook of Pediatrics, 21st ed. Kliegman RM et al (eds). 2020, pp. 607-614
• Tintinalli's Emergency Medicine: A Comprehensive Study, Chapter 215 - directly from library
• PMC review: Epidemiology, clinical aspects, and management of pediatric drowning