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Near Drowning-Revised 2007TPA.pp

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Near Drowning-Revised 2007TPA.pp Powered By Docstoc
					Pediatric Near Drowning
     Fellows conference
        July 19, 2007
Question 1

• True or False?
  – Near drowning is the accounts for the highest
    unintentional death in children?
Question 2

• Aspiration of ____ cc/kg is required before
  altered blood volume
• Aspiration of ____ cc/kg is required before
  electrolyte abnormalities
• Most near drowning victims aspirate ____ cc/kg
Question 3

• True or false?
  – Increased intracranial hypertension is the most
    significant contribution to CNS injury in the first 24
    hours?
Question 4

• Children with seizure disorders are more likely
 to drown where?
Question 5

• True or false ?
  – If there is a family history of near drowning one can
    do genetic testing which may further identify family
    members at risk?
  – There is a clinical test which may also be helpful?
Near Drowning
• Objectives
  – Define near drowning
  – Discuss
     • incidence
     • epidemiology
     • causes
  – Review prognostic indicators
  – Discuss therapeutic interventions
  – Discuss opportunities that impact outcome
Near Drowning
Definitions
• Drowning:   To die within 24 hours
                    of a submersion
 incident

• Near Drowning: To survive at least
                     24 hours after a
                    submersion incident
                      (submersion)
    Near Drowning
    Incidence
• 140,000 annual submersion deaths worldwide
• 6-8,000 deaths in USA
• > 7000 additional pts. require medical
  attention
• incidence: holidays, warm weather
• Leading cause of injury in toddlers
• 3rd leading cause of all death < 15 yr.
• 2nd leading cause of all accidental deaths
Near Drowning
•“Tragically 90% of all fatal
 submersion incidents occur
 within ten yards of safety.”

          Robinson, Ped Emer Care; 1987
Relative Contribution of Various Submersion
Media to Drowning Accidents

  Salt Water                                     1 - 2%
  Fresh Water                                    98%
    swimming pools: public                 50%
    swimming pools: private                3%
    lakes, rivers, streams, storm drains   20%
    bathtubs                               15%
    buckets of water                       4%
    fish tanks or pools                    4%
    toilets                                1%
    washing machines                       1%
Near Drowning
Groups at Risk
•   Toddlers (40% of deaths < 5 y.o.)
•   School age boys
•   Teenagers
•   Males > females (5:1)
•   African-American children
•   Children with:
     – seizures
     – cardiac dysrhythmias
      Near Drowning
      Risk Factors: Age
600

500

400

300                                         Male
                                            Female
200

100

 0
       0-4 yr   5-9 yr   10-14 yr   15-19
Toddler Drownings

• Tend to occur because of lapse in supervision
• Majority in afternoon/early evening-meal time
• Responsible supervising adult in 84% of cases
• Only 18% of cases actually witnessed
   Causes of Near Drowning
   Recreational Boating

• 90% of deaths due to drowning
• 1,200/year
• Small, open boats
• 20% of deaths
  – too few or no floatation devices !
Other Causes
Diving Injuries
• 700-800 per year
• Peak incidence 18-31 years
  – No formal training
  – 1st dive in unfamiliar water
  – 40-50% alcohol related
Other Causes
Spas, Hot Tubs

• Entrapment
 –drains
   •hair, body parts, clothing
 –winter pool/spa covers
   Bucket Drowning 1984-1989
   Risks
• Males > females
• African-Americans > Caucasians
• Warm months > cold
 –Peak = October
Near-Drowning
Epilepsy
• 2.5-4.6% of drowning victims had pre-existing seizure
    disorder
•   Drowned children with epilepsy more likely to: be older
    than 5, drown in bathtub, not be supervised
•   Relative risk of drowning for children with epilepsy:
     – 96 in bathtub (95% CI 33-275)
     – 23 in pool (95% CI 7.1-77.1)



                   -Diekema et al., Pediatrics 1993
Near-Drowning
Long QT Syndrome (LQTS)
• Swimming may be a trigger for LQTS event
• Near-drowning event may be first presentation of LQTS
    (15% of 1st LQTS syncopal events)
•   Gene-specific KVLQT1 mutation associated with
    swimming trigger and submersion event
•   Can test with cold water face immersion
•   Importance: early diagnosis of survivor, or of family
    members; consider with unexplained submersion

                   -Ackerman et al., NEJM 1999
                                 laryngospasm        aspiration
                                    aborted              of
                                                    water (90%)



               aspiration   swallows
Unexpected        and
Submersion                   water
             laryngospasm

                                                   anoxia, seizures
                                   laryngospasm      and death
                                       recurs          without
                                                  aspiration (10%)
         Stage I                Stage II            Stage III
      (0-2 minutes)          (1-2 minutes)
        Pathophysiology of Anoxia
     Pulmonary              Heme       CNS
      Hypercapnea           DIC      Anoxic damage
                                     Cerebral edema
   GI                                Defective
                                          autoregulation
Hypercapnea               Asphyxia
Mucosal sloughing                    Increased ICP


        Cardiac                          Renal
    Myocardial ischemia
                                          ATN
       Fibrillation
Near Drowning
Multi-Organ Effects
• Hypoxic/ischemic cerebral injury
• Fluid overload
• Pulmonary injury
• Hypothermia
Near Drowning
 Multi-Organ Effects

• Cerebral hypoxia is the
 final common pathway
 in all drowning victims
Near Drowning
CNS Injury
• Initial Hypoxia
• Post resuscitation cerebral hypoperfusion
  – Increased ICP (doubtful)
  – Cytotoxic cerebral edema
  – Excessive accumulation of cytosolic calcium causing
    cerebral arteriolar spasm
  – Increased free radicals
Near Drowning
CNS Injury
• With significant hypoxia can have Lance-Adams
 syndrome
  – Post hypoxic (action) myoclonus
  – Often mistaken for seizures
  – Happens more often when coming out of sedation
  – Must be differentiated from myoclonic status which
    has poor prognosis
Near Drowning
Pulmonary Injury

• Aspiration as little as 1-3 cc/kg can cause
 significant effect on gas exchange
  – Increased permeability
  – Exudation of proteinaceous material in alveoli
  – Pulmonary edema
  – decreased compliance
   Near Drowning
   Pulmonary Injury:
   Fresh Water vs. Salt Water
• Theoretical changes not supported clinically
  – Salt water: hypertonic pulmonary edema
  – Fresh water: plasma hypervolemia, hyponatremia
  – Unless in Dead Sea
• Humans (most aspirate 3-4cc/kg)
  – Aspirate > 20cc/ kg before significant electrolyte
    changes
  – Aspirate > 11cc/kg before fluid changes
The Bottom Line
Fresh Water and Salt Water

• Both forms wash out surfactant
• Damaged alveolar basement
 membrane
  – Pulmonary edema
  – ARDS
Effect of Immediate Resuscitation
on Outcome
• Review of 166 near-drowning children in
  California
• Children with good outcome 4.75 times more
  likely to have had immediate bystander CPR
  than poor outcome patients


                -Kyriacou et al., Pediatrics, 1994
   Treatment
   Pre-Hospital
• Immediate, effective CPR
  – Oxygenation, ventilation ASAP
  – Chest compressions
  – C-spine stabilization
• Avoid drainage procedures
C-Spine Injuries Among Submersion
Victims
• “Immobilize all near-drowning patients”
• 2244 submersion victims - Washington
• 11 C-spine injuries (0.5%)
• All 11 in open bodies of water; all had history of
    diving (RR 229), MVC, fall; witnessed, > 15
•   No C-spine injury in 880 low-impact events
•   “Routine immobilization does not appear to be
    warranted”
                 -Watson et al., J Trauma 2001
Treatment
Transport
• Continue CPR
• Establish airway
• Remove wet clothes
• Hospital evaluation
Treatment
Emergency Department
• Continue established therapies
• History, physical, labs
• Admit if: CNS or respiratory symptoms
• Observe in ED for minimum 4-6 hours if:
  – Submersion > 1 min.
  – Cyanosis on extraction
  – CPR required
Predicting Ability for ED Discharge

• Several studies support selected ED discharge
• Child can safely be discharged home if at 6
 hours after ED presentation:
  – GCS > 13
  – Normal physical exam/respiratory effort
  – Room air pulse oximetry oxygen saturation > 95%



              -Causey et al., Am J Emerg Med, 2000
 ICU Management Strategies
 Non-invasive Ventilation
• Nasal /face mask
• Increase in small increments to
 maintain:
  – FIO2 < 0.40
  – QS/QT < 20%
  – PaO2/FIO2 > 300
• Wean slowly
  ICU Management Strategies
  Intubation/Ventilation
  Indications
• SpO2 < 90% on FIO2 > 0.6
• PaCO2 > 50 with pH < 7.3
• Increased work of breathing
• Abnormal CNS exam
ICU Management Strategies
Respiratory
• Oxygenate - avoid hypoxemia
• Ventilate - avoid significant
  hyperventilation
• PEEP may be beneficial but is not
  prophylactic
• Exogenous surfactant
   Management Strategies
   Cardiovascular
• Re-warming ( to a degree ? benefit
 hypothermia)
  – LOC 34 C
  – Pupils dialate 30 C
  – V Fib 28 C
  – EEG iso-electric 20C
• CBF decrease 6-7% per degree C drop
Management Strategies
Central Nervous System
• Protect against 20 injury
  – Perfuse it or lose it !!
• ICP monitoring not beneficial or
  recommended
• Some still monitor if:
  – Successful CPR followed by coma
  – Sudden, unexplained deterioration
   Management Strategies
   Problem:
“Studies evaluating results of cerebral
  resuscitation measures have failed to
  demonstrate that treatment directed at
  controlling increased intracranial pressure
  and maintaining normal cerebral
  perfusion pressure improves outcome”
                   Orlowski, PCNA 34:85, 1987
Historical Therapy:
HYPER-Directed Therapy
• Hyper-hydration: diuretics
• Hyperventilation: hypocarbia via controlled
  ventilation
• Hyperpyrexia: aggressive hypothermia to 30
  degrees C
• Hyperexcitability: pentobarbital coma
• Hyperrigidity: neuromuscular blockade
              -Conn et al., Can J Anesth 1979
CONN (Toronto) - HYPER Therapy
                Normal Severe CNS Death
                         Deficit
 Awake upon
 ER arrival     100%                -              -
       n = 34
 Blunted        100%                -              -
       n = 12
 Comatose        44%             24%           32%
       n = 18
                 -Conn et al., Can J Anesth 1979
MODELL (FL) - NO HYPER Therapy
                Normal Severe CNS Death
                         Deficit
 Awake upon
 ER arrival     100%               -              -
       n = 34
 Blunted         92%               -             8%
       n = 12
 Comatose        44%             17%             39%
       n = 18
            -Modell et al, Crit Care Med, 1984
Management Strategies
Central Nervous System
• ICP monitoring may not change
  outcome, just predict it
• Low ICP     Better outcome
• High ICP     Poor outcome

                  -Sarnaik et al., Crit Care Med, 1985
   ICU Management Strategies
   Other Issues
• Antibiotics - no benefit of prophylaxis,
  may increase super-infection
• Fulminant Strep pneumoniae sepsis
  has been described after severe
  submersion
• Steroids - no demonstrated benefit
Factors Considered Predictive
of Poor Submersion Outcome
    • Submersion time
    • Serum pH                   Survive
                                 or not?
    • Need for CPR in the E.D.
    • Time to first gasp
    • Neuro evaluation
     Near Drowning
     Prognostic Indicators
Peterson 1977       Anoxic encephalopathy if:
                     CPR in ER
                     Submersion > 5 minutes
                     Seizures, flaccidity,
                     fixed/dilated pupils, coma
                     in E.D.
     Near Drowning
     Prognostic Indicators
Pearn 1979     Time to first spontaneous gasp:
                   < 5 minutes - most survive
                   > 60 minutes -CNS injury
                     inevitable

Allman 1986    GCS = 3 in ICU:
                   Death or vegetative state
   Near Drowning
   Orlowski Prognostic Criteria
• Age < 3 years
• Estimated submersion > 5 min.
• No CPR > 10 min.
• Coma in ED
• pH < 7.10
Outcome and Predictors of
Outcome in Pediatric Submersion
Victims
     • Two pre-hospital risk factors
      – length of submersion
      – length of CPR


             Quan et al, Pediatrics, Oct 1990
Outcome and Predictors of
Outcome in Pediatric Submersion
Victims
• SURVIVAL:
  –0/20 with CPR > 25 minutes



               Quan et al, Pediatrics, Oct 1990
Outcome and Predictors of Outcome
in Pediatric Submersion Victims
Submersion
0 - 5 minutes      7/67    10%
6 - 9 minutes      5/9     56%
10 - 25 minutes   21/25    88%
> 25 minutes       4/4    100%
  Near Drowning
  Concern
• Prolonged resuscitation in the
 Emergency Department may increase
 the proportion of “successful”
 resuscitations without normal neurologic
 recovery!!
   Near Drowning
   Therefore:
• Initiate full, immediate resuscitation
• Elicit circumstances of event
• After 25 min... of full but unsuccessful
 resuscitation think “PROGNOSIS” before
 continuing to resuscitate
 Near Drowning
 Social and Economic Effects
• Divorce
• Sibling psychosocial maladjustment
• 100,000 years of productive life lost
• $4.4 million/year in direct health care
  costs
• $350-450 million/year in indirect costs
  – $100,000/year to care for the neurologically
    impaired survivor of a near drowning
Near Drowning:
Pediatrician Anticipatory Guidance
• Survey to 800 pediatricians
• 85% believe community involvement in
  legislation important
• 4% actually involved
• 40% gave written water safety materials
• 50% gave anticipatory guidance
                 -O’Flaherty et al., Pediatrics, 1997
Near Drowning
Keeping Your Child Safe
• Never leave a child alone in
  or near water, even for a
  minute
• Limit pool access.
• Remove potential hazards
Children with Epilepsy:
Safety Recommendations
• Child can swim in lifeguard-supervised
  swimming pool - no open water
• Older child should shower in a non-glass cubicle
  - no bath
• Leave bathroom unlocked
• Supervision!
Near Drowning
Swimming Pool Lore

•My Child is “Water Safe”
 because he/she has taken
 swimming lessons.
 Near Drowning
 Keeping Your Child Safe
• Learn CPR
• Use approved personal flotation
  devices
• Teach safe water behavior
   Near Drowning
   Summary
• Frequently preventable
• Mortality & morbidity 20 to:
  – Hypoxic ischemic injury
  – Multisystem organ dysfunction
• CPR is most important therapy
  – Prolonged     Poor prognosis
   Near Drowning
   Summary
• Submersion time
  – Prolonged     Poor prognosis
• Prevention through:
  – Education
  – Supervision
  – Barriers
Near Drowning
The Best Approach Therefore:

       •P revention !
       •P revention !
       •P revention !
    Near Drowning
    What can you do?
• P revention !
  – Get parents involved in support groups
• P revention !
  – Support legislative actions that require fencing
    etc.
• P revention !
  – Promote SAFEKIDS and other safety movements
Questions????
                                Central Nervous System
Pulmonary System                1. anoxic damage
 1. secondary apnea,            2. defective autoregulation
    aspiration                  3. cerebral edema
 2. hypercapnea                 4. increased ICP

                       Asphyxia


Cardiac
1. myocardial ischemia            Renal
                          low
2. fibrillation           BP      1. acute tubular necrosis
                                  2. acute cortical necrosis
Pulmonary System          Central Nervous System
1. alveolar fluid         1. cerebral edema
2. “ARDS”                 2. intracranial hypertension
3. hypoventilation


                 Water Overload

Gastrointestinal              Dilution Effects
1. gastric distension         1. hypokalemia
2. vomiting, aspiration       2. hemodilution
3. ileus                      3. hemolysis
                    Hypothermia
               VASODILATION CENTRAL
 CARDIAC        decreased ICP NERVOUS
dysrhythmia     decreased BP  1. reduced metabolism
                                       2. reduced ICP
                                       3. ?protection?
                                       4. may produce picture
                                          of clinical death

     RENAL
                                     DEATH
    FAILURE
      --- Rogers, Pediatric Critical Care

				
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