Pediatric Drowning

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					Pediatric Drowning
Presented by Peter Antevy, M.D.
Joe DiMaggio Children’s Hospital
Hollywood, Florida Department of Health

Pediatric Drowning
Image of 3 children playing in the water at the beach. A no swimming sign is posted in
the foreground.

Pediatric Drowning – Objectives
- Drowning from a medical perspective.
- Where we’ve been. Where are we going?
- The body during submersion.
- CPR that you won’t forget.
- Prevention.
- The future and new ideas.

Pediatric Drowning – Allan’s Story
Image of Alan prior to the injury.

Pediatric Drowning – Allan is down.
- Recognize – Understand – React.
- Will you step in?
- Can you control your adrenaline surge?
- Will you do something wrong?
- Do you know the physiology?

Pediatric Drowning – Allan is down.
- Rescue arrives in 4 minutes.
- Child found blue and asystolic.
- CPR ensues.
- Child transported rapidly to Joe DiMaggio Children’s Hospital.
        - Note importance of specialty pediatric center close by.
- He is unconscious.

Pediatric Drowning – Allan is down.
- Emergency Department arrival.
        - Copious amounts of emesis.
        - Moderate respiratory distress.
        - O2 sat of 92% on 100% non-rebreather.
        - Minutes later he vomits a frothy pink fluid.
- What is happening?

Pediatric Drowning – Emergency Department management
- Placed on a ventilator.
- Labs suggest significant illness.
       - Oxygen starvation
       - Elevated acid levels
- IV medications and fluid
- Transferred to Pediatric Intensive Care Unit (PICU)
- Ultimate neurologic outcome is difficult to assess in the severely ill drowning victim.

Pediatric Drowning – PICU Course
- Severe lung swelling at 12 hours.
- Significant brain swelling over 24 hours.
- Tracheostomy and Gastrostomy tubes.
- Multiple specialists involved.
- 3 month hospitalizations.

Pediatric Drowning – A mother’s reflection.
- Initial explanation did not sink in.
- I was told he didn’t drown, so I thought he’d be okay.
- They asked if I want to disconnect the ventilator at 48 hours.
- Things sunk in at 3 weeks.

Pediatric Drowning – Allan’s story.
Images of Allan in the hospital shortly after the injury.

Pediatric Drowning – Last week.
Image of Allan taken a week before the May 29, 2009, Water Safety and Drowning
Prevention Marketing Symposium.

Pediatric Drowning – History
 - 1237 BC (3000 years ago)
        - First recorded illustration of resuscitation.
        - King of Aleppo.
 - Then nothing for centuries.
        - Penalties imposed.
        - “You may pull body out of the water, if he appears dead, then leave his feet in
        the water.”
Image of a mosaic of the King of Aleppo.

Pediatric Drowning – History
- Until the 18th Century drowning was accepted as “part of life”.
- Bystander rescue of the drowning victim was not considered until the late 1700’s.
- Prevention efforts begun.
        - Posters in coffee shops.

Pediatric Drowning – History
- Abraham Calcoen (1766)
        - How to assist the drowning victim.
               1. Warming him up in front of a big fire.
                2. Open his intestines through the rear with a tobacco pipe or a sharp
                knife.
                3. Rubbing him warm with a woolen cloth.
                4. Letting his blood.
                5. Rubbing his head with alcohol.
Image of Abraham Calcoen. Images also of a fire, intestines, blood letting and a kitten
with it’s head being rubbed by a hand.

Pediatric Drowning – History
- Baptist van Engelen (1767)
        - Encouraged resuscitation.
        - Promoted knowledge of resuscitation.
        - Dutch Society to Rescue People from Drowning.
- Baptist:
        - Suggested that financial rewards be given.
        - All costs for drowning victim to be paid for.
- Do Something!

Pediatric Drowning – History
- World Congress on Drowning 2002.
        1. New definition
        2. Preventative strategies needed.
        3. Police officers and firefighters must learn to swim.
        4. Rescue techniques must be investigated.
        5. CPR must be learned by lay persons and/or resuers.
        6. Hospital treatment should be concentrated.

Pediatric Drowning – History
Same slide as previous slide on the World Congress on Drowning 2002. The first point,
“New Definition of Drowning” is emphasized.

Pediatric Drowning – Terminology
- “Drowning”
        - Submersion leads to respiratory impairment.
              - Survival not included.
              - The terms “Near Drowning” and “Dry vs. Wet” are incorrect.

Heading: Drownings Ages 0-4 by Place of Occurrence, 2001-2005.
- Pie Chart of Drowning Deaths where N equals 389.
       - Pools are 64 percent.
       - Other places of drownings are 19 percent.
       - Natural Water is 9 percent.
       - Bathtubs are 8 percent.
- Pie chart of Near Drowning Hospitalizations where N equals 1,109.
       - Place of occurance not given in 99 percent of the drownings.
       - Other place given in 1 percent of drownings.
Pediatric Drowning – Epidemiology
- 500,000 deaths per year worldwide.
        - China and India (40% of total)
        - Ranks higher than death through war!
- 4,000 per year in the United States
        - 3, 000 are children.
        - Fatality rates are highest in children under 5 years.

Pediatric Drowning – Epidemiology
- In US, number 2 cause of accidental death in children.
- In 18 states, in children under 5 years old, it’s number 1.
- Worldwide, nearly 1 out of every 1000 boys will die by drowning before reaching his
20th birthday.

Pediatric Drowning – Epidemiology
- For every drowning death there are 3.5 hospitalizations.
- For every hospitalization there are 4 emergency department evaluations.
- 15% of survivors will die in the hospital.
- Average cost per year: 2 billion.

Title: Unintentional Drowning Death Rates in the United States, 1996-1998.
Image of the U.S.
 - States with 2.04 to 6.45 deaths per 100,000 population include Oregon, Idaho,
Montana, South Dakota, Oklahoma, Arkansas, Louisiana, Mississippi, Alabama, South
Carolina, Florida, Alaska and Hawaii.
 - States with 1.56 to 2.03 deaths per 100,000 population include Washington, Nevada,
Arizona, Wyoming, North Dakota, Texas, Missouri, Kentucky, Tennessee, Georgia,
Virginia, West Virginia and Maine.
 - States with 1.18 to 1.55 deaths per 100,000 population include California, New
Mexico, Colorado, Kansas, Minnesota, Wisconsin, Michigan, Indiana, North Carolina,
Delaware, Rhode Island and Vermont.

Title: United States and Florida 0-4 year old drowning deaths from 1989 to 1998
Line Chart shows that from the years represented, Florida had a higher rate per 100,000
population of drowning deaths than the United States rate.

Pediatric Drowning – Florida Statistics
Figure showing a map of Florida.
- Drownings
        - 376 Deaths per Year
        - United States rate of 1.7
        - Florida rate of 2.7
        - Excess Deaths per Year is 151
Title: Drowning Deaths and Rates of Selected States and the United States, Ages 1 to 4,
from 2000 to 2004.
 - Florida had 73 deaths in 2000, 62 deaths in 2001, 67 deaths in 2002, 83 deaths in 2003,
and 56 deaths in 2004. A total of 341 deaths, making Florida's rate 8.38.
 - Arizona had 23 deaths in 2000, 27 deaths in 2001, 19 deaths in 2002, 20 deaths in
2003, and 19 deaths in 2004. A total of 108 deaths, making Arizona's rate 6.50.
 - Arkansas had 2 deaths in 2000, 3 deaths in 2001, 3 deaths in 2002, 2 deaths in 2003,
and 1 death in 2004. A total of 11 deaths, making Arkansas' rate 5.70.
 - Texas had 50 deaths in 2000, 47 deaths in 2001, 37 deaths in 2002, 57 deaths in 2003,
and 43 deaths in 2004. A total of 234 deaths, making Texas' rate 3.39.
 - Hawaii had 1 death in 2000, 1 death in 2001, 3 deaths in 2002, 3 deaths in 2003, and 2
deaths in 2004. A total of 10 deaths, making Hawaii's rate 3.09.
 - California had 71 deaths in 2000, 68 deaths in 2001, 60 deaths in 2002, 52 deaths in
2003, and 57 deaths in 2004. A total of 308 deaths, making California's rate 3.05.
 - In the United States there were 493 deaths in 2000, 458 deaths in 2001, 454 deaths in
2002, 456 deaths in 2003, 430 deaths in 2004. A total of 2,291 deaths, making the
overall U.S. rate 2.94.

Title: Pool Drowning Deaths Ages 0 to 4 years old, from 2001 to 2005 and pools by
county in 2006.
 - Broward County had 29 deaths and with 113,157 pools has the most pools of any
Florida county.
 - Miami-Dade County had 23 deaths. The county has 76,477 pools the third largest
number of pools in a county.
 - Hillsborough County had 22 deaths. The county has 71,960 pools, the fourth largest
number of pools in a county.
 - Orange County had 21 deaths. The county has 61,096 pools, the seventh largest
number of pools in a county.
 - Palm Beach County had 14 deaths. The county has 101,463 pools, the second largest
number of pools in a county.
 - Brevard County had 10 deaths. The county has 43,153 pools, the ninth largest number
of pools in a county.
 - Duval County had 10 deaths. The county has 23,226 pools, the seventeeth largest
number of pools in a county.
 - Lee County had 10 deaths. The county has 62,481 pools, the sixth largest number of
pools in a county.
 - Pinellas County had 10 deaths. The county has 65,505 pools, the fifth largest number
of pools in a county.
 - Polk County had 9 deaths. The county has 29,291 pools, the thirteenth largest number
of pools in a county.
 - Seminole County had 8 deaths. The county has 38,086 pools, the tenth largest number
of pools in a county.
 - Marion County had 6 deaths. The county has 13,077 pools, the twenty-third largest
number of pools in a county.
 - Pasco County had 6 deaths. The county has 29,760 pools, the twelfth largest number
of pools in a county.
- Osceola County had 5 deaths. The county has 18,943 pools, the eighteenth largest
number of pools in a county.
- St. Lucie County had 5 deaths. The county has 18,301 pools, the twentieth largest
number of pools in a county.
- Volusia County had 5 deaths. The county has 27,622 pools, the fourteenth largest
number of pools in a county.

Title: Drowning Rates by Age Group, 2001 to 2005, based on rates per 100,000
population.
The line chart shows a large spike in the number of near drowning hospitalizations in the
1 to 4 year old age group, a rate above 20 per 100,000 population. Drowning deaths are
the highest in the 1 to 4 year old age group, a rate close to 10 per 100,000 population. All
other rates for both drowning deaths and near drowning hospitalizations are below 5 per
100,000 population.

Pediatric Drowning – Epidemiology
- Males predominate in drownings in all age groups (peaks at 2 and 18 years).
        - About 80% of submersion deaths are male.
- Native Americans and African Americans have higher numbers.

Pediatric Drowning – Epidemiology
Chart Showing Drowning Deaths by gender, per 100,000 Population.
Males throughout all age groups have higher rates of drowning than females.

Pediatric Drowning – High Risk Groups / Risk Factors
- Toddlers
        - Lack of supervision
        - Inadequate barriers
        - Abuse
- Adolescents
        - Drugs
        - Dares
        - Diving

Pediatric Drowning – Swimming Pool Fatalities
- 95% occur in pools (in-ground)
- 50% in family’s own pool.
- Almost all the rest at friend’s pool.
- 70% “supervised” by parents
- Only 30% wearing swimsuits.
- Most enter from home (unfenced side).
- Most are “silent”.
- Death rate 86% if over a 10 minute submersion.

Pediatric Drowning - Locations
Pie Chart showing Pediatric Drowning Locations.
- Private Pools are 50 percent.
- Public Pools are 3 percent.
- Lakes and Rivers are 22 percent.
- Bathtubs are 15 percent.
- Buckets are 6 percent.
- Toilets are 1 percent.
- Washing machines are 1 percent.
- Salt water is 2 percent.

Pediatric Drowning – Pools
- Children under 5 at greatest risk
- Between noon and dinner
- 14 times greater than death from a motor vehicle crash in kids under 4.
- 60-90% occur in residential pools.
- Be wary of the drain.

Drain Danger
Image of a suction injury on a child’s torso.
Image of Virginia Graeme Baker.

Pediatric Drowning – Bucket Drownings.
 - 5 Gallon Buckets
 - Must keep empty and away from child.
 - One report of bucket filled with diapers leading to death.
Image of a warning typically seen on a 5 gallon bucket.

Pediatric Drowning – Toilet Bowls
- Curiosity Kills!
- Bathroom should be off limits to toddlers.
- Prevention?
- Toilet bowl locks.

Pediatric Drowning – Bathtubs
- 80% of these are accidental
        - A review of 21 bathtub deaths revealed 67% had historical or physical exam
        findings suggestive of abuse.
- Typical age 8-18 months.
        - Infants as young as 10 months can climb into the bathtub.
- Low socioeconomic homes.

Pediatric Drowning – Bathtubs
- The usual series of events.
        - Family routine suddenly broken.
               - Acute illness
               - Marital strife
       - Stressed mother trying to cope with bathing and feeding several kids.
       - Telephone or doorbell rings.
       - Mother leaves infant in the care of older kids.
       - Older kids climb out and infant drowns.

Pediatric Drowning – Bathtubs
- Utah’s bathtub drowning rate is 300% higher than the national average.
        - Why?
- Japan’s bathtub drowning rate is extremely high too!
        - Why?

Pediatric Drowning – Shallow Water Blackout
- 10 year old girl
- “I can swim to the other side of the pool underwater”
- Hyperventilated beforehand
- What happened?

Pediatric Drowning – Shallow Water Blackout
- Questions.
        1. What is the breathing mechanism of the brain?
        2. Does your pO2 increase when you hyperventilate?
        3. Who is at risk?

Pediatric Drowning – Shallow Water Blackout
Graph showing normal Oxygen levels and normal Carbon Dioxide levels during normal
breathing and during a normal dive. A line shows the point when rising Carbon Dioxide
levels triggers the urgent need to breathe.

Pediatric Drowning – Shallow Water Blackout
Graph showing Oxygen levels and Carbon Dioxide levels during a Shallow water
blackout. A line shows the point when rising Carbon Dioxide levels triggers the urgent
need to breathe. During a shallow water blackout, hyperventilation causes the carbon
dioxide levels to drop prior to the dive. The urgent need to breathe, triggered by rising
carbon dioxide levels, is not reached until after the blackout kicks in.

Pediatric Drowning – Pathophysiology
Image of a child holding her breath.

Pediatric Drowning – Pathophysiology
Holding your breath leads to decreased oxygen and increased carbon dioxide which leads
to panic.

Pediatric Drowning – Pathophysiology
Reflex Aspiration leads to Glottic Closure.

Pediatric Drowning – Pathophysiology
Ingest large amount of water.

Pediatric Drowning – Pathophysiology
- With prolonged hypoxia the laryngospasm abates.
        1. Surfactant destroyed.
        2. Impaired gas exchange.
        3. Pulmonary edema.
        4. Decreased Oxygen and Increased Carbon Dioxide.
        5. Acidosis.

Pediatric Drowning – Pathophysiology
1. Panic
2. Reflex aspiration (lungs)
3. Laryngospasm
4. Water swallowed.
5. Water aspirated.
6. Surfactant destroyed.
7. Pulmonary edema.
- Fluid required is 1 milliliter per kilogram.

Pediatric Drowning – Cold Case.
- 10 and 7 year old brothers swimming in Lake Powell.
- Both found submerged 30 minutes later.
- Both died!
- Cause of death?

Pediatric Drowning – CO - ld Case.
- Both were excellent swimmers.
- No evidence of trauma on post-mortem.
- One test revealed the diagnosis.
- Carbon Monoxide Level.

Pediatric Drowning – Cold Case.
- Carbon monoxide poisoning – Lever of 59 and 52% after brief exposure.

Pediatric Drowning – Carbon monoxide poisoning.
Title: Guidelines for Carbon Monoxide in the Air. Measured in parts of Carbon
Monoxide per a million parts of air abbreviated as P.P.M.
- 87 PPM is the World Health Organizations limit for a 15 minute exposure.
- 200 PPM is the N.I.O.S.H. ceiling limit.
- 1,200 PPM is immediately dangerous to life and health.
- 12,8000 PPM has a danger of death in 1 to 3 minutes.

Pediatric Drowning – Carbon monoxide poisoning.
Image of the back of a motorboat.
- 200 PPM measured 10 feet away from the boat.
- 7,000 to 10,000 ppm measured on the swim platform on the back of the boat.
- 85,000 ppm measured where the generator exhaust leaves the boat.

Pediatric Drowning – Carbon monoxide poisoning.
Image of a man leaning against the back of a boat.
 - "Teak Surfing" has a measurement of 26,700 PPM because it is done very close to the
boat's exhaust.

Pediatric Drowning – Teak Surfing
An image of young people Teak Surfing and a diagram of how teak surfing is done.
 - Teak Surfing is when an individual hangs off the back platform of a motorboat, with
the majority of their body in the water, only their head and arms above water and "surfs"
while the boat is moving.

Pediatric Drowning – Carbon monoxide poisoning.
Image of the back of a motorboat.
 - 10,000 PPM Carbon monoxide while the engine is idling.
 - An example on a cabin cruiser platform: Fatal poisoning is estimated within a 3 minute
exposure.
 - 12 people poisoned on platforms of stationary motorboats: 3 died and 8 lost
consciousness.

Pediatric Drowning – Carbon monoxide poisoning.
Image of individuals on a motorboat in open water.
 - 34 people poisoned on platforms of moving motorboats. 17 died and 10 lost
consciousness. Only 5 of these people were teak surfing. 20 were holding onto the
platform while the boat moved along slowly, 5 miles per hour or "idle speed".

Pediatric Drowning – Treatment.
- On scene management
        - Most significant aspect of resuscitation.
        - Most important maneuver is…..
        - Reinstitution of effective respiration!

Pediatric Drowning – Treatment.
Image of a young child being attended to by medical professionals poolside.
 - This could be you!

Pediatric Drowning – Treatment
- Are C-spine precautions necessary?
        - Protect the C-spine when:
                1. Events of accident are unknown.
                2. Victim was diving.
                3. Signs of trauma are evident.
        - Hwang et. Al. (Arch Pediatr Adol Med. 2003)
               1. 143 submersion victims.
               2. 7 had C-spine injuries.
               3. All were diving related.

Pediatric Drowning – Managing the airway.
- Basic airway maneuvers (BLS)
- 2 breaths.

Pediatric Drowning – Basic Principles
- Open the airway.
        - Positioning
        - Oral airways
        - Jaw thrust
        - Chin lift
- Slow ventilatory delivery.
- Smaller tidal volumes
- Cricoid pressure.

Pediatric Drowning – Rescue Breathing.
- What is it about drowning that makes it hard to ventilate?
        1. Loss of surfactant.
        2. Pulmonary edema.
        3. Decreased Pulmonary compliance.

Pediatric Drowning – Chest Compressions
- Under 1 year old.
        - Image of a CPR doll with the correct position for chest compressions for under 1
        year olds. The index finger and middle finger are placed in the center of the
        chest, aligned with the nipples.
- 1- 8 years old
        - A drawn image representing the correct position for chest compressions for 1 to
        8 year olds. The palm of the hand is placed in the center of the chest.

Pediatric Drowning – CPR
- Lift chin and give 2 breaths
- Check for a pulse
- Chest compressions – 100 times per minute.
        - 30 to 2 ratio if one rescuer
        - 15 to 2 ratio if 2 rescuers
- Remember the BeeGees or Queen.

Pediatric Drowning – Emergency Room Treatment
- Initial Emergency Department resuscitation should be aggressive.
- Can we predict the outcome?
        - Fixed and dilated pupils.
        - Need for Emergency Department CPR
        - pH under 7.0
 - Good neurological outcomes reported in 13% of warm water pediatric drownings
requiring Emergency department CPR (Lavelle et. Al. 1993 and Kyriacou 1994).

Pediatric Drowning – Submersion Time
Chart showing submersion time duration in minutes with a percentage of risk of a bad
outcome.
- For zero to five minute submersion there is under 20 percent risk of a bad outcome.
- For a six to ten minute submersion there is under an 70 percent risk of a bad outcome.
- For an eleven to fifteen minute submersion there is an 80 percent risk of a bad
outcome.
- For a sixteen to twenty-five minute submersion there is just over an 80 percent risk of a
bad outcome.
- For an over twenty-five minute submersion, there is just under a hundred percent risk
of a bad outcome.

Pediatric Drowning – CPR Duration
Chart showing CPR duration and the percent of the risk of death or severe damage.
 - For zero to five minutes of CPR having to be performed there is just over a zero
percent risk of death or severe damage.
 - For six to ten minutes of CPR having to be performed there is under twenty percent risk
of death or severe damage.
 - For eleven to fifteen minutes of CPR having to be performed there is just over a 60
percent risk of death or severe damage.
 - For sixteen to twenty-five minutes of CPR having to be performed there is just over a
fifty percent risk of death or severe damage.
 - Over 25 minutes of CPR having to be performed there is just under a hundred percent
risk of death or severe damage.

Pediatric Drowning – Emergency Room Resuscitation
- Prolonged resuscitation (ACLS greater than 25 minutes) of warm water pediatric
drowning victims is NOT indicated.
- The longest emergency department CPR with a good neurologic outcome was 12
minutes.

Pediatric Drowning – Emergency Department Management
- Predictors of a positive outcome.
        - Non-comatose state on emergency department arrival.
               1. Alert – 100% survival (91 to 91 cases)
               2. Lethargic or confused – 94% survival (29 or 31 cases).
               3. Comatose – 15% survival (11 of 72 cases); 53% died.
               - Graf et. Al. 1995.

Pediatric Drowning – Bystander CPR
- Family members performed CPR in 20% of cases.
- 65 received bystander CPR prior to paramedic arrival.
- 41 of 63 cases breathing and with pulses when EMS arrived.
- All 41 cases survived to hospital discharge.
- Sirbaugh (Ann Emerg Med, 1999).

Pediatric Drowning – Bystander CPR
- Pearn’s series from Hawaii (1979)
        - 75 children received bystander CPR
               - All apneic and unconscious when extracted from the water.
               - 70 (93%) survived with a normal neurologic outcome.

Pediatric Drowning – Prevention
- The ONLY Cure
        - Remove the hazard.
        - Create barriers.
        - Protect those at risk.
        - Counter the damage.

Pediatric Drowning – Prevention
- Which parents are most aware?
        - Those who already have experience with injury to their child.
        - Those who see their child as difficult to manage.
        - Those who are stressed themselves.

Pediatric Drowning – Prevention
- Barriers
        - Prevent unsupervised access by children.
               - Swimming Pools
                        - 4 sided fence
                        - 4 foot high
                        - self closing or self latching gate
               - Hot tubs
               - Streams
               - Irrigation and drainage canals.

Pediatric Drowning – Prevention
Image of a pool with a cover over it.

Pediatric Drowning – Prevention
- Bathroom door barriers (handle)
- Toilet bowl locks
- Empty and put away all buckets.

Pediatric Drowning – Prevention
- Swimming lessons early (?)
        - Self rescue techniques at all ages.
        - Do not allow a false sense of security.
       - No child is ever “drown proof”
- Approved floatation devices.
- Boating safety
       - Don’t forget about carbon monoxide.

Pediatric Drowning – Prevention
- Check depth before first dive.
- Increase surveillance for children with seizure disorder.
- Educate about effects of alcohol.

Pediatric Drowning – Prevention
 - The Florida Residential Swimming Pool Safety Act.
Image of a fence with four sided fence.
 - 15% of US pools adequately fenced.

Title: Percentage of Drowning Deaths in Florida swimming pools, ages 0 to 4 from 1999
to 2005.
 - In 1999, 69 percent of drowning deaths occured in a swimming pool.
 - In 2000, 64 percent of drowning deaths occured in a swimming pool.
 - The New Pool Barrier Law went into effect on October 1, 2000.
 - In 2001, 68 percent of drowning deaths occured in a swimming pool.
 - In 2002, 68 percent of drowning deaths occured in a swimming pool.
 - In 2003, 60 percent of drowning deaths occured in a swimming pool.
 - In 2004, 63 percent of drowning deaths occured in a swimming pool.
 - In 2005, 61 percent of drowning deaths occured in a swimming pool.

Pediatric Drowning – Prevention
 - Other ideas
Image of an ad for Watch Around Water. The ad placed in shallow water at a kiddy pool.
The ad is an image of a child, face down, seeming to be submerged under the water. The
words "Where's your child?" and the Watch around water logo are at the bottom of the
ad.

Pediatric Drowning – Prevention
- How do we stop this pervasive problem?
- Where can you help?
        - Prior to the event
        - The event
        - After the event.

Pediatric Drowning – Objectives
- Drowning from a medical perspective.
- Where we’ve been … where are we going?
- The body during submersion.
- CPR that you won’t forget.
- Prevention
- Ideas for your community.

Pediatric Drowning
Presented by Peter Antevy, M.D.
Joe DiMaggio Children’s Hospital
Hollywood, Florida
pantevy@mhs.net

				
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