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• Drowning defined as:

death secondary to asphyxia and
within 24 hours of submersion which
may be immediate or follow resuscitation

• Submersion injury:
Survival after more than 24 hr is termed
regardless the victim later dies or recovers

1-toddler age<5 yr
2-in 15-19 years old.
• Male predominant in All ages .
• Male/ Female
• 2:1 in toddlers 10:1 in teenager
• The site of drowning ,most
common depending on age.
Relevant factors:
• Water Tonicity
• Time submersion
• water Temperature
• symptoms associated injuries .
• Undetected primary cardiac
arrhythmia( long QT)
• response to initial CPR
Drowning begin with:

1. Panic, breath holding, ear

2. reflex inspiratory and
3. laryngospasm that leads to
4. hyperventilation followed by
voluntary apnea .
• Asphyxia may occur with:
1. pulmonary aspiration
(wet drowning).

2. laryngospasm (10-20%)
until cardic arrest
)dry drowning)
Anoxic-ischemic injury

• All organs may injured from hypoxia

and ischemia .

• CNS injury
(ICP ,cerebral edema)
The most frequent cause of
mortality and long- term morbidity
Anoxic-ischemic injury
• Pulmonary:
wash out surfactant
Pulmonary edema, ARDS
• Cardiovascular:
Arrhythmia( hypothermia ,hypoxemia)
• Acid-base
• Electrolytes
Anoxic-ischemic injury

• Renal
ATN (hypoxemia,shock,
• Gasterointestinal
hepatic trasaminases and serum
pancratic enzymes are often acutely
Aspiration and pulmonary injury

• Pulmonary aspiration occurs in the

great majority of submersion .

Pneumonia may result from :

• gastric contents
• water salinity
• pathogenic organisms
• toxic chemical
Fluid and electrolyte alteration
• The great majority of submersion do
not aspirate large volumes of fluid to
result in significant electrolyte
• Sea water
• Fresh water
• Moderate hypothermia T(32-35)
increase oxygen consumption.

• Below T 32:
(sever hypothermia) shivering ceases and
cellular metabolic rate decreases

• Deep coma with fixed and dilated

pupils and absent reflexes at T (25-29)
may give the false appearance of death
Lab & imaging studies

• CBC ,Electrolytes ,U/A
• Chet x Ray - cervical spine X Ray

• non contrast head CT scan???

• Head CT scan is not helpful
unless :
1. Suspicion of associated trauma
2. to rule out other possible causes
of coma

• MRI may detect change

associated with hypoxic- ischemic
Clinical Manifestation

• Victims in cardiac arrest

require aggressive and prolong
Pre hospital treatment
• Careful search for pulses.

If pulses presented :
• Chest compression withhold
Sinus bradicardia and atrial
fibrillation require no immediate
• Initial resuscitation:

• air way should be clear

• Abdominal thrust should not be

• Cervical spine should be protected
Emergency unit management

• All pediatrics should be observed for at

least 8-12 hr even they are
asymtomatic on presentation.

• Serial monitoring of repeated careful

pulmunary and neurologic

• Chest X RAY
Emergency unit management

Patients discharge after 8-12

hours if no evidence of :

• significant injury
• bronchospasm
• tachypnea
• inadequate oxigenation
hospitalized Children
• Supplement O2
• NaHCO3
• diuretic for pulmonary edema .
• broncodilators for brochospasme .
• Antibiotic for contaminated water.
• Anticonvolsion treatment for seizure

• NG tube
• ECG monitoring for diagnosis and
treatment of arrhythmia.
• Hypothermia treatment
• If a child is hypoglycemic 0/5-
1g/kg dextrose
ETT is needed if…

1. apnea ,cyanosis .
2. hypoventilation.
3. hemodynamic istability.
4. protect air way in patient with
depressed Mental
Treatment (con)
• A few patients develop require mechanical
for at least 24-48 hours.

• evaluated of oxigenation with ABG

• Rewarming effort should be continued

until T is at least 32-34c (passive, active)
• Patients should closely evaluated for
The neurological status

• Neurologic examination during the first

24-72hr are the best prognostic of CNS
Prognosis (continue)

1.Overall about 75% of pediatric

submersion victims survive.

• Good recovery did not occur in:

Abnormal brainstem function
• Absence of purposeful movement at
24 hr
Poor prognosis

1. Submersion duration>10 minute

2. Age <3 years
3. CPR>25minutes
4. patient core<T33c
5. GCS<5
6. persistent apnea that CPR is
need in an ED.
• PH<7.1
• Water temperature >10 c
• Children who remain comatose
24 hr after initiating
Treatment discontinue

• submersion victim in non-icy

water that remain systole
• despite 30-45 min of aggressive