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P E D I AT R I C
EmERgEnCy mEDICInE PRACTICE

AN EVIDENCE-BASED APPROACH TO PEDIATRIC EMERGENCY MEDICINE s EBMEDICINE.NET
An Evidence-Based
Ketamine:
ProceduralApproach
To The Evaluation
And
Pediatric
Sedation In
The
Treatment Of
Drowning And
Emergency
Department
You
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Submersion
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ED awaiting procedural sedation. One patient is waiting for fracture reduction
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statistical
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(from
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Emergency
Medicine
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recovery) for this patient?
ogy
and
of drowning, discuss the evidence behind
management
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contraindications? review factors associated with prog nosis
Would
giving
for analgesia
lead topreventative
complicationsmeasures.
during his
(and
theirnarcotics
exceptions),
and discuss
later sedation?
June 2011
January
2011
Volume8,8,Number
Number16
Volume
Authors
Author
EmilyMadati,
Rose, MD
P. Jamil
MD
Assistant
Professor
of Clinical
Emergency
Assistant
Professor,
University
of California
SanMedicine,
Diego School Of
Department
of Emergency Medicine, Keck School of Medicine
Medicine,
San Diego,CA
at Los Angeles County and University of Southern California
Peer Reviewers
Medical Center, Los Angeles, CA
T. Kent
Denmark,
Baruch
Krauss,
MD MD, FAAP, FACEP
MedicalDivision
Director,
Simulation
Center;
Associate
Attending,
of Medical
Emergency
Medicine,
Childrens
Hospital
Professor
of Emergency
Medicine
and
Pediatrics,
Loma
Boston;
Associate
Professor of
Pediatrics
Harvard
Medical
School,
LindaMA
University Medical Center and Childrens Hospital,
Boston,
Linda,MD
CA
JanLoma
Luhmann,
Instructor, Pediatrics, Division of Pediatric Emergency Medicine St.
Louis
Childrens
Hospital, St. Louis, MO
Peer
Reviewers
Alfred Sacchetti, MD
RobertDirector
R. Cooney,
MD
Associate
Emergency
Services, Our Lady of Lourdes
Core Center,
Faculty,Camden,
Department
Medical
NJ of Emergency Medicine, Memorial
Medical Center, Johnstown, PA
CME Objectives
Paula Whiteman, MD, FACEP, FAAP
Medical
Director,
Pediatric
EncinoUpon
completion
of this
article,Emergency
you shouldMedicine,
be able to:
Regional
Medical
Center,dosing
Encino,
Attending
1. Tarzana
Cite the
appropriate
ketamine
forCA;
its various
routes of
Physician,
Cedars-Sinai Medical Center, Los Angeles, CA
administration.
2. CME
CiteObjectives
ketamines more common and dangerous side effects,
and manage these complications should they arise.
of this
should be abletotoketamine
3. Upon
Citecompletion
the absolute
and article,
relativeyou
contraindications
competently:
use in patients.
drowning.
4. 1. CiteDefine
the benefits
and drawbacks of ketamine and when
2. to coadminister
Describe drowning
pathophysiology.
medications
(eg, atropine, glycopyrrolate,
3. midazolam,
Improve patient
awareness
of epidemiology and risk
ondansetron
and propofol).
factors
Datefor
ofdrowning.
original release: December 1, 2010
4.
Cite
management
drowning 10,
victims
Datethe
of acute
most recent
review:of
November
2010and cite
the literature
behind
various
recommendations.
Termination
date:
December
1, 2013
5.
Recognize when
to discharge
patient after drowning and
Medium:
Print andaOnline
theparticipation:
indications for
admission.
Method of
Print
or online answer form and evaluation
6. to beginning
Cite recommendations
for drowning
Prior
this activity, see
Physicianprevention.
CME Information on
backrelease:
page. June 1, 2011
Date of original
Date of most recent review: May 10, 2011
Termination date: June 1, 2014
Medium: Print and Online
Method of participation: Print or online answer form and
evaluation
Prior to beginning this activity, see Physician CME
Information on page 17.
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Thisissue
issueofofPediatric
from these articles and related articles within a

websites search engine (such as Science Direct) were
also obtained. Very few randomized controlled trials
exist in the management of drowning, which makes
Class I evidence for management recommendations
rare. There are general pediatric cardiopulmonary
resuscitation guidelines with more evidence, but
drowning patients are typically small subsets within
the larger studies or completely excluded from the
data. Frequently, even larger resuscitation studies
are merely observational. Cardiac arrest secondary to drowning has a slightly better outcome as
compared to all causes of arrest, and the etiology is
multi-factorial. The critical factor is whether significant hypoxemia and resultant cerebral damage has
occurred prior to cardiac arrest. Multiple case reports and case series have been published to evaluate or validate prognostication rules. Currently, there
are no established rules or consistent algorithms
regarding length of resuscitation, and multiple case
reports of surprising survival have been published.
Complicating the ability to establish a standard
is the reality that each drowning circumstance is
unique. The underlying health of the patient, length
of submersion time, water temperature, the presence
of bystander cardiopulmonary resuscitation (CPR),
availability of tertiary care, and specialized treatments such as extra-corporeal membrane oxygenation (ECMO) are different in each case and all contribute to a patients ultimate neurological outcome.
Terminology
In the early 1970s, 2 types of drowning were used
to classify patients: to drown with or without aspiration and to nearly-drown with or without aspiration.
These terms were confusing, and it was difficult to
categorize a patient that was apneic and asystolic
on scene but eventually survived. Did they go from
a state of having drowned to near-drowned? The
term submersion injury was also frequently used
to describe the continuum of drowning. In 2002, the
World Congress on Drowning was held in Amsterdam, The Netherlands. The results of this conference
were published in Circulation in 2003 and contained
new definitions of drowning.1 As a result of this
conference, drowning is defined as a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium. A liquid/
air interface is present at the entrance of the victims
airway, preventing the breathing of air. The victim
may live or die, but whatever the outcome, they
have been involved in a drowning incident.1-2
Critical Appraisal Of The Literature

A literature search of PubMed, Ovid MEDLINE,
Google scholar, MDConsult, UpToDate, and Best
BETS was performed using the key terms drowning,
near-drowning, submersion injury, accidental death, and
cardiopulmonary arrest in children. Referenced sources
Epidemiology
The true incidence of drowning is actually unknown
because it is not mandatory to report drowning
deaths. Estimates range from 150,000 to 500,000
deaths per year worldwide.2-6 The total number
of drowning accidents are estimated to be 500 to
600 times higher.6-7 According to the World Health
Organization, 409,272 people drowned in 2000. This
statistic only includes accidental drowning and does
not include drowning due to cataclysms, transport
accidents, assaults, and suicide.8 It is estimated that
annually there are approximately 2 million survivors
of a drowning event worldwide.2
Drowning is a leading cause of mortality in
children between 1 and 14 years of age.6 Death by
submersion is the second most common cause of
accidental death in children, exceeded only by motor
vehicle accidents, and is the third most common cause
of accidental death overall in the United States.3 It is
the second most common cause of accidental death in
persons under 45 years of age and the leading cause
of death in children under 5 years of age in states
where pools and/or beaches are more accessible
(such as California, Arizona, and Florida). From an
epidemiologic perspective, drowning is more common during summer months. It is also more com-
Table Of Contents
Terminology................................................................ 2
Critical Appraisal Of The Literature....................... 2
Epidemiology............................................................. 2
Etiology........................................................................ 3
Pathophysiology........................................................3
Differential Diagnosis................................................ 4
Prehospital Care......................................................... 4
Emergency Department Evaluation........................ 5
Diagnostic Studies...................................................... 5
Treatment..................................................................... 6
Special Circumstances............................................... 6
Clinical Pathway For Pediatric

Submersion Injuries............................................ 8
Prevention................................................................... 9
Risk Management Pitfalls In The Treatment

Of Drowning Or Submersion Injuries........... 10
Controversies/Cutting Edge.................................. 11
Disposition................................................................ 11
Cost-Effective Strategies.......................................... 12
Summary................................................................... 12
Case Conclusion....................................................... 12
References.................................................................. 13
CME Questions......................................................... 16
Pediatric Emergency Medicine Practice 2011
ebmedicine.net June 2011
mon in African Americans and in those from a lower

socioeconomic groups.9-11 Males in the African and
Western Pacific regions have the highest drowningrelated mortality rates worldwide.8
drowning. Seventy percent of the deaths were children < 5 years old and 62% were in the familys backyard pool.24 Brenner et al reviewed death certificates
of accidental drowning and found that 55% of infant
drownings were in bathtubs. In children ages 1 to 4,
56% of drownings were in artificial pools and 26% in
other bodies of freshwater. In older children, 63% of
drownings were in natural bodies of freshwater.25
Non-accidental Trauma
Deaths due to drowning are deemed homicide in
1.2% to 8% of all drowning cases.12-15 If the death is
ruled a homicide, it most likely involves a child under 5 years of age, is at home, and most commonly
involves the primary caregiver.14,16,17 Up to 38% of
bathtub drownings in children younger than 5 years
are thought to be inflicted.18-19
Risk Factors
Risk factors for drowning include environmental circumstances such as flooding, risk-taking behaviors
(primarily a problem with teenagers), alcohol or illicit drug use (in children or the supervising adults),
inadequate adult supervision,8,26 access to poorly or
unfenced bodies of water,27 hypothermia (secondary to rapid exhaustion or cardiac arrhythmias),
concomitant trauma, underlying medical condition
such as seizure,2 undetected primary cardiac arrhythmia (eg, prolonged QT), hypoventilation prior
to a shallow dive, inability to swim, exhaustion, or
overestimation of swimming capabilities.9,23,28 Ethnic
minority groups have higher drowning rates, which
may be secondary to a relative lack of opportunities to learn to swim.8 However, even accomplished
swimmers are at risk. Almost half of all persons who
drown are under 20 years of age and 35% of them
are accomplished swimmers.2 In addition, males are
more likely to die or be hospitalized due to drowning than females.8
Survival
One meta-analysis evaluated survival of hospital
cardiac arrests in children. In 442 arrests, the overall
survival rate was 22.7%. However, only 6% of survivors were neurologically intact.20 In another chart
review of 95 patients with prehospital cardiopulmonary arrest (including but not limited to drowning)
from 1988-1993, only 27% of patients survived to
discharge. Two of 15 of these survivors were neurologically devastated.21 Another study of 255 patients
in cardiac arrest secondary to drowning showed a
survival rate of 22.7%. Final neurological outcome
was not mentioned in this study.22

On a promising note, the death rate from drowning has decreased. Factors contributing to this decline include advanced emergency services, improving pool safety standards and lifeguard training, and
improved CPR in the general population. The death
rate from drowning in 1970 was 3.87 deaths/100,000.
In 1980, the death rate was 2.67/100,000; in 1990, it
was 1.6/100,000; and in 2000, it was 1.24/100,000.2
These statistics include all survivors and do not differentiate between neurological outcomes.
Pathophysiology
The drowning process begins when the victims
airway is submerged. Typically, submersion is followed by a period of panic, voluntary breath-holding, and a struggle for air.2 Children can struggle
for only 10 to 20 seconds before final submersion;
adults may be able to struggle for up to 60 seconds.7 Reflex inspiratory efforts typically ensue,
and aspiration or reflex laryngospasm occurs when
water contacts the lower respiratory tract.9,28-30
Water is frequently swallowed. As laryngospasm
resolves, the drowning victim actively breathes the
liquid medium. It has previously been proposed
that approximately 10% of humans die without aspirating liquid. This has been challenged, and one
study showed that 98.6% of 578 drowning victims
had evidence of water in the lungs.2,31
Etiology
Location
There is a general bimodal distribution of both age
and etiologies. The first is children less than 5 years
old who are typically inadequately supervised in
locations such as swimming pools or bathtubs. In
one study, the proportion of children ages 0 to 4
that drowned in pools, bathtubs, and open water
were nearly equal.11 The second age peak is among
males between ages 15 and 25. Drowning at this
age tends to occur at rivers, lakes, and beaches.9,23
Overall, 50% of drowning episodes occur in swimming pools, 20% occur in lakes, rivers, streams, or
storm drains, and 15% occur in bathtubs. It is possible (and not infrequent) for toddlers to drown in
buckets or toilets.2

An evaluation of child deaths in Arizona from
1995-1999 was published in Pediatrics in 2002.24 In
that time period, there were 187 deaths secondary to
June 2011 ebmedicine.net
Hypoxia
Hypoxia and resultant ischemia are typically the
cause of morbidity and mortality in drowning.
Surfactant wash-out, pulmonary hypertension,
and shunting all contribute to the development of
hypoxemia.2 Profound alterations in arterial oxygenation may occur when as little as 1 to 2.2 mL/kg of
water are aspirated into the lungs.2,32 Patients may
3
Prehospital Care
have persistent hypoxia for days and even weeks

after an episode of drowning.2,33
Resuscitation
Pulmonary Effects
Begin care with an initial primary survey and follow

stabilization and resuscitation guidelines via the pediatric advanced life support (PALS) algorithm. Initiate CPR as soon as possible. For more information
on PALS, see the November 2009 Pediatric Emergency
Medicine article, Push Hard And Push Fast: The
Who, How, And Why Of Pediatric Advanced Life
Support (PALS).
Increased permeability of the capillary endothelium and surfactant disruption cause acute lung
injury or acute respiratory distress syndrome.
Aspiration leads to abnormal surfactant function
which causes alveolar collapse, atelectasis, intrapulmonary shunting, and pulmonary injury.30 Aspiration of sand has been described in drowning,34
and neurogenic pulmonary edema may complicate
pulmonary function.35
Oxygen
Administer oxygen (even if the patient looks well)
unless normal pulse oximetry has been established.
In general, most drowning victims should be taken
to the hospital for evaluation since children may initially look well but have the potential to deteriorate.2
Systemic Effects
Hypoxemia causes neuronal injury and circulatory
collapse with multiple organ system dysfunction
and eventual end-organ damage.30 In submersion,
oxygen is depleted, and carbon dioxide is not eliminated. As a result, the victim becomes hypercarbic,
hypoxemic, and acidotic.7 Arrhythmias may occur
secondary to either hypoxia or hypothermia. Fluid
shifts require more than 11 mL/kg of body weight
aspiration before blood volume changes occur and
more than 22 mL/kg before electrolyte changes take
place.7,9,37-39 It is rare for victims to aspirate more
than 3 to 4 mL/kg.9 Electrolyte abnormalities generally do not occur unless the victim is submerged in
unusual media (such as the hypertonic environment
of the Dead Sea).40
Cervical Spine Immobilization

Maintain cervical spine immobilization if there is a
history of diving, significant trauma, or if intoxication may have contributed to the drowning event.
Cervical spine injuries have occurred in ocean bathers where they are rolled over by a wave and strike
their head on the sand.45

Without history of trauma, there is little evidence
to support routine cervical spine immbolization.30,46-47
Drowning injuries in younger patients have a low incidence of traumatic injuries. A cohort of 2244 drowning patients had 0.5% incidence of cervical spine
injury. All 11 patients with cervical spine injury had
drowned in open bodies of water, had clinical signs of
serious injury, and had a history of diving, motorized
vehicle crash, or fall from height46 (Class III evidence).
It is not necessary to routinely immobilize all drowning patients, especially young children. Cervical
immobilization hinders the ability to care for a patient
and may be unnecessary in many cases.
Hypothermia
Hypothermia is defined as core temperature below
35C (95F).41 Continued aspiration of cold water
can produce extremely rapid core cooling as long as
circulation remains intact.42 This acute submersion
hypothermia may protect the brain temporarily from
lethal damage.43 Brain hypothermia is neuro-protective, especially if it occurs prior to the onset of brain
ischemia44 The adverse physiologic effects of hypothermia include: bradycardia, decreased cardiac output, hypotension, depressed immune function, and
abnormalities in metabolic, endocrine, renal, and
coagulation functions. At 30C (86F), arrhythmias
occur, and insulin is ineffective. Pupils and cardiac
output are both two-thirds of normal output.41 At
29C (85.2F), the pupils become dilated, and there is
alteration of consciousness. At 26C (78.8F), major
acid-base disturbances occur.41
Heimlich Maneuver
Contrary to older recommendations, the Heimlich
maneuver is inappropriate unless a foreign object is
obstructing the airway.30 Abdominal thrusts increase
the risk of aspiration.7,48 No attempts should be
made to drain water from the lungs before pulmonary resuscitation is begun.
CPR And Survival

Immediate resuscitation of children who have
drowned improves their outcome.49-51 Cardiopulmonary resuscitation performed by a bystander more
than doubles a patients chance of survival.52-56 Witnessed submersion improves the likelihood of survival20 secondary to its association with decreased
time to effective resuscitation. Unfortunately, most
pediatric drowning and cardiopulmonary arrests are
unwitnessed and receive no bystander CPR.52,57-58
Differential Diagnosis
Consider an underlying etiology or predisposing
condition as a cause of the drowning such as nonaccidental trauma, QT prolongation or other cardiac
arrhythmia, seizure, trauma, or cervical spine injuries. Be aware of drug and alcohol use that may have
predisposed the patient to drowning.
Patients requiring resuscitation longer than 25 minutes tend to have worse prognosis.50,59
is not always helpful as it may not reflect the severity of the pulmonary involvement. One study (that
included both adults and children) by Ballesteros
demonstrated that patients with abnormal chest xrays had better outcomes as compared to those with
normal x-rays.3 The clinical examination is more reliable for pulmonary pathology. As previously stated,
both salt and freshwater wash out surfactant which
often results in noncardiogenic pulmonary edema
and acute respiratory distress syndrome (ARDS). As
a result, diffuse pulmonary edema may initially be
present or may appear later.
Emergency Department Evaluation

Initial emergency department (ED) evaluation
should continue resuscitation that began in the field.
Airway
If a child is altered and/or clinically unable to
protect the airway, perform emergency intubation.
Evaluate whether the cervical spine needs to be immobilized.
Brain Imaging
Obtain computed tomography (CT) of the head if
the patient is altered and concomitant trauma occurred or is suspected. In drowning that does not
involve trauma, a head CT is typically not helpful
and not routinely recommended. In one retrospective study of drowning patients, an abnormal CT
was associated with a poor outcome (death or persistent vegetative state) in patients with a decreased
Glasgow Coma Scale (GCS) score. The most frequent
finding was loss of gray-white matter differentiation and low-density changes in the basal ganglia.61
Computed tomography scans are not sensitive in detecting early neurologic injury.62 Magnetic resonance
imaging (MRI) and magnetic resonance spectroscopy (MRS) have been evaluated for prognostication
and both are found to be inconsistent and not good
determinants of prognosis.62-63
Though typically not performed in the ED, an
electroencephalogram (EEG) may help with prognosis. A burst-suppression pattern on post-arrest EEG
is both sensitive and specific for poor neurologic
outcome,62,64 though serial EEGs are often required.65
Breathing
Bronchospasm is common in drowning events. It
responds similar to asthma with administration of
inhaled bronchodilators. Monitor pulse oximetry
and administer oxygen, especially if the child is
hypoxic. Pulse oximetry readings in small infants
are likely to be unreliable at skin temperatures of
less than 27C (81F).60 Continuous positive airway
pressure (CPAP) or the administration of positive
end-expiratory pressure (PEEP) may be required for
persistent hypoxemia.
Circulation
Examine the child for perfusion and intact pulses.
Perform chest compressions if indicated.
Disability
Perform a baseline neurologic examination including pupil evaluation and document it. Associated
trauma or cervical spine injury may complicate a
drowning event in an older child, and it is important
to immediately note any neurological deficit.
Cervical Spine Imaging
Exposure
Pursue further imaging if concomitant trauma (eg,

diving) is suspected or if circumstances such as
intoxication affect the ability to assess the cervical
spine.
Remove wet clothing and inspect the child for hypothermia, evidence of trauma, or other injuries.
History
Once the primary survey has been completed and
emergent/urgent treatments have begun, obtain
further history when available. Important details
to obtain include circumstances around the event,
witnesses, the possibility of foreign body aspiration, submersion time, concomitant trauma, drug
use, and contributing past medical history (such as
seizure, syncope, or arrhythmia).
Laboratory
In an alert and cooperative patient, labs are rarely
helpful and are not routinely indicated. Electrolyte
abnormalities are unlikely to occur secondary to
osmotic changes in drowning. Patients with severe
hypoxic injury may be acidotic and have other
abnormalities associated with diffuse hypoxic injuries. In hypothermic children or patients in whom
resuscitation is required, a complete blood count,
chemistry, and blood gas may be useful for management. The pediatric risk of mortality (PRISM)
score also includes coagulation studies. (For more
information on PRISM, see the Special Circumstances section.) Many studies have evaluated
glucose, potassium, and pH levels as predictors of
Diagnostic Studies
Chest X-ray
In drowning, the chest x-ray can vary from normal
to diffuse pulmonary edema.9,23,29 Chest imaging is
only indicated when a patient is symptomatic and
outcome.3,6,66-67 However, no consistent prediction

rule has been established.
comatose after resuscitation from cardiac arrest.71

A New England Journal of Medicine study by Hutchison et al published in 2008 did not demonstrate
improved outcome with hypothermia treatment in
children with traumatic brain injury.154 Further study
is also needed to establish therapeutic hypothermia
guidelines and recommendations for monitoring/
correcting associated electrolyte abnormalities, cold
dieresis, hyperglycemia, and mechanisms to avoid
temperature fluctuations in treatment.72-74 Temperature fluctuations, especially temperature below the
target range of 32C (90F) have been associated
with increased mortality.75
Treatment
Pulmonary Treatment
Administer oxygen and bronchodilators as needed.
Positive pressure may be necessary68 and ventilator
settings should follow ARDS protocol/recommendations of low tidal volume and physiologic PEEP.9
Bronchoscopy may be indicated if sand or particulate matter aspiration is suspected.34
Systemic Treatment
Seizures
Volume depletion may occur in drowning, and

saline administration is often required. Hypotension
may ensue secondary to a cold dieresis. This occurs because antidiuretic hormone (ADH) release is
decreased after vasoconstriction, which causes blood
to move to the core causing central volume receptors
to sense fluid overload.9
Control seizures they may worsen underlying

ischemic injury. Consider subclinical seizures in an
intubated and paralyzed patient.77 Avoid neuromuscular blockade or consider obtaining EEG
tracing in these patients. Seizures are not predictive of outcome in patients with hypoxic ischemic
encephalopathy.65
Management Of Hypothermia
Treatments No Longer Recommended
Rewarming techniques should be used until the

patient is warmed to approximately 32C to 34C
(90F-94F).9 Mild hypothermia (core temperature
30C-35C or 90F-95F) often will respond to passive rewarming such as heated, humidified oxygen,
warmed intravenous fluids (heated to 40C-44C or
104F-111F), and insulation with blankets. Active
external rewarming techniques include forced air
rewarming or radiant heat from a source such as a
heat lamp. A Bair Hugger works well for surface
rewarming and has low potential for burning the
skin.56 Invasive active internal rewarming is often
required with non-responsive moderate (28C-32C
or 82F-90F) and severe (< 28C or < 82F) hypothermia. This includes nasogastric tube lavage,
urinary bladder lavage, and more extensive measures such as left intra-thoracic (via thoracostomy
tubes) and intra-peritoneal lavage. After-drop is a
common phenomenon, where continued drop in
core temperature occurs following removal from
cold stress.69 Extracorporeal techniques may also be
used for rewarming. (For more information, see the
Controversies/Cutting Edge section.)
Treatments no longer recommended include glucocorticoids (steroids have not been shown to be
helpful and have increased risk of infection and
other complications)30 and prophylactic antibiotics (the use of antibiotics in drowning is unnecessary unless the child was submerged in grossly
contaminated water such as sewage). Prophylactic
antibiotics have not been shown to affect outcome
in drowning victims.30
Special Circumstances
Prognosis
Multiple studies have been performed to evaluate
prognostication rules. Most of these studies were
retrospective, observational, and contained a small
number of patients. Because of the nature of most of
the literature, a decision tool has not been successfully and consistently validated. Complicating the
ability to create a standard is the fact that numerous
case reports exist that tell of survivors under surprising circumstances. These cases are typically exceptions to previously created or suggested rules.
The PRISM score was originally created as a
predictor of death in the pediatric intensive care
unit (PICU) and described by Pollack et al in 1988.78
Spack,79 Zuckerman,80 and Gonzalez-Luis81 have
evaluated this tool, and it appears that it is more
useful as a predictive tool in the ED.80 However, it is
most consistent with a very high or very low score
and is less helpful if the results are in the middle
range.81 Frequently, it is in treating those mid-ranged
children that physicians need more guidance. The
PRISM score compiles multiple data points including:
Therapeutic Hypothermia
There are no published randomized controlled trials (RCTs) of hypothermia in children after cardiac
arrest. Current recommendations are based on
extrapolation from existing RCTs in adult and newborn humans. Studies in adults have demonstrated
an improved long-term survival after resuscitation
from ventricular fibrillation followed by hypothermia treatment.76 The American Heart Association
guidelines in 2006 recommend that hypothermia be
considered in children for 12 to 24 hours who remain
vital signs, GCS score, electrolytes, coagulation factors, and oxygen saturation. The probability of death
is then calculated using a complicated equation. The
process of collecting multiple data points followed by
a complicated calculation makes this score unrealistic
to routinely use in a busy ED.
The Orlowski scoring system has also been
described but has limited sensitivity and specificity.
The scoring system has 5 unfavorable prognostic factors: age 3 years, estimated submersion time of > 5
minutes, no attempts at resuscitation for 10 minutes
after rescue, coma on admission to the ED, and severe acidosis with an arterial blood gas pH value of
7.10 or less.7 Since 2 of the 5 factors are very subjective and subject to measurement bias, it is clear why
this would be a difficult tool to validate.
Ultimately, there are no indicators at the rescue
site or in the hospital that are absolutely reliable with

respect to death or survival.48 See Tables 1 and 2.
Exceptions
Case reports of remarkable survival accounts point
to exceptions to prior suggested rules.101 One example is the resuscitation of a 5-year-old boy following a 22-minute submersion in ice water.102 Multiple
similar case reports have been documented.91,103-104
The longest recorded submersion time of 66 minutes was a 2-year-old girl reported in 1988 by Bolte
et al.104 This case has the longest reported submersion time to survive and be neurologically intact.
She was found completely submerged, apneic, with
fixed and dilated pupils, and with no palpable pulse.
Cardiopulmonary resuscitation was maintained for
more than 2 hours, and extracorporeal rewarming
was used. Her initial pH was 7.25 and she had a core
temperature of 19C (66F) upon arrival.104
Another case presents an exception to the rule
that neurologic status at 24 hours is predictive of
outcome. In this 2004 case report, a 2 year-old boy
was submerged for at least 20 minutes in Florida,91
and CPR was administered for 1 hour. The patient
had regained pulses upon arrival to the ED. Rectal
temperature upon hospital arrival was < 26.7C
(80F). This patient emerged from a coma 72 hours
later and was completely neurologically normal 6
months after event.91
Several features are present in case reports with
successful outcomes: the victims are usually small
children, the duration of submersion is less than 15
Table 1. Factors Often Associated With A

Poor Prognosis

Submersion time (>10 minutes)3,48,59,66,82-87

Resuscitation time (>15-25 minutes)59,84,88
Core body temperature < 35C (95F)48,89a
Water temperature (>10C [50F])
Time to effective life support > 10 minutes6,22,67,86
Glasgow Coma Scale score < 53,66,79,90-93
pH on presentation < 7.191,93-94
Age < 348,95 c
Persistent apnea in the emergency department66,93
Requirement of CPR in the emergency department85
Requirement of 2 to 3 doses of epinephrine88,93-94
Aspiration48,83
Central body temperature < 35C (95F) at admission48 b
Rapid rewarming6
Male6 93-94 d
Asystole6,79
Elevated potassium6, 67 e
Lactate > 666
Glucose >3003,6,66
Fixed and dilated pupils6,85,92,94, 96 f
Table 2. Factors Often Associated With A

Good Outcome

Low core temperature has been shown to be associated with poor

prognosis, but patients that survive and are neurologically intact are
typically hypothermic. A study by Youn, 2009,86 did not support a correlation between core body temperature and outcome.
b
Eich, 2007,6 and Suominen, 199782 and 2002,83 showed no predictive
value between water temperature and survival
c
The correlation between age and prognosis remains controversial.
Studies have conflicting results.6
d
Males have a four-fold increased risk of drowning as compared to
females. There is a higher prevalence of male drowning, but it is
unclear if girls have better outcomes after resuscitation than boys.6
e
Hyperkalemia greater than 10 mmol/dL is not compatible with successful resuscitation in patients with hypothermia.97-98
f
One study, published in 1991, evaluated children that presented
apneic and cyanotic to the hospital after a drowning event. Thirtythree of the children had fixed and dilated pupils. Ten of those 33 fully
recovered, 13 died, and 10 survived with severe neurological deficit.96
a
Witnessed arrest6,86
Intact pulses upon arrival to emergency department89
Bradycardic rhythm (as opposed to asystole)6
Submersion time < 5 minutes
Alert upon arrival to emergency department79,96
Reactive pupils3
Female95
Bystander CPR53-55,99 or prompt initiation of resuscitation6,22,49,100
Hypothermia48,89 a
In most children, hypothermia is a poor prognostic sign as it is

frequently related to a long submersion time. However, hypothermia
occurs quickly with immersion in ice water and does not necessarily
indicate prolonged submersion. Several studies have demonstrated
that the relationship between body temperature and survival outcome
is not clear.6,82-83,86 Hypothermic protection is dependent on slowing
cerebral metabolism before irreversible hypoxic-ischemic injury has
occurred and only occurs in the most frigid water.101 The speed of
cooling may be more important than the actual temperature. If the
body is quickly cooled before ischemia has occurred, this appears to
be protective. If a child is immersed in icy water, he is cooled quickly
and his brain may cool to protective levels prior to ischemic effects.
Clinical Pathway For Pediatric Submersion Injury
Initiate CPR. Monitor. Remove wet clothing.
Were trauma or drugs involved?

NO
YES
No spinal precautions are

necessary.
Use spinal precautions.

(Class II)
NO
YES
Does patient have spontaneous respirations?

Assist with bag valve mask.
Does patient respond
with spontaneous respirations?
YES
Administer O2.
NO
NO
Intubate. Is there a pulse?
YES
Does patient have normal

respiratory examination?
Add PEEP. Move to ICU or

transfer to tertiary care
YES
NO
Perform PALS. Is patient

normothermic?
YES
NO
Consider albuterol.
Admit patient.
Discontinue resuscitation.
(Class II)
YES
Discharge home after 4

hours of observation.
YES
NO
Perform active rewarming

measures.
Was patient in icy water?
Is submersion time < 20

minutes in cool water or
< 60 minutes in icy water?
Is there a pulse?
Continue PALS.
YES
NO
Is core temperature > 30C

(86F)?
YES
Move patient to ICU or

center.
Abbreviations: CPR, cardiopulmonary resuscitation; ICU,

intensive care unit; PALS, pediatric advanced life support;
PEEP, positive expiratory-end
pressure.
(Class II)
NO
NO
Is there a pulse after 20
minutes?
YES
Move patient to ICU or

center.
Resuscitation greater than

2 hours?
NO
YES
YES
Class of evidence definitions

are available on page 18.
NO
(Class II)
Continue resuscitation to 2
hours. Is there a pulse?
NO
(Class II)
lished in 2004 demonstrated that there were no survivors with good neurologic outcome who received
more than 3 boluses of epinephrine or > 31 minutes
of resuscitation.54 Quan et al found a duration of
resuscitation by emergency medicine technicians
of > 25 minutes to be associated with death in all
children and adolescents in cardiorespiratory arrest
after drowning.84

An expert review of pediatric resuscitation by
the international liaison committee on resuscitation
concluded that while short duration of CPR is associated with better outcome, good outcome can occur
with 30 minutes of CPR with warm water submersion and 60 minutes of CPR with ice-water submersion.65,117
minutes, there is early commencement of resuscitation efforts, and the water temperature of submersion is below 10C (50F).101 Patients who survive
submersions longer than this are usually submerged
in colder temperature water.101 Despite those cases,
water temperature is not always predictive of a good
outcome.82-83
Prognosis Summary
Drowned children who present with stable vital
signs and normal mental status have a survival
rate of almost 100% without neurological sequelae.96,105-106 Children with spontaneous ventilation
immediately after CPR,107 requiring < 10 minutes
of CPR, or arriving to the ED with a pulse after
a drowning event generally survive with little to
no impairment.65 Most drowning victims suffer a
period of unconsciousness secondary to cerebral
hypoxia, and many will present with alteration of
consciousness.2 Prior studies have demonstrated
that between 90% and 100% of patients who present
initially stuporous but capable of being aroused with
purposeful movements to pain survive intact after
drowning.105-106

Patients presenting to the ED in a coma have
worse outcomes. Conn and Modell demonstrated in
1980 that survival with normal brain function occurred in only 44% of these patients. In addition, 39%
died, and 17% had incapacitating brain damage.105-106

Families often have unreasonable expectations
of a doctors ability to resuscitate a child. They often
dont understand that even if their child regains
circulation, he or she child may be neurologically
devastated. Medical television shows have contributed to the optimism of survival rates and often omit
the risks of excessive resuscitation.108
Aggressive resuscitation seems to simply increase the number of survivors with poor neurologic outcome.79,89 In 2002, Suominen stated that
if a victim has been submerged in warm water (>
5C [41F]) for longer than 25 minutes, there are
practically no chances of survival. Resuscitation
likely would result in persistent vegetative state or
death.83 An Ovid MEDLINE search of 12 studies showed that continuing CPR longer than 30
minutes in normothermic patients doesnt produce
additional survivors.55,88,109-115 However, this Ovid
MEDLINE search contained studies that were
performed prior to Utstein style of reporting.1 Biggart and Bohn concluded that prolonged in-hospital
resuscitation and aggressive treatment of drowning
victims who initially have absence of vital signs and
are not hypothermic either result in eventual death
or increase the number of survivors with a persistent
vegetative state.89

The duration of CPR and the need for multiple
doses of medications certainly affect prognosis. A
study of outpatient pediatric cardiac arrest pubJune 2011 ebmedicine.net
Prevention
Education and regulations regarding prevention
and management of the acute drowning victim are
essential to decrease the incidence of drowning
and deaths from drowning. Strategies for prevention include promoting appropriate barriers around
water structures with self-closing and self-latching
gates118 and improving families awareness that each
child is at risk.119 There is a trend of rebelling against
child safety in the media, and multiple editorials
have discussed that we cannot baby-proof the
world.120 Though paranoia is not encouraged, there
are effective preventative measures that have been
demonstrated to reduce deaths due to drowning. An
additional educational tool is to add general prevention guidelines with ED discharge paperwork.121 It
is important to note that most toddlers can easily
climb a chain linked fence.122 Most children are able
to climb a 48-inch wall before 4 years of age and can
do so in less than 2 minutes.123 Installation of 4-sided
fencing (greater than 4 feet tall) that isolates the pool
from the house prevents more than 50% of swimming pool drownings among young children.124 The
probability of drowning in an unfenced pool is between 2 to 5 times higher than a fenced pool.125 It is
also recommended that toys, which may lure a child
into the area, be removed from the area surrounding
the pool when not in use.126
Appropriate supervision is probably the most
important aspect of prevention. Education regarding
the need for supervision including specific recommendations is important. Less than half of surveyed
mothers routinely drain water from buckets in the
home.127 Unfortunately, clinicians dont often counsel children and families on drowning prevention.128
Specific recommendations regarding adult supervision from the Centers for Disease Control include no
alcohol use, no phone use, and no performing other
tasks while supervising children around water.126
Families must be aware that epilepsy is a risk factor for submersion injury, including drowning in a
9
Risk Management Pitfalls In The Treatment Of Drowning

And Submersion Injuries
1. A 6-year-old male in cardiac arrest presented to
my ED today with unknown down time. He was
hypothermic upon arrival, so we continued the
code past shift change. I have heard of amazing survival reports in the literature, and I was
hopeful I could save this child. My ED director was waiting for my sign out and told me I
should have stopped the resuscitation an hour
ago when the potassium came back at 11.5. How
was I supposed to know when to stop?
A potassium level greater than 10 is not compatible with successful resuscitation in hypothermic
patients. Severe hyperkalemia indicates significant ischemia occurred prior to hypothermia.
The code should have been called when this lab
value was known.
not be called dead until they are warm and

dead. Rewarming should occur until the child
is approximately 34C.
6. I discharged the patient after he improved with
albuterol. I watched him for an hour (he had a history of asthma). How could I know he was going
to return with worsening respiratory distress?
Symptomatic patients should be admitted after
drowning, especially if they have underlying
pulmonary pathology. They have the potential
to deteriorate.
7. The child drowned in a hot tub but was only
submerged for about 5 minutes. I told the
mother his prognosis should be good as his submersion time was so short. How was I supposed
to know that he had neurologic damage?
As hypothermia has neuro-protective effects,
hyperthermia can adversely affect the time in
which neurological injury can occur.
2. An 18-month-old female was brought in by

the family maid after she was found with her
head in a bucket of cleaning water. I didnt believe this could happen and called the police.
Unfortunately, a toddler drowning in an unattended bucket of water is not uncommon.
Though one should always consider the possibility of non-accidental trauma in drowning
cases, the story is plausible.
8. A 4-year-old child presented after he fell into

the family pool. A sibling immediately rescued
him, and he choked a bit but was spontaneously breathing when paramedics arrived. I
wanted to admit him for fear he may deteriorate. My pediatrician recommended I send him
home. Should I accept the liability?
There are no prospective randomized controlled
trials evaluating when to discharge patients after
drowning. Case series seem to suggest that a
child who has a normal oxygen saturation and
pulmonary examination may be safely discharged 4 hours after the drowning event.
3. A 2-year-old male was brought in to the ED in

cardiac arrest and required epinephrine prior to
regaining a weak pulse. He remained comatose
and minimally responsive. I told the mother
that the child had no chance of normal survival
after a drowning incident, and she filed a complaint to administration.
There are multiple case reports of surprising survival in drowning victims that do not always follow
consistent resuscitation expectations or statistics.
9. A 10-year-old child was found floating in his

neighbors pool. It had been hours since he was
last seen. The child is cool, apneic, and pulseless on scene. Paramedics are calling in requesting you to call the code. Should you?
It is always best to err on the side of caution,
especially with respect to pediatric submersion
injuries. When in doubt, always resuscitate. Very
few pediatric codes should be called in the field.
4. A mother brought her son to our ED, but I

thought something was wrong with her story.
She said I didnt know the child was drowning because I didnt hear him panic and he did
not call for help.
Most people are unable to call for help during
a drowning event. This is an important educational reminder to parents regarding supervision
and drowning prevention.
10. A 6-month-old female presents in cardiac arrest after being found submerged in the bathtub. The mother looked so nice and polite that
I didnt even consider non-accidental trauma.
Unfortunately, one should always consider nonaccidental trauma in bathtub-associated drowning. The primary caregiver (often the mother) is
the most frequent culprit.
5. We pronounced the child dead after working on him for over an hour. His core temperature was 29C. I thought there was no
chance of survival. We received a call from
the morgue that the child was moving.
Children with hypothermia upon arrival should
10
dren. It is theorized that the hypothermia used in the

earlier studies was too cold (30C-33C [86F-92F]),
too long (for days), not good controls (historical
controls only), and combined with barbiturate coma.
Current trials are less cold (33C-34C [92F-94F),
for a shorter duration of time (24-48 hours), and
without barbiturates.70,74,142

Mild induced hypothermia is the most clinically
promising recent goal-directed postresuscitation
therapy for adults. Sentinel articles in adults have established that induced hypothermia could improve
outcome for comatose adults after resuscitation from
cardiac arrest associated with ventricular fibrillation.52,143-144 Benefit has not been rigorously studied
and reported in children or in patients with nonventricular fibrillation arrest.52 Promising results exist in neonates suggesting that cooling may improve
outcomes in neonatal hypoxic-ischemic encephalopathy.52,145-146 Hypothermia is common after cardiac
arrest in children.147 More research is necessary to
define the features of subgroups of children who
would benefit from hypothermic treatment.70,73,142
Nitric oxide and liquid ventilation have both
been discussed as a potential adjuvant to drowning
management.7 However, supporting evidence via
studies is limited.
tub.129 A wonderful education opportunity is when a

child presents to the ED with a febrile seizure. In addition, infant bath seats, especially unattended, are
not protective from drowning events.130-132

Inability to swim or over-estimation of swimming abilities also increases the risk of drowning.
Participation in formal swimming lessons was
shown in 1 study to be associated with a reduction in the risk of unintentional drowning death
for children ages 1 to 4.33 However, this study was
a small retrospective review with wide confidence
intervals, and precise estimate of risk reduction is
not available.133-134
Controversies/Cutting Edge
Surfactant
The pathophysiology of drowning includes pulmonary wash-out of surfactant. Because of this, it
has been proposed that surfactant may improve
outcomes in drowning victims with significant
pulmonary complications. Several case reports have
described its use, but data is limited, and no large
randomized controlled trials have been performed
to evaluate its use.135-137 Its availability and expense
also limit its adoption for routine use.
Disposition
Extracorporeal Membranous Oxygenation

Extracorporeal cardiopulmonary resuscitation after
active chest compressions may improve survival.
The use of extracorporeal membranous oxygenation (ECMO) in pediatric critical care has been
well-established, and its use for selective circumstances, such as post cardiac surgery with depressed
myocardium, has shown success.52,138-139 Improved
outcomes have been demonstrated in postcardiac
arrest patients that received mechanical circulatory
support with ECMO compared with non-ECMO use
in the PICU.52,140 An advantage of extracorporeal
rewarming in drowning victims is early restoration
of normoxic cerebral perfusion regardless of the
cardiac rhythm, reduction of the blood viscosity,
and controlled restoration of body temperature.101
Extracorporeal rewarming was used in the longest
submerged patient that survived neurologically
intact (childs core temperature was 19C [66F], and
she was submerged for at least 66 minutes).141
Drowned children admitted to the hospital with

stable vital signs and normal mental status have a
survival rate of almost 100%.6 Historically, patients
have been admitted to the hospital for 24-hour observation after drowning events. There was concern
that patients may develop secondary drowning, a
latent post-immersion respiratory syndrome where
deterioration of pulmonary function occurs after an
episode of deficient gas exchange due to loss/inactivation of surfactant.148
Pearn discussed this concept of secondary
drowning and published a case series in 1980 of
patients who deteriorated during their hospital
course.148 However, when each case that he discusses is reviewed, it is noted that all developed symptoms or had something abnormal on physical examination within a 4-hour window of presentation to
the ED. The concern of secondary drowning has
created a fair amount of unjustified fear that patients
may deteriorate once discharged home despite
looking well in the ED. Several studies have questioned the practice of routine hospital admission for
drowning.149-150 These studies are small and retrospective, making their recommendations for earlier
discharge Class III evidence. The patients who were
discharged after 4 to 6 hours of observation in these
studies were alert, had a normal physical examination, and had oxygen saturation > 95%.
As is often the case in emergency medicine, the
Hypothermia
Prior studies in the 1970s and 1980s used hypothermia, barbiturate coma, neuromuscular blockers,
hyperventilation, and dehydration to enhance neurologic outcome. Several studies showed that these
treatments were not effective and simply resulted in
more neurologically devastated survivors.2,70,79,89,105
Therefore, hypothermia was dismissed as not
improving outcome. However, adult studies have
increased interest in the use of hypothermia in chilJune 2011 ebmedicine.net
11
dichotomy of easy disposition decisions is that they

are really minor or really severe. Any child that
arrives in a serious state, such as cardiopulmonary
arrest, and survives deserves special attention.
Patients that initially require oxygen or improve
after a trial of bronchodilators also deserve diligent
monitoring. Ultimately, the decision is based on the
history, physical, ED course, the appearance of the
child, clinical gestalt, reliability/comfort of the parents, accessibility to return to the hospital, and all of
the other factors we consciously and subconsciously
weigh in our decision-making in the ED. Each case
is different. Each child had unique circumstances
regarding the drowning event, and it is therefore extremely difficult to create black and white, dogmatic
rules regarding disposition. That said, if a child
looks great and does not have any respiratory difficulty, discharging them home after 4 hours in the
ED is recommended. It is generally recommended
that symptomatic patients should be admitted until
symptoms resolve.9

The other very difficult decision is when to stop
resuscitation. Unfortunately, the literature does not
help us much in each individual case. There are several factors that are associated with a poor prognosis, but statistics do not help us to know whether the
child in front of us at this moment will survive and
lead a normal life or if that child will be neurologically devastated and require intensive home nursing
or care in a facility in the future. In these children,
we must resuscitate enough, yet not too much. It has
been shown that aggressive and prolonged resuscitation simply increases the number of survivors with
poor neurological outcome. There is much fear and
angst regarding how long to resuscitate a child. And
there have been cases in the news of children who
have drowned, were pronounced dead, and were
found with a pulse or moving later in the morgue.
Bedside ultrasonography is helpful in resuscitation to evaluate the presence of cardiac motion.
Literature in adults seems to suggest that outcome
is extremely poor in patients who have cardiac
standstill on bedside echocardiography.151 Bedside
ultrasonography to evaluate cardiac motion is fairly
consistent for even a novice user.152 Performing this
during resuscitation is a useful tool in considering
when to cease efforts. In addition, it is also reasonable to resuscitate a child until mild hypothermia
(32C-34C [90F-93F) is reached.
be both emotionally and financially devastating

for families. Typically, more than one-fourth of the
hospitalization costs are not covered by insurance.154
Cost-effective (and life-protective) strategies should
be focused on prevention with water safety and appropriate barriers and education including CPR.
Summary
Drowning is a common and preventable cause of
death in children. Prevention is the most effective
measure as there is significant morbidity and mortality in drowning events. Extensive resuscitation measures often do not bring back a child and can result
in neurologic devastation. Prognosis is difficult to
estimate in an altered patient during resuscitation.
Hypothermia is protective but only if cerebral metabolism is slowed before hypoxic-ischemic injury
occurs. The most important prognostication factor
is submersion time, but exceptions exist. Deaths
have occurred with short submersions lasting only
minutes, and normal survival has been described
with submersion over an hour. Patients presenting
with a normal mental status, normal vital signs, and
normal pulmonary examination may be discharged
after 4 hours in the ED. Patients with a depressed
mental status who are responsive to stimuli need to
be admitted but typically do well. In general, admit
any patients that are symptomatic after drowning
events. Outcomes of patients that are comatose upon
arrival cannot be predicted. Resuscitation should
continue until a patient is warmed to approximately
32C to 34C (90F to 93F) unless there is a condition that is incompatible with life (such as significant
trauma or lividity). There is no standard for time of
resuscitation, but favorable outcomes have occurred
in patients resuscitated for up to 30 minutes in
warm-water submersions and 60 minutes in coldwater submersions. Longer resuscitations have been
successful with the use of ECMO but only in case
reports. Consider ECMO as part of your resuscitation and rewarming plan if it is immediately available in your facility. Use bedside ultrasound as an
adjuvant in guiding your resuscitation. Resuscitate
long enough to give the child a chance but not
exhaustively so as only to revive a neurologically
devastated child.
Case Conclusion
Cost-Effective Strategies
The child was considered low-risk for cervical spine injury

and was not immobilized. She was successfully intubated upon arrival to the ED. Chest compressions were
continued, and a dose of epinephrine was administered.
Weak cardiac activity was noted on bedside ultrasound,
and pulses were regained. Core temperature was noted to
be 30C (86F), and gentle rewarming techniques were
begun including removing wet clothing, infusing warmed
Though one childs life saved with normal neurological outcome is priceless, one must consider the
risk of reviving a neurologically devastated child.
Victims of drowning events often are admitted to
the ICU and are aggressively managed only to die
or remain in a vegetative state. This experience can
12
normal saline, and placing a Bair Hugger on the

patient. The patient remained comatose while in the ED.
The PICU had an available bed, and the patient went up
to the unit intubated but with intact circulation. While in
the PICU, the child was enrolled in an ongoing hypothermia trial and her temperature was maintained at 32C
to 34C (90F to 93F). Over the next 12 hours, your
patients neurological condition rapidly improved, and she
was extubated the next morning. You visited as a follow
up and saw her running around in the hallway, awaiting
transfer to a step-down bed. The PICU team mentioned
that social work was involved as the family happened to
have 2 prior Child Protective Services reports on file for
child neglect and drug use.
16. Griest K, Zumwalt R. Child abuse by drownig. Pediatrics.

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125. Fergusson D, Horwood L. Risks of drowning in fenced and
unfenced domestic swimming pools. NZ Med J. 1984;97:777779.
126. Centers for Disease Control. Nonfatal and fatal drownings in
recreational water settings--United States, 2001-2002. Morbidity and Mortality Weekly Report. 2004;53(21):447-455.
127. Morrongiello B, Kiriakou S. Mothers home-safety practices
for preventing six types of childhood injurries: what do they
do, and why? Journal of Pediatric Psychology 2004;29(4):285297.
128. Barkin S, Gelberg L. Sink or swim--clinicians dont often
counsel on drowning prevention. Pediatrics. 1999;104(5):obtained from MDConsult.com.
129. Diekema D, Quan L, Holt V. Epilepsy as a risk factor for
submersion injury in children. Pediatrics. 1993;91(3):612-616.
130. Byard RW, Donald T. Infant bath seats, drowning and neardrowning. J. Paediatr. Child Health. 2004;40:305-307.
131. Rauchschwalbe R, Brenner R, Smith G. The role of bathtub seats and rings in infant drowning deaths. Pediatrics.
1997;100(4):e1-5.
132. Thompson K. The role of bath seats in unintentional infant
bathtub drowning deaths. Medscape General Medicine.
2003;5(1):obtained from www.Medscape.com.
133. Brenner R, Saluja T, Haynie D, et al. Swimming lessons may
15
CME Questions
reduce risk of drowning in young children. Arch Pediatr

Adolesc Med. 2009;163:203-210.
134. McIntosh G. Translating best evidence into best care. The
Journal of Pediatrics. 2009:447.
135. Onarheim H, Vik V. Porcine surfactant (Curosurf) for acute
respiratory failure after near-drowning in 12 year old. Acta
Anaestesiol Scand. 2004;48:778-781.
136. Staudinger T, Bankier A, Strohmaier W, et al. Exogenous
surfactant therapy in a patient with adult respiratory distress
syndrome after near drowning. Resuscitation. 1997;35:179182.
137. Cubattoli L, Franchi F, Coratti G. Surfactant therapy for
acute respiratory failure after drowning: Two children victim
of cardiac arrest. Resuscitation. 2009;80:1088-1089.
138. Morris MC, Wernovsky G, Nadkarni VM. Survival outcomes
after extracorporeal cardiopulmonary resuscitation instituted during active chest compressions following refractory
in-hospital pediatric cardiac arrest. Pediatric Crit Care Med.
2004;5(5):440-446.
139. Mohri H, Dillard D, Crawford E, et al. Method of surfaceinduced deep hypothermia for open-heart surgery in infants.
Journal of Thoracic and Cardiovascular Surgery. 1969;58:262-270.
140. de Mos N, van Litsenburg R, McCrindle B, et al. Pediatric
in-intensive-care-unit cardiac arrest: incidence, survival, and
predictive factors. Crit Care Med. 2006;34(4):1209-1215.
141. Bolte RG, Bowers RS, Thorne JK, et al. The use of extracorporeal rewarming in a child submerged for 66 minutes. JAMA.
1988;260(3):377-379.
142. Polderman K. Induced hypothermia and fever control for
prevention and treatment of neurological injuries. Lancet.
2008;371:1955-1969.
143. The Hypothermia After Cardiac Arrest Study Group. Mild
therapeutic hypothermia to improve the neurologic outcome
after cardiac arrest. The New England Journal of Medicine.
2002;346(8):549-556.
144. Bernard S, Gray T, Buist M, et al. Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. The New England Journal of Medicine. 2002;346(8):557563.
145. Gluckman P, Wyatt J, Azzopardi D, et al. Selective head cooling with mild systemic hypothermia after neonatal encephalopathy: multicentre randomised trial. Lancet. 2005;9460:663670.
146. Shankaran S, Laptook A, Wright L, et al. Whole-body hypothermia for neonatal encephalopathy: animal observations
as a basis for a randomized, controlled pilot study in term
infants. Pediatrics. 2002;110(2):377-385.
147. Hickey R, Kochanek P, Ferimer H, et al. Hypothermia and
hyperthermia in children after resuscitation from cardiac
arrest. Pediatrics. 2000;106(1):118-122.
148. Pearn J. Secondary drowning in children. British Medical
Journal. 1980;128:1103-1105.
149. Noonan L, Howrey R, Ginsburg C. Freshwater submersion
injuries in children: a retrospective review of seventy-five
hospitalized patients. Pediatrics. 1996;98(5):368-371.
150. Causey A, Tilelli J, Swanson M. Predicting discharge in
uncomplicated near-drowning. American Journal of Emergency
Medicine. 2000;18(1):obtained from MDConsult.com.
151. Blaivas M, Fox JC. Outcome in cardiac arrest patients found
to have cardiac standstill on the bedside emergency department echocardiogram. Acad Emerg Med. 2001;8(6):616-621.
152. Niendorff DF, Rassias AJ, Palac R, et al. Rapid cardiac
ultrasound of inpatients suffering PEA arrest performed by
nonexpert sonographers. Resuscitation. 2005;67:81-87.
153. Ronco R, Gonzalez G. Drowning and early cranial computed
tomography findings: Just another piece of information.
Pediatr Crit Care Med. 2008;9(6):653.
154. Hutchison JS, Ward RE, Lacroix J, et al. Hypothermia
therapy after traumatic brain injury in children. N Engl J
Med. 2008; 358(23) 2447-2456
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1. A teenager is not breathing after a witnessed
diving accident. What is the appropriate order
of events in the management of this child?
a. Cervical spine immobilization,

compressions, assess breath sounds, jaw

thrust
b. Jaw thrust, cervical spine immobilization,

intubation, assess breath sounds, check for

pulses
c. Intubation, compressions, cervical spine

immobilization, assess breath sounds
d. Check for pulses, assess breath sounds,

intubate, chest compressions
2. In which patient should cervical spine immobilization be performed?
a. 2-year-old found floating in the family pool
b. 4-year-old drowned in a lake
c. 10-year-old with history of epilepsy

drowned in the ocean
d. 17-year-old submerged in water at the

bottom of a cliff
3. Chest x-rays are very useful in determining
treatment for drowned patients.
a. True
b. False
4. A drowned patient is brought in by paramedics in full arrest. Which of the following would
lead you to discontinue the resuscitation?
a. Core temperature < 30C (86F)
b. Reactive pupils
c. Potassium 10.2
d. Pulseless electrical activity with cardiac

activity seen on bedside ultrasound
5. What is the minimum height that a pool fence
should be to decrease the risk of an accidental
drowning?
a. 2 feet
b. 3 feet
c. 4 feet
d. 5 feet
16
6. A 5-year-old was found floating in the family

pool after an unknown submersion time. No
bystander CPR was performed, and paramedics have been resuscitating the child for 25
minutes. At what temperature should the child
be warmed to prior to stopping resuscitation?
a. 37C (99F)
b. 34C (93F)
c. 31C (88F)
d. 30C (86F)
Physician CME Information

Date of Original Release: June 1, 2011. Date of most recent review: May 10,
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7. A 2-year-old girl is found in a pool moments

after her mother heard splashing. Which of the
following factors is the best indicator of her
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a. Age < 3
b. Female sex
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d. Submersion time
8. An infant bath seat is a good safety measure to
decrease the risk of drowning.
a. True
b. False
9. A 12-year-old boy had a witnessed drowning
event at a local pool. He was apneic on-scene
and some helpful bystanders attempted the
Heimlich maneuver prior to rescue breathing.
What is your main concern?
a. Aspiration
b. Retained foreign body
c. Hyperthermia
d. Post-traumatic pancreatitis
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10. What medical condition significantly increases

a childs risk of drowning?
a. Congenital heart disease
b. Epilepsy
c. Hypothyroidism
d. Muscular dystrophy
e. Tourette syndrome
17
Need To Know The Latest

Info On Managing Pediatric
Traumatic Injuries?
Class Of Evidence Definitions

Each action in the clinical pathways section of Pediatric Emergency
Medicine Practice receives a score based on the following definitions.
Class I
Always acceptable, safe
Definitely useful
Proven in both efficacy and effectiveness
Level of Evidence:
One or more large prospective studies
are present (with rare exceptions)
High-quality meta-analyses
Study results consistently positive and
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Class II
Safe, acceptable
Probably useful
Level of Evidence:
Generally higher levels of evidence
Non-randomized or retrospective
studies: historic, cohort, or case
control studies
Less robust RCTs
Results consistently positive
Class III
May be acceptable
Possibly useful
Considered optional or alternative
treatments
Indeterminate
Continuing area of research
No recommendations until further
research
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Level of Evidence:
Evidence not available
Higher studies in progress
Results inconsistent, contradictory
Results not compelling
Significantly modified from: The Emergency Cardiovascular Care Committees
of the American Heart Association and
representatives from the resuscitation
councils of ILCOR: How to Develop Evidence-Based Guidelines for Emergency
Cardiac Care: Quality of Evidence and
Classes of Recommendations; also:
Anonymous. Guidelines for cardiopulmonary resuscitation and emergency
cardiac care. Emergency Cardiac
Care Committee and Subcommittees,
American Heart Association. Part IX.
Ensuring effectiveness of communitywide emergency cardiac care. JAMA.
1992;268(16):2289-2295.
Initial Evaluation And Resuscitation Of

The Injured Child covers such crucial clinical
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Recognizing signs of traumatic brain injury
and improving outcomes
Establishing a stable airway
Resolving fluid administration debates and
providing appropriate resuscitation
Employing diagnostic modalities that impact
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Recognizing and reversing shock
Choosing the appropriate endotracheal tube
Identifying appropriate facilities and equipment
Overcoming the challenges of treating children
vs. adults
Using and interpreting the FAST examination
Evaluating the use of diagnostic peritoneal
lavage
Reviewing guidelines for the care of pediatric
head injuries
Diagnosing and treating spinal cord injury and
thoracic trauma
Providing specialized pediatric orthopedic care
Level of Evidence:
Generally lower or intermediate levels
of evidence
Case series, animal studies,
consensus panels
Occasionally positive results
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And Resuscitation Of The Injured Child, including
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EM Critical Care (EMCC)
Coming In Future Pediatric Emergency

Medicine Practice Issues
EB Medicine is proud to add critical care to the list of

publication topics that we offer to clinicians. EM Critical
Care (EMCC) will help emergency clinicians manage
critically ill patients in the ED. Subscriptions include:

Bleeding Disorders
Intussusception
Testicular Torsion
Bi-monthly evidence-based print issues with clinical

recommendations that improve patient care
Monthly e-newsletter with challenging case studies
Full online access to searchable issues
Free CME: 18 AMA PRA Category 1 CreditsTM per
year
Free trauma CME credits
In This Months Emergency Medicine Practice

Traumatic Hand Injuries: The Emergency
Clinicians Evidenced-Based Approach
By:
Aaron Andrade, MD
Emergency Medicine Physician, Alameda County
Medical Center, Highland General Hospital,
Oakland, CA
Subscribe today by calling 1-800-249-5770 or visiting

www.ebmedicine.net/EMCCinfo.
In This Months EM Critical Care

Respiratory Monitoring
In The Emergency Department
H. Gene Hern, MD, MS, FACEP, FAAEM

Residency Director, Alameda County Medical Center,
Highland General Hospital, Oakland, CA
By:
Chad M. Meyers, MD
Director of Emergency Critical Care, Department of
Emergency Medicine, Bellevue Hospital, New York, NY;
Assistant Professor of Clinical Emergency Medicine,
NYU School of Medicine, New York, NY
Hand trauma presents with such a wide variety

of conditions with differing outcomes that a
commanding knowledge of hand trauma and
anatomy is essential to any practicing emergency
clinician. While most patients will require minimal
treatment, emergency clinicians must be able to
correctly identify conditions that threaten longterm hand function and conditions that require
specialty consultation or surgical repair. This issue
of Emergency Medicine Practice focuses on the
diagnosis and treatment of the widely diverse
presentation of traumatic hand injuries using the
best available evidence from the literature.
Scott Weingart, MD, FACEP

Assistant Professor, Department of Emergency
Medicine, Mount Sinai School of Medicine, New York,
NY; Director of Emergency Critical Care, Elmhurst
Hospital Center, New York, NY
Monitoring the respiratory status of emergency
department (ED) patients is a critical step to
understanding their condition and monitoring their
response to interventions. End-tidal carbon dioxide
(ETCO2) is used for verifying endotracheal tube (ETT)
placement, monitoring during procedural sedation,
monitoring after traumatic brain injury (TBI), estimating
prognosis of continued cardiopulmonary resuscitation
(CPR), and detecting return of spontaneous circulation
(ROSC) during cardiac arrest.
In caring for critically ill patients, the emergency
clinician should be familiar with and comfortable using
both pulse oximetry and capnometry, with special
attention paid to the limitations of each method.
This issue of EMCC discusses the use of
pulse oximetry and ETCO2 in the assessment and
management of the critically ill patient in the ED.
Emergency Medicine Practice subscribers: visit

www.ebmedicine.net/topics to view this issue.
Not an Emergency Medicine Practice subscriber?
Visit www.ebmedicine.net/EMPinfo today for an
exclusive discount!
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P E D I AT R I C

EmERgEnCy mEDICInE PRACTICE

from these articles and related articles within a

Critical Appraisal Of The Literature

ebmedicine.net June 2011

mon in African Americans and in those from a lower

Pediatric Emergency Medicine Practice 2011

have persistent hypoxia for days and even weeks

Begin care with an initial primary survey and follow

Cervical Spine Immobilization

CPR And Survival

ebmedicine.net June 2011

Emergency Department Evaluation

Cervical Spine Imaging

Pursue further imaging if concomitant trauma (eg,

Pediatric Emergency Medicine Practice 2011

outcome.3,6,66-67 However, no consistent prediction

comatose after resuscitation from cardiac arrest.71

Volume depletion may occur in drowning, and

Control seizures they may worsen underlying

Treatments No Longer Recommended

Rewarming techniques should be used until the

ebmedicine.net June 2011

site or in the hospital that are absolutely reliable with

Table 1. Factors Often Associated With A

Submersion time (>10 minutes)3,48,59,66,82-87

Table 2. Factors Often Associated With A

Low core temperature has been shown to be associated with poor

June 2011 ebmedicine.net

In most children, hypothermia is a poor prognostic sign as it is

Pediatric Emergency Medicine Practice 2011

Clinical Pathway For Pediatric Submersion Injury

Initiate CPR. Monitor. Remove wet clothing.

Were trauma or drugs involved?

No spinal precautions are

Use spinal precautions.

Does patient have spontaneous respirations?

Does patient have normal

Add PEEP. Move to ICU or

Perform PALS. Is patient

Discharge home after 4

Perform active rewarming

Was patient in icy water?

Is submersion time < 20

Is core temperature > 30C

Move patient to ICU or

Abbreviations: CPR, cardiopulmonary resuscitation; ICU,

Move patient to ICU or

Resuscitation greater than

Class of evidence definitions

Pediatric Emergency Medicine Practice 2011

ebmedicine.net June 2011

Pediatric Emergency Medicine Practice 2011

Risk Management Pitfalls In The Treatment Of Drowning

not be called dead until they are warm and

2. An 18-month-old female was brought in by

8. A 4-year-old child presented after he fell into

3. A 2-year-old male was brought in to the ED in

9. A 10-year-old child was found floating in his

4. A mother brought her son to our ED, but I

ebmedicine.net June 2011

dren. It is theorized that the hypothermia used in the

tub.129 A wonderful education opportunity is when a

AmEx: ____________________________ Exp: _