Drowning & electrical injuries Dr. Minoo Saeidi Assisstant professor of pediatrics

drowning It is more common in children under 5 and 15 to 24 years old Falling in to the swimming pool, open water, bathtub Suicide, child abuse Boys are four times susceptible than girls Aspiration of small amount of water into the larynx, trigger breath holding and laryngospasm, after that aspiration of the larger volume of water or gastric content into the lung, destroying surfactant, pulmonary endothelial injuries, increased capillary permeability, impaired ventilation and oxygenation, hypoxia, circulatory collapse

Disorders associated with drowning

Prehospital care Rapid resuscitation after safe removal of the victim Cervical spine injuries is rare (0.5%) Use high flow oxygen Warm the patient Monitoring if possible Establish IV access if possible ED transfer is necessary if: Drowning amnesia for the event, Loss or depressed consciousness, Observed period of apnea, Who required a period of artificial ventilation

Emergency department care Assess and secure the airway Provide oxygen Determine core temperature (warmed IV fluid, blanket, warmer) Assist ventilation if needed routine cervical immobilization and CT of brain is not necessary GCS>13 and O2Sat >95% are low risk; observe them for 4 to 6 hours Laboratory data and chest X ray are not valuable in deciding (don’t request) When they should return; Fever, Pulmonary symptoms, Mental status changes

Emergency department care GCS< 13; administer supplemental oxygen, ventilatory support Intubate if: PaO2<80 with FIO2 40 to 60% Request lab data, chest X ray Monitoring PR, RR, T, BP, O2Sat Don’t use prophylactic antibiotics for aspiration pneumonia If the patient is normothermic on arrival and cardiac rhythm is asystole; discontinue prolonged CPR because of profound neurological complication

Continued management Cardiac monitoring (infusion of Dopamine, echocardiography, CV line) Neurologic monitoring (brain edema, neurologic deficit) Monitor ICP (don’t improve outcome) Hypothermia management Avoid ventilator associated barotrauma Consider Aeromonas when treat pulmonary infections

Poor prognostic factors in drowning Bystander CPR at the scene (20% die later in hospital) CPR in emergency department Prolonged CPR in ED (longer than 30 minutes) Asystole at the scene Coma for more than 72 hours GCS 5 or less Fix dilated pupils Seizure Longer submersion time (more than 15 minutes, especially more than 60 minutes)

Prevention tips Parental vigilance during bathing Never leave an infant in bath seats Four sided pool fences Use personal floatation devices Education Only swim in a lifeguarded area Supervising in or near water

Electrical injury Low voltage < 1000 V (household) High voltage > 1000 V (occupational) Electric arc Household electricity is AC (alternating current) Electricity of batteries is DC (direct current) Alternating current can cause ventricular fibrillation and tetany Both of them can hurl the victim away, severe blunt injury Better prognosis in children

Current flow in the body

Mechanism of damage Direct tissue damage due to electric power Tissue damage due to thermal energy Mechanical injuries due to falling or muscle contraction

High voltage/low voltage

Clinical features Cardiac dysrhythmia (asystole, VF, QT prolongation, bradycardia) Neurologic impairment (transient loss of consciousness, confusion, seizure, agitation, focal neurologic deficit, aphasia, quadriplegia, hemiplegia, visual disturbances, deep coma) Spinal cord injury (compressive fracture of spine, direct injuries to spinal cord cells, vascular injury to the cord, late onset spinal cord injury, progressive demyelination, GBS like illness) Peripheral nerve injury (Paresthesia even late onset) Cutaneous involvement (entry and exit wounds, burn) Orthopedic injuries (fracture, posterior shoulder dislocation)

Clinical features Inhalation injury (pulmonary hemorrhage and edema) Ocular injuries (cataract, corneal scar, keratitis, retinal detachment, macular edema, uveitis, intraocular hemorrhage, optic nerve damage) Auditory injuries (hemorrhage in the middle ear, TM, cochlea and vestibular system, late onset mastoiditis, early or late onset hearing loss) Vascular damage (aneurysm, thrombosis) Muscle damage (spasm, compartment syndrome) Renal involvement (myoglobinuria, ATN) Coagulation disorders (DIC) GI injuries (ileus, intra abdominal hemorrhage, GI perforation)

Prehospital care tips Rescuer safety is very important Stay at least 10 m from downed power line Support structures may be electrically alive Eliminate electrical source immediately Don’t touch the victim until contact with the electrical source is eliminated Consider neck immobilization Do CPR as early as possible

Management in ED Consider ABC Maintain cervical immobilization Cardiac monitoring in symptomatic and high voltage electrical injuries Treat arrhythmia like you do in advanced life support Do careful vascular and neurologic exam Fluid administration (maintain diuresis until CPK level is less than 5 times normal)

Discharge/admission Discharge to home: Voltage <600, Asymptomatic, Normal ECG on arrival, Normal complete examination Observe for 6 hours: Voltage<600, Unwell, Any in ECG Admit to the hospital: Voltage > 600 even there is no apparent injury, Beyond superfacial skin injury unrelated to the voltage, Any abnormal lab data or ECG unrelated to the voltage, Oral and lip burn in children because of scar separation and severe bleeding after 5 days, Child with unreliable parents

Prevention tips Put child-safety covers on all electrical outlets Get rid of equipment and appliances with old or frayed cords and extension cords that look damaged Position television and stereo equipment against walls so small hands don't have access to the back surfaces or cords Don't run electrical wires under rugs or carpet If an appliance appears faulty stop using it and have it checked at once

References Essentials of Nelson, Drowning, chapter 43 Tintinallis Emergency Medicine, Drowning, chapter 215 Tintinallis Emergency Medicine, Electrical and lightning injuries, chapter 218