3. Drowning 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

4. Epidemiology Age 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.

5. Relevant factors: Water Tonicity Time submersion water Temperature symptoms associated injuries. Undetected primary cardiac arrhythmia( long QT) response to initial CPR

6. Drowning begin with: 1. Panic, breath holding, ear hunger 2. reflex inspiratory and aspiration. 3.laryngospasm that leads to hypoxemia 4.hyperventilation followed by voluntary apnea.

7. Pathophysiology Asphyxia may occur with: 1. pulmonary aspiration (wet drowning). 2. laryngospasm (10-20%) until cardic arrest )dry drowning)

8. 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

9. Anoxic-ischemic injury Pulmonary: wash out surfactant Pulmonary edema, ARDS Cardiovascular: Arrhythmia( hypothermia,hypoxemia ) Acid-base Electrolytes

10. Anoxic-ischemic injury Renal ATN (hypoxemia,shock, hemoglobinuria) Gasterointestinal hepatic trasaminases and serum pancratic enzymes are often acutely elevated

11. 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

12. Fluid and electrolyte alteration The great majority of submersion do not aspirate large volumes of fluid to result in significant electrolyte disturbances. Sea water Fresh water

13. Hypothermia 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

14. Lab & imaging studies ABG CBC,Electrolytes,U/A Chet x Ray - cervical spine X Ray non contrast head CT scan???

15. Imaging Head CT scan is not helpful unless : 1.Suspicion of associated trauma injury 2. to rule out other possible causes of coma MRI may detect change associated with hypoxic- ischemic injuries

16. Clinical Manifestation Victims in cardiac arrest require aggressive and prolong CPR.

17. Pre hospital treatment Careful search for pulses. If pulses presented : Chest compression withhold Sinus bradicardia and atrial fibrillation require no immediate treatment

18. Treatment Initial resuscitation: CPR air way should be clear Abdominal thrust should not be used Cervical spine should be protected

19. 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 assessment. Chest X RAY

20. Emergency unit management Patients discharge after 8-12 hours if no evidence of : significant injury bronchospasm tachypnea inadequate oxigenation

21. hospitalized Children Supplement O2 NaHCO3 diuretic for pulmonary edema. broncodilators for brochospasme. Antibiotic for contaminated water. Anticonvolsion treatment for seizure

22. Treatment NG tube ECG monitoring for diagnosis and treatment of arrhythmia. Hypothermia treatment passive,active If a child is hypoglycemic 0/5- 1g/kg dextrose

23. ETT is needed if… 1. apnea,cyanosis. 2. hypoventilation. 3. hemodynamic istability. 4. protect air way in patient with depressed Mental

24. Treatment (con) A few patients develop require mechanical ventilation. 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)

25. Patients should closely evaluated for The neurological status Neurologic examination during the first 24-72hr are the best prognostic of CNS outcome.

26. 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

27. 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.

28. prognosis PH<7.1 Water temperature >10 c Children who remain comatose 24 hr after initiating resuscitation

29. Treatment discontinue submersion victim in non-icy water that remain systole despite 30-45 min of aggressive CPR