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Case # 00832989

Case # 00832989. Mary Palomaki St. Barnabas Hospital 30 September 2009. 11 month old male. Brought in by EMS as medical notification. What happened? . Baby boy was in the bathtub with his cousin. His aunt was supervising.

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Case # 00832989

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  1. Case # 00832989 Mary Palomaki St. Barnabas Hospital 30 September 2009

  2. 11 month old male • Brought in by EMS as medical notification

  3. What happened? • Baby boy was in the bathtub with his cousin. • His aunt was supervising. • His aunt removed his cousin from the bathtub and brought him into another room • She left the patient unattended. • The aunt then told the patient’s 15 y/o mother to go take the patient out of the bathtub.

  4. In the bathroom… • The patient was left alone in the bathtub: • 3/4 full adult size bathtub • Warm water • Water not running, not draining • Mother and Aunt estimate patient was left alone for 2-3 minutes

  5. When Mom entered the bathroom, • She found the patient: • unresponsive • floating face up • a large, distended abdomen • Mom called the aunt • His aunt gave rescue breaths and pumped on the chest • The patient responded by vomiting, crying/gurgling, and defecating • 4-5 minutes of “CPR” was given and 911 was called

  6. Upon EMS Arrival • Baby boy found to have spontaneous respiration with RR 30 and HR 130 • He was wrapped in towels and actively vomiting • He did not cry until he was en route to the hospital

  7. Past Medical History: • Birth History: Term, NSVD, no complications • No hospitalizations • No surgeries • No known drug allergies • Immunizations: Up to date • Social: Patient lives with mother, grandmother, care for by his aunt during daytime

  8. Physical Exam 17:00 • Initial Vital Signs: T:97.0 F, P:127, RR: 35 O2 Sat: 98% on 100% ventimask • Weight estimated at 10 kg on broselow tape • Gen: Acute distress, GCS: 8 (1;no eye opening +3;infant consistently inconsolable + 4;infant withdrew from pain) • Heent: NC/AT, Pupils 3 mm bilaterally, sluggish reaction to light, eyes closed, lips pink • Skin: cold, clammy, pink, no bruising, no old scars

  9. Physical Exam Continued • CVS: s1/s2, no murmur, distal pulses 2 + • Resp: + nasal flaring, + subcostal, + suprasternal retractions, B/L air entry, + crackles B/L, R>L • Abd: + distention, + tympanic to percussion, firm to palpation • Extremities: cap refill < 2 sec., no cyanosis • Neuro: No response to mother’s voice, withdrawal and cry to pain, 3+ patellar reflexes, + B/L clonus of ankles 2-3 beats after forced flexion

  10. Initial intervention • Patient was placed on 100% ventimask initially • Placed on monitor • IV inserted • 250 mL bolus of NS given • NG tube placed to decompress stomach • Foley placed

  11. Initial Labs: • ABG (17:05): 7.237 /30.6/ 240/ 99.2/ -13.4 (on 100% FIO2) • Na: 123, K:3.7, Cl:103, Glu: 243, LA: 5.5 • CBC (17:15): 12.5>12.1/37.9<315 N:17.8%, L: 78% • CMP: (17:15): 124|97|16 / 127 4.0|11|0.5 \ 8.5 Mg 1.6 Pho 5.3 AST 75 ALT 31 Alk phos 215 Alb 3.5 Pro 5.5

  12. Chest X-ray • Distended stomach

  13. ED course • Patient declined in mental status, with decreased response to pain, and no cry • Patient had two short episodes of tonic-clonic activity about 5 seconds each, which responded to ativan 0.5 mg IVP • A second 250mL bolus of NS given • Patient became increasingly tachypneaic with RR 54, and O2 sat 85% • Patient was placed on NCPAP with peep of 5 with long nasal prongs • Ceftriaxone 500 mg IV given for prophylaxis of aspiration pneumonia

  14. Vital Signs • 17:20 • HR 163 BP 165/93 RR 38 O2 sat 95% • 17:30 • T 99.4 HR 174 RR 54 BP 137/93 O2 sat 85% (CPAP initiated at this time)

  15. Repeat Labs (18:25): • ABG: 7.33/ 33.2/ 125/ 98.6/ -7.7 (on 100% FiO2) • Na: 121, K:3.1, Cl:103, Glu: 181, LA: 2.4 • CMP: 125|101|15 / 174 3.5|15 |0.4\ 8 Alb: 3.1 Pro 4.9

  16. Overview • Definition • Epidemiology • Accidental vs. Non-accidental drowning • Pathophysiology • Management • Prevention

  17. Definition • 2002 World congress on drowning defined drowning as • “a process resulting in primary respiratory impairment from submersion in a liquid medium” Shepard, Suzanne et al. Drowning. Emedicine.medscape.com/article/772753-overview. Updated 6/9/2009.

  18. Fatal Drowning Statistics • In 2005, 3,582 fatal unintentional drownings in U.S. • 1 in 4 drownings were children < 14 years old • Drowning is the second-leading cause of unintentional injury-related death for children ages 1 to 14 years • Fatal drowning rate of African American children ages 5 to 14 is 3.2 times that of white children in the same age range. • Fatal drowning rate is 2.4 times higher for American Indian and Alaskan Native children than for white children in the same age range. Water Injuries-Fact Sheet. www .cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet Accessed 25 Sept 2009.

  19. Location of Drowning • Brenner et al. looked at death certificates from victims of unintentional drownings in 1995 • Infant drownings: 55% in bathtubs • Age 1-4 years,56% in artificial pools and 26% in otherbodies of freshwater • Children 63% of drownings werein natural bodies of freshwater Brenner RA, Trumble AC, Smith GS, Kessler EP, Overpeck MD. Where children drown, United States, 1995. Pediatrics 2001;108(1):85ミ

  20. Features which differentiate between accidental, non-accidental, and homicidal submersion injuries to children • Accidental submersion: • Typically a baby momentarily left alone or with a sibling in the bath • Majority of children 8-15 months of age • Child the youngest in the family • No features suggesting child abuse • Epilepsy related: • Child with history of epilepsy • Bathing alone • A child older than 24 months • Non-accidental submersion: • Atypical submersion description, with inconsistent details • Late referral to hospital • Associated history of child abuse • Child outside 8-24 month age span • Child left with unsuitable carer • Homicidal drowning: • Maternal history of mental illness • Child outside the 8-24 month age range • Previous history of child abuse Kemp, Alison et al. Accidents and child abuse in bathtub submersions. Archives of Disease in Childhood 1994; 70: 435-438.

  21. “Hypoxic March of Drowning”A pathophysiology summary • Involuntary submersion • Voluntary apnea, tachycardia, hypoxia, hypercarbia • Involuntary inspiration • Triggered by hypercarbia and hypoxia • arterial hypoxemia, tissue hypoxia, tissue acidosis, and tachycardia • Water enters lungs • Increased peripheral airway resistance, pulmonary vessel vasoconstriction/hypertension with shunting of blood, decreased lung compliance, decreased surfactant Pearn, John. The management of near drowning. BMJ 1995. (291) 1447-1452

  22. “Hypoxic March of Drowning” continued • Decompensation -gasping with further inhalation -swallowing with emesis -loss of consciousness • Neuronal dysfunction -blood brain barrier breaks down • Cardiac dysfunction -bradycardia, arrhythmias, asystole 7. Brain Death 8. Somatic Death

  23. Diving Reflex • Infants and young children • Sudden contact with water less than 20 degrees Celsius • Causes: • Bradycardia • vasoconstriction of nonessential vascular beds • shunting of blood to the coronary and cerebral circulation • Shepard, Suzanne et al. Drowning. Emedicine.medscape.com/article/772753-overview. Updated 6/9/2009.

  24. Dry Drowning • 10-20% of patients experience a laryngospasm that prevents aspiration of fluid into the lungs • Tight spasm often persists until cardiac arrest • Lungs remain dry • Large volumes of fluid ingested into stomach • Major cause for electrolyte abnormalities in children (hyponatremia from fresh water, hypernatremia from salt water)

  25. Wet Drowning • 1-3 mL/kg water aspirated hinders gas exchange • When fluid is in the lungs, vagus nerve stimulates vasoconstriction pulmonary vessels and pulmonary hypertension • Freshwater diffuses rapidly across alveolar-capillary membrane and saltwater damages the membrane • Surfactant is denatured by freshwater and washed away by salt water • In both salt water and freshwater aspiration, compliance is decreased

  26. What happens in the brain during drowning? POP QUIZ

  27. What is cerebral perfusion pressure? • The pressure gradient driving cerebral blood flow • CPP = MAP- ICP • How can one calculate cerebral blood flow (CBF)? • CBF=CPP/CVR • CVR=cerebral vascular resistance

  28. Cerebral Auto-regulation Systemic hypoxia Increase in CBF Redistribution of cardiac output Epinephrine released Increase in systemic BP Cerebral blood flow increased

  29. If systemic BP not able to maintain CBF: • Decreased blood (02) supply to brain • Intracellular energy failure • Decreased brain temperature • Release of neurotransmitters • G-aminobutyric acid transaminase (GABA) • Decreased cerebral 02 demand

  30. Hypoxic-Ischemic Encephalopathy • Initial phase • Energy failure from hypoxia/ischemia • Reperfusion Injury • 6-24 hours later • Cerebral edema, apoptosis

  31. Mechanism of Hypoxic-Ischemic Encephalopathy • Excitatory amino acids, glutamate and aspartate, are released in response to hypoxia/ischemia • Activation receptors, NMDA, AMPA, Kainate • Ion channels open • Influx of calcium into cells • Cell death • Lipid peroxidation of cell membranes • Destruction of Na+/K+ ATPase • Cerebral edema, neuron death • Increased rate of apoptosis • Related to influx of calcium into cell and nucleus

  32. Complications of hypoxic-Ischemic Encephalopathy • Autonomic instability • Hypertension • Tachycardia • Diaphoresis • Agitation • Muscle rigidity

  33. Aspiration • Chemical Pneumonia • pH less than 2.5 • Volume greater than 0.3mL/Kg • Inflammatory reaction by cytokines • TNF-alpha, IL-8 • Bacterial Pneumonia • Anaerobic organisms

  34. Other organ involvement • Occur 24-72 hours after initial insult • Heart: decreased contractility, dilation, tricuspid regurgitation, “tako-tsubo stress induced cardiomyopathy • Renal: acute tubular necrosis, oliguria, anuria • Hepatic: increased LFT’s, hypoalbuminemia, coagulopathy, hyperbilirubinemia • Rhabdomyolysis

  35. Management: CPR • Bystander resuscitation necessary • 30% pediatric cardiac arrest patients receive bystander CPR • PUSH HARD, PUSH FAST • Minimize interruptions • Some bystander CPR, better than none • Heimlich maneuver contraindicated because it can cause emesis, aspiration • Rescue breaths at rates > 20 breaths/min contraindicated because venous return can be obstructed

  36. Arrival to the hospital • General Assessment: • Appearance • Work of Breathing • Circulation • Primary Assessment: • Airway • Breathing • Circulation • Disability • Exposure Pediatric Advanced Life Support Provider Manual

  37. Management • ET intubation: • Cannot maintain PaO2 > 80 mm Hg on 100% O2 by face mask • Inability to protect airway or handle secretions • Respiratory failure - PaCO2 >45 mm Hg • Worsening ABG results • Peep: • shifts interstitial pulmonary water into the capillaries • increases lung volume by preventing of alveolar collapse • provides better alveolar ventilation and decreases capillary blood flow

  38. Management • ECMO • If despite intubation, cannot oxygenate • Broncoscopy • Removal of vomit, debris in lungs • Albuterol • For bronchospasm • Aspiration Pneumonia • Clindamycin for bacterial pneumonia is drug of choice • Manage electrolyte abnormalities • hypoglycemia

  39. Management of Hypothermia • Two types: • 1. Rapid immersion in cold water, rapid onset of hypothermia, core temperature < 86 degrees F • Neuroprotective, preferential shunting of blood to heart, brain • 2. Gradual onset of hypothermia • Rapidly re-warm patients with gradual onset of hypothermia • patients at risk for ventricular fibrillation and neuronal injury

  40. Management • Do not stop resuscitation of a patient until their core temperature is at least 30 degrees Celsius!

  41. Prognosis • Related to duration of submersion • Time greater than 25 min, prognosis is poor • Indicators of poor outcome: • Fixed, dilated pupils • Low GCS • coma • Survivors of resuscitation have good neurological outcomes if they show purposeful movement within 24 hours

  42. Prevention • Designate a responsible adult to supervise water related activities • Adults should not be doing other tasks at the same time as supervision, no alcohol while supervising • Swim with a buddy • No alcohol before, during swimming • Learn to swim • AAP does not recommend swimming lessons as a primary prevention method for children under 4 years old • Learn CPR Water Injuries-Fact Sheet. www .cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet Accessed 25 Sept 2009

  43. Prevention • Fence swimming pools on 4 sides, at least 4 feet tall • Do not use air or foam filled water toys in place of life-jackets

  44. References: Brenner RA, Trumble AC, Smith GS, Kessler EP, Overpeck MD. Where children drown, United States, 1995. Pediatrics 2001;108(1):85ミ Kemp, Alison et al. Accidents and child abuse in bathtub submersions. Archives of Disease in Childhood 1994; 70: 435-438. Meyer, Robin et al. Childhood Drowning. 2006. Peds In Rev 27: 163-166 Pearn, John. The management of near drowning. BMJ 1995. (291) 1447-1452 Pediatric Advanced Life Support Provider Manual Shepard, Suzanne et al. Drowning. Emedicine.medscape.com/article/772753-overview Updated 15 Jun 2009 Water Injuries-Fact Sheet. www .cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet Accessed 25 Sept 2009 Zanelli, Santina. Hypoxic-Ischemic Encephalopathy. emedicine.medscape.com/article/973501-overview. Updated 15 Dec 2008

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