1 / 46

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.

Antony
Download Presentation

Case # 00832989

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  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

More Related