Approach Considerations

Management of hypoxemia is the key to the management of drowning. A surprising degree of hypoxia may be present in a relatively asymptomatic patient. Obtain continuous pulse oximetry.

Obtain arterial blood gas (ABG) levels in all patients with any history of submersion injury. ABG analysis is probably the most reliable clinical parameter in patients who are asymptomatic or mildly symptomatic. ABG analysis should include co-oximetry to detect methemoglobinemia and carboxyhemoglobinemia.

Remember that cervical spine trauma may be present in any victim of shallow- or rocky-water immersion injury. If the victim is unable to give a clear history of the events, has evidence of head or facial injury, or is found unresponsive in a pool or other shallow body of water, protect the cervical spine until injury is excluded.

Obtain blood for a rapid glucose determination, complete blood count (CBC), electrolyte levels, lactate level, and coagulation profile, if indicated. Collect urine for urinalysis, if indicated. Measure liver enzymes, especially aspartate aminotransferase and alanine aminotransferase. Consider a blood alcohol level and urine toxicology screen for use of drugs. Cardiac troponin I testing may be useful as a marker to predict children who have an elevated risk of not surviving to hospital discharge.

Renal function tests

If initial test results show elevated serum creatinine level, marked metabolic acidosis, abnormal urinalysis, or significant lymphocytosis, serial estimations of serum creatinine should be performed.

Acute renal impairment is known to occur frequently in drowning, and, while usually mild (serum creatinine level < 0.3 mmol/L or 3.4 mg/dL), severe renal impairment requiring dialysis may occur.

Radiography

Chest radiography may detect evidence of aspiration, pulmonary edema, or segmental atelectasis suggesting the presence of foreign bodies (eg, silt or sand aspiration). It may also be used for evaluation of endotracheal (ET) tube placement. Extremity, abdominal, or pelvic imaging may be used if clinically indicated.

Computed tomography

A cervical spine radiograph or computed tomography (CT) scan is indicated in individuals with a history of possible cervical trauma or with neck pain or if doubt exists about the circumstances surrounding the submersion injury. Noncontrast head CT scanning is also indicated in an individual with altered mental status and a suggestive or unclear history.

Electrocardiography

Electrocardiography (ECG) should be performed in patients with significant tachycardia, bradycardia, or underlying cardiac disease. Consider ECG if the patient has arrhythmias or if arrhythmias are suspected.^[57]

Monitor the patient with ECG if rewarming is necessary, because dysrhythmias are common when rewarming patients who suffer cold-water immersion injuries.

Catheter monitoring

Arterial and central venous catheters may be useful in monitoring cardiac output and related hemodynamic parameters. Pulmonary artery catheters are less frequently used, yet may prove useful in patients with unstable cardiovascular status or in those who require multiple inotropic and vasoactive medication requirements.

Intracranial pressure monitoring is used in patients with traumatic brain injury or mass lesions (eg, hematomas).

Urinary catheterization for ongoing urine output measurement may be warranted.

Treatment & Management

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Author

G Patricia Cantwell, MD, FCCM Professor of Clinical Pediatrics, Chief, Division of Pediatric Critical Care Medicine, University of Miami Leonard M Miller School of Medicine/ Holtz Children's Hospital, Jackson Memorial Medical Center; Medical Director, Palliative Care Team, Holtz Children's Hospital; Medical Manager, FEMA, South Florida Urban Search and Rescue, Task Force 2

G Patricia Cantwell, MD, FCCM is a member of the following medical societies: American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Heart Association, American Trauma Society, National Association of EMS Physicians, Society of Critical Care Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Coauthor(s)

Michael J Verive, MD, FAAP Pediatrician, UP Health System Portage

Michael J Verive, MD, FAAP is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Chief Editor

Joe Alcock, MD, MS Associate Professor, Department of Emergency Medicine, University of New Mexico Health Sciences Center

Joe Alcock, MD, MS is a member of the following medical societies: American Academy of Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM Professor of Emergency Medicine, Education Officer, Department of Emergency Medicine, Hospital of the University of Pennsylvania; Director of Education and Research, PENN Travel Medicine; Medical Director, Fast Track, Department of Emergency Medicine

Suzanne Moore Shepherd, MD, MS, DTM&H, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

William H Shoff, MD, DTM&H Former Director, PENN Travel Medicine; Former Associate Professor, Department of Emergency Medicine, Hospital of the University of Pennsylvania, University of Pennsylvania School of Medicine

William H Shoff, MD, DTM&H is a member of the following medical societies: American College of Physicians, American Society of Tropical Medicine and Hygiene, International Society of Travel Medicine, Society for Academic Emergency Medicine, Wilderness Medical Society

Disclosure: Nothing to disclose.

Acknowledgements

Barry J Evans, MD Assistant Professor of Pediatrics, Temple University Medical School; Director of Pediatric Critical Care and Pulmonology, Associate Chair for Pediatric Education, Temple University Children's Medical Center

Barry J Evans, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American Thoracic Society, and Society of Critical Care Medicine