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Key points

• Children should be observed for four to eight hours following a drowning event, even if asymptomatic
• Hypothermia is common post drowning and should be corrected during resuscitation by removing wet clothes and applying warm blankets. In Queensland active warming measures are rarely needed and hyperthermic should be avoided.
• Consider possibility of an underlying condition (such as epilepsy, cardiac dysrhythmias and hypoglycaemia).
• Consider non-accidental injury (NAI) or neglect in a child presenting with incongruent histories, an obvious lapse in supervision, a delay in seeking care for submersion or other injuries suggestive of NAI (bruises, old fractures).
• Cervical spine immobilisation is not recommended in the absence of head or neck trauma.
• Corticosteroids are not recommended and are potentially harmful.
• Prophylactic antibiotics are not routinely recommended.

Purpose

This document provides clinical guidance for all staff involved in the care and management of a child presenting to an Emergency Department (ED) in Queensland following a drowning event.

This guideline has been developed by senior ED clinicians and Paediatricians across Queensland, with input from PICU, Infectious Diseases and Pharmacy, Queensland Children’s Hospital, Brisbane. It has been endorsed for statewide use by the Queensland Emergency Care of Children Working Group in partnership with the Queensland Emergency Department Strategic Advisory Panel and the Healthcare Improvement Unit, Clinical Excellence Queensland.

Introduction

Drowning is defined by the World Health Organisation as a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium, irrespective of whether the incident is fatal or not.

Following a drowning event, the child may:

• be asymptomatic
• have some respiratory compromise
• be apnoeic or in cardiac arrest

In Queensland, the ratio of non-fatal to fatal drowning is 10:1 with approximately two thirds of the non-fatal group admitted to hospital.¹

Hypoxia can cause irreversible neurological injury within 4-10 minutes. Most late deaths and long-term sequalae are neurological.

Epidemiology

The following factors increase the risk of drowning:

• epilepsy – (4-14 fold increase, more likely to be older (more than five years) compared with drownings in children without epilepsy)
• cardiac dysrhythmias – congenital long QT syndrome, catecholaminergic polymorphic ventricular tachycardia and Brugada syndrome may be triggered by swimming
• hypoglycaemia – due to known underlying conditions like diabetes or new metabolic disorders
• hyperventilation – causes hypocapnia which reduces the respiratory stimulus to breathe and can lead to syncope underwater
• hypothermia resulting in body temperature less than 35°C – can cause poor muscle coordination and weakness which interferes with swimming and self-rescue attempts. Rare in Queensland as usually in children who fall through ice
• alcohol and illicit drugs – should be considered in adolescents

Pathophysiology

Drowning usually occurs in seconds to minutes with the following sequence of events:
	Initial struggle for 20-30 seconds (unable to call for help as breathing takes priority).
	Submersion (airway below the surface of water, water spat out or swallowed).
	Voluntary breath holding (60 seconds maximum).
	Small amount of water aspirated triggering cough reflex and laryngospasm.
	Respiratory impairment leads to hypoxia, hypercarbia and acidosis.
	Arterial oxygen tension decreases, laryngospasm abates and more water is aspirated.
	Cerebral hypoxaemia leads to loss of consciousness and apnoea.
	Cardiac deterioration with bradycardia and hypotension secondary to hypoxia lead to a cardiac arrest.

Outcome and predictors of outcome

The strongest predictors for outcome are submersion time and CPR duration.

Based on studies conducted at University of Washington.²

A study in Southern California^3-5 found a poor outcome was likely for a child with any of the following:

• CPR in ED
• apnoea and coma in the ED
• pH less than 7.0

Several studies have found poor prognostic indicators at time of arrival to the Emergency Department to include:

• Duration of submersion > 5 minutes
• Time to effective basic life support > 10 minutes
• Resuscitation duration > 25 minutes
• Apnoea
• Coma
• CPR in the ED
• pH < 7.1 upon presentation

Prognostic factors independently associated with discharge from the Emergency department include:

• Oxygen saturations > 95% on arrival
• Did not receive supplemental oxygen in the ED
• No pre-hospital intervention required
• Witnessed submersion event

Assessment

Clinical assessment (history and examination) should occur concurrently with patient management (paying particular attention to the optimisation of respiratory function).²

History

History taking should include:

• details of the drowning event including:
  • circumstances leading to the drowning
  • duration of person missing
  • duration of immersion

• Witnessed vs unwitnessed
• Bystander CPR applied and whether lay person or health professionalresuscitation descriptors (duration of CPR/time to ROSC, type of arrest (asystolic vs VT/VF) and number of doses of adrenaline, administration of other drugs)
• Type of water patient was immersed in (fast flowing water that may have cooled patient down vs pool/lake)
• Circumstances suggestive of trauma (fall before submersion etc)

• past medical history including:
  • epilepsy
  • personal and family history of cardiac dysrhythmias
  • hypoglycaemia
  • drug and alcohol use

Depending on the circumstances and severity, it may be appropriate to have a social worker with the caregivers, especially in the case of a cardiac arrest or in a post-arrest situation. Child protection issues should also be considered depending on the scenario.²

There is no quality evidence to suggest any change in management for fresh water versus salt water drowning events, and as such these cases should be managed the same. Similarly, the temperature of the water will not affect outcome in Queensland.

Examination

Emergency care should always involve a rapid primary survey with evaluation of (and immediate management of concerns with) airway, breathing, circulation and disability (ABCD).

Complete a secondary survey to assess for other injuries and signs of non-accidental injury.

Measure core temperature with a rectal thermometer. Limit significant hypothermia by avoiding prolonged exposure. Avoid hyperthermia.

Investigations

Children who are asymptomatic, alert and with normal vital signs rarely require further investigation.

Seek senior emergency/paediatric advice as per local practice if unsure of need for head CT.

Management

Refer to the emergency management flowchart [PDF 509.55 KB] of a child following a drowning event.

Airway and breathing

Contact paediatric critical care specialist (onsite or via Retrieval Services Queensland (RSQ)) for a child who is post cardiac arrest or critically unwell.

Ventilation with lung protective measures should be employed to avoid lung injury.  Aim for normocapnia or mild hypocapnia. FiO2 should be weaned as able to avoid pulmonary oxygen toxicity.

There is no evidence to support the use of corticosteroids.

Cervical spine protection

Immobilisation of the cervical spine is not routinely recommended as the risk of a spinal injury occurring with drowning event is low (estimated at less than 0.5%).^2,6

Refer to the Cervical spine Guideline for a child with head and/or neck trauma.

Circulation

Fluid resuscitation using crystalloid solution (e.g. 0.9% Sodium chloride 20 mL/kg) via either IV or Intraosseous (IO) access is recommended for the critically unwell child.

Cardiac dysfunction with decreased cardiac output and high systemic and pulmonary vascular resistance may occur secondary to hypoxia associated with drowning. If this persists after adequate oxygenation, ventilation and perfusion have been re-established seek paediatric critical care advice. Inotropic agents may be required.

Disability

While little can be done to change the neurological damage caused by the primary hypoxic event, secondary injury can be avoided by the prevention of hypoxia and hypotension and maintenance of normoglycaemia, normothermia and normocapnia. Warm slowly and avoid temperatures > 37.5.

Seizures following hypoxic brain injury are common. Referral to neurologist for evaluation of seizures will usually occur following transfer to critical care service. There is no evidence for prophylactic anticonvulsant medications.²

Gastrointestinal and genitourinary

Nasogastric tube insertion is recommended in any child with a decreased level of consciousness to prevent aspiration due to vomiting.

Urinary catheter insertion is recommended in a critically unwell child to measure urine output and facilitate a strict fluid balance.

Hypothermia

Remove wet clothes and apply warm blankets to prevent further drop in core temperature.

An RCT found targeted hypothermia (33°C) did not improve survival or consistently improve functional outcomes at 12 months when compared to normothermia (36.8°C).⁷ Active rewarming with heating blankets, warm air blowers and radiant lamps should only be considered for patients with a core temperature less than 33-34°C or in rare instances in which hypothermia has led to arrhythmias/haemodynamic instability.

Contact paediatric critical care specialist (onsite or via RSQ) for a child with a core temperature less than 33-34°C.

Core rewarming measures that may be used in ED include warm IV fluids to 39°C and warm ventilator gases to 40°C.

Other measures which require specialist input from critical care include gastric/bladder lavage with 0.9% Sodium chloride to 42°C, pleural or pericardial lavage, endovascular warming and extracorporeal blood re-warming.⁸

Infection

Prophylactic antibiotics are not routinely recommended.

Antibiotics have not been shown to improve outcome and should be restricted to patients demonstrating signs of infection or sepsis, or in the rare patient who was submerged in grossly contaminated water.

For the guidance on the management of water-immersed wound infections in children [PDF 181.31 KB].

Mandatory notification

In Queensland, most fatal paediatric immersion events involve young children gaining unintended access to home/ domestic swimming pools. Domestic pool fencing legislation has been in place since 1991 and was recently strengthened with a requirement for pool fence inspections. Under the Building Act 1975 doctors are required to notify QH of any presentations involving immersion of a child under five years in a “regulated” pool (home, shared unit complex or resort pool). The notification form [DOC 295 KB] can be accessed. Reporting will trigger a local council inspection of the fence regardless of the method of access. It is important to let the family know that this will occur. The most important information to report is the address of the pool.

Escalation and advice outside of ED

Clinicians can contact the services below if escalation of care outside of senior clinicians within the ED is needed, as per local practices. Transfer is recommended if the child requires a higher level of care.

Critically unwell or rapidly deteriorating child

Non-critical child

Inter-hospital transfers

Disposition

When to consider discharge from ED

Children who are asymptomatic should be observed for a minimum period of four to eight hours and this may involve admission to ED SSU where available and appropriate. Discharge may be considered providing there is no clinical deterioration in this time (i.e. child remains asymptomatic with a normal respiratory examination, SpO2 >95% and there are no ongoing safety concerns that would present a barrier to discharge).  Education and written information on water safety should be provided to all families prior to discharge.

Follow-up

• with GP within 48 hours.

When to consider admission

In symptomatic children, consider referral to inpatient service if:

• Increased respiratory effort
• SpO₂ <95%
• Abnormal lung examination
• Underlying medical cause for drowning is suspected.

Related documents

• Cervical spine Guideline
• Water safety – Parent Information