A 3-year-old girl is brought to the emergency department by ambulance after being found unresponsive in her family's pool an hour ago. She and her mother had been playing on the back porch until the mother went inside for less than 1 minute to answer the phone. When the mother came back outside, she found the girl floating face down in the pool. The mother immediately pulled her out and began rescue breathing, and the neighbor called an ambulance. The emergency medical team arrived 5 minutes later, at which time the patient was awake, alert, and coughing. She is an otherwise healthy girl with no prior hospitalizations. On arrival, temperature is 36.7 C (98.1 F), blood pressure is 100/60 mm Hg, pulse is 104/min, and respirations are 20/min; pulse oximetry is 99% on room air. Physical examination shows a smiling, alert young girl running around the room. Heart rate and rhythm are regular, and the lungs are clear to auscultation with no adventitious sounds or increased work of breathing. Which of the following complications is this patient at greatest risk of developing?
Drowning injuries | |
Risk factors |
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Complications |
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Poor prognostic indicators |
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Drowning, defined as respiratory impairment due to submersion in liquid, is a leading cause of accidental death in children. Children age <5 are at increased risk due to inadequate supervision around pools/bathtubs, and males age 15-25 are also at high risk due to risk-taking behaviors and concomitant drug or alcohol use.
Complications of drowning are a result of hypoxemia from fluid aspiration. The aspirated liquid washes out pulmonary surfactant and increases alveolar-capillary membrane permeability, which can lead to the development of noncardiogenic pulmonary edema, respiratory insufficiency, and acute respiratory distress syndrome (ARDS).
Signs and symptoms of ARDS (eg, dyspnea, wheezing, crackles, cyanosis) typically begin within the first 8 hours, and respiratory insufficiency can progress insidiously over 72 hours after the initial event. Therefore, despite currently being asymptomatic, this patient is still at risk for ARDS. All patients with a nonfatal drowning event, even with normal vital signs and examination findings, should be admitted to the hospital for cardiopulmonary monitoring for at least 8 hours. In this case, the patient has an excellent prognosis because she was submerged briefly, resuscitated quickly, and is now back to baseline activity.
(Choice B) Acute tubular necrosis is an uncommon complication of drowning that results from ischemic injury to the renal tubules, typically in the context of hypovolemic shock. This patient has normal vital signs and therefore is at low risk for kidney injury.
(Choice C) Arrhythmias (eg, sinus tachycardia, sinus bradycardia) can be precipitated by hypothermia and hypoxemia but would be unlikely in a child with normal cardiac examination and vital signs.
(Choice D) Cerebral edema and increased intracranial pressure from hypoxic-ischemic brain injury due to drowning are more likely with a prolonged submersion time (>5 min) or when resuscitative efforts are delayed or prolonged. This patient's submersion time and resuscitation were brief.
(Choice E) Gastric perforation is a rare drowning complication that can occur when prolonged cardiopulmonary resuscitation is performed on a patient with a full, distended stomach (from swallowing liquid). Abdominal pain and tenderness would be expected, and this patient's brief resuscitation makes this complication unlikely.
Educational objective:
Drowning is defined as respiratory impairment from submersion in liquid. Aspirated liquid causes hypoxemia and can wash out pulmonary surfactant, leading to acute respiratory distress syndrome (ARDS). Because ARDS can develop insidiously, cardiopulmonary monitoring is required in all patients after a drowning event, even if asymptomatic.