A 5-year-old boy is brought to the emergency department by his mother after drowning. They were at a pool party when another child told the mother that her son was under water and not moving. She immediately pulled the boy out and administered 3 rescue breaths, and he started coughing up water. On arrival, temperature is 36.1 C (97 F), blood pressure is 105/60 mm Hg, pulse is 112/min, and respirations are 26/min. Oxygen saturation is 97% on room air. The patient is awake, alert, and well appearing. He is talkative and playful and asking to eat at a restaurant. The lungs are clear to auscultation bilaterally. Neurologic examination is normal. What is the appropriate disposition of this patient?
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This patient who experienced nonfatal drowning is now alert and well appearing, with normal vital signs and a normal physical examination. However, he is at risk for developing delayed pulmonary complications.
Aspiration of a large amount of fluid often occurs during drowning. Even if the fluid is coughed out quickly (as this patient did) and normal ventilation is restored, the fluid may have already caused damage capable of resulting in delayed pulmonary complications. This damage may include:
Direct tissue injury from chemicals or contaminants in the fluid, leading to inflammation
Washout of alveolar surfactant, leading to alveolar collapse
Disruption of the osmotic gradient of the alveolar-capillary membrane, leading to increased fluid permeability
Together, these insults can progressively impair oxygen exchange and cause atelectasis, decreased lung compliance, and noncardiogenic pulmonary edema. Without treatment, these complications can rapidly progress to life-threatening acute respiratory distress syndrome.
Most asymptomatic patients who develop delayed pulmonary complications exhibit symptoms within the first 8 hours; therefore, they should be closely observed in the emergency department or another hospital unit (rather than discharged home) for at least that long (Choice D). At the end of the prolonged observation period, chest x-ray should be repeated. If it is normal and the patient remains asymptomatic with normal vital signs (including oxygen saturation), then the patient can be discharged.
(Choice B) Arterial blood gases (ABGs) are often measured in drowning victims (even if asymptomatic) and sometimes demonstrate hypoxemia and metabolic acidosis. However, even patients with normal ABGs require a prolonged (ie, ≥8 hr) observation period due to the risk of delayed pulmonary complications.
(Choice C) In asymptomatic patients, early chest x-rays (eg, at initial evaluation) may be falsely reassuring because pulmonary complications can be delayed. Instead, a chest x-ray should be obtained at the end of the prolonged (ie, ≥8 hr) observation period.
Educational objective:
Patients who are asymptomatic after nonfatal drowning should undergo prolonged (ie, ≥8 hr) observation due to the risk of delayed pulmonary complications.