From the Guidelines
The emergency room workup for a child with submersion injury should begin with a thorough assessment of airway, breathing, and circulation, followed by stabilization as needed, according to the 2024 American Heart Association and American Academy of Pediatrics guidelines 1. The initial assessment should include vital signs such as oxygen saturation, temperature, heart rate, respiratory rate, and blood pressure.
- Laboratory tests should include:
- Arterial blood gas analysis to assess oxygenation and acid-base status
- Complete blood count
- Electrolytes
- Blood glucose
- Renal function tests
- Chest radiography is essential to evaluate for pulmonary edema, aspiration, or pneumonia.
- Continuous cardiac monitoring is necessary as dysrhythmias may develop.
- Pulse oximetry should be maintained, and supplemental oxygen provided based on saturation levels, as oxygen administration is recommended when available 1. If the child is unconscious or has altered mental status, consider head CT to rule out traumatic brain injury that may have preceded the submersion.
- Temperature management is crucial, as hypothermia is common; gradual rewarming at 0.5-1°C per hour is recommended for severely hypothermic patients.
- Bronchodilators such as albuterol (2.5-5 mg via nebulizer) may be needed for bronchospasm.
- Antibiotics are not routinely indicated unless signs of infection develop. The severity of submersion injury varies widely, from mild respiratory symptoms to severe hypoxic brain injury, so observation for at least 6-8 hours is recommended even for seemingly well children, as pulmonary complications can develop hours after the event, and the use of an automated external defibrillator (AED) after initiation of high-quality CPR may be lifesaving in cardiac arrests following drowning whenever possible, on the basis of the available evidence 1.
From the Research
Workup for Submersion Injury in Children
The workup for submersion injury in children involves several key steps, including:
- Restoring normal ventilation and circulation as quickly as possible to limit the extent of hypoxic insult 2, 3
- Diagnostic testing for symptomatic patients, which may include:
- Treatment of hypothermic patients using passive external, active external, and active internal rewarming techniques 2, 3
Risk Factors and Prevention
Risk factors for drowning victims include:
- Epilepsy
- Underlying cardiac dysrhythmias
- Hyperventilation
- Hypoglycemia
- Hypothermia
- Alcohol and illicit drug use 2 Prevention is an important public health measure, and it is estimated that > 90% of drownings are preventable 4
Resuscitation and Management
The goals of resuscitation are immediate ventilation and oxygenation to prevent hypoxic end-organ damage to the heart and brain 5 Prehospital care should focus on providing advanced cardiac life support, including intubation as needed, as soon as possible 5, 6 The decision to admit to an ICU should consider the patient's drowning severity and comorbid or premorbid conditions 4