What is the management of a near-drowning in a one-year-old?

Management of Near-Drowning in a One-Year-Old

The management of a near-drowning in a one-year-old should focus primarily on immediate restoration of oxygenation and ventilation, followed by standard pediatric basic and advanced life support protocols, as drowning generally progresses from respiratory arrest to cardiac arrest due to hypoxia. 1

Immediate Rescue and Initial Assessment

• Ensure rescuer safety first before attempting rescue
• Assess responsiveness and breathing
• If trained and safe to do so, consider in-water rescue breathing to prevent progression to cardiac arrest 1
• Move the child to a safe environment (dry land, boat) as quickly as possible

Resuscitation Algorithm

For Responsive Child with Breathing:

• Position to optimize airway
• Administer oxygen if available (aim for SpO₂ >94%)
• Monitor vital signs continuously
• Transport to emergency department for evaluation

For Unresponsive Child:

1. Begin with airway assessment and rescue breathing

   • Open airway using head tilt-chin lift maneuver
   • Provide 2 rescue breaths (mouth-to-mouth, pocket mask, or bag-mask ventilation)
   • Check for pulse (≤10 seconds)

2. If pulse present but no breathing:

   • Continue rescue breathing (1 breath every 3-5 seconds)
   • Administer oxygen when available
   • Reassess pulse every 2 minutes

3. If no pulse or uncertain:

   • Begin high-quality CPR immediately
   • Compression-to-ventilation ratio of 15:2 (with advanced airway: continuous compressions with 1 breath every 6 seconds)
   • May initiate with either breathing (A-B-C) or compressions (C-A-B) 1
   • Minimize interruptions in chest compressions

4. Apply AED as soon as available

   • Dry chest before applying pads
   • Follow AED prompts
   • Resume CPR immediately after shock or "no shock" decision 1

Advanced Life Support Measures

• Establish vascular access (IV/IO)
• Consider endotracheal intubation for airway protection
• Correct hypothermia if present
• Treat dysrhythmias according to pediatric ACLS protocols
• Consider ECMO for rewarming in severe hypothermia cases or refractory cardiopulmonary failure 1

Hospital Management

• Continue respiratory and hemodynamic support
• Obtain chest radiograph to assess for aspiration pneumonitis/ARDS
• Laboratory studies: CBC, electrolytes, glucose, blood gas analysis
• Monitor for complications: pulmonary edema, ARDS, electrolyte abnormalities
• Consider targeted temperature management (TTM) - either 32-34°C or 36-37.5°C (both approaches show similar outcomes) 1

Common Pitfalls to Avoid

1. Delaying rescue breathing - Hypoxia is the primary enemy in drowning 2
2. Attempting Heimlich maneuver - Not recommended for routine use in drowning victims
3. Focusing on water removal from lungs - Minimal amounts can be absorbed; prioritize ventilation
4. Premature termination of resuscitation - Continue CPR for at least 30 minutes, especially in hypothermic patients 3
5. Failing to transport for observation - All symptomatic patients require hospital evaluation

Prognosis Factors

• Duration of submersion (>10 minutes associated with poor outcomes)
• Time to effective CPR
• Initial presenting rhythm
• Response to initial resuscitation
• Water temperature (cold water may provide some neuroprotection)

Disposition

• All near-drowning victims require hospital transport for observation and evaluation
• Completely asymptomatic patients with normal vital signs, oxygenation, and chest radiographs require at least 4-6 hours of observation 4
• Many victims will require at least 24 hours of observation 4
• Patients with any respiratory symptoms, abnormal vital signs, or altered mental status require admission

The cornerstone of successful management is immediate attention to oxygenation and ventilation, followed by standard pediatric resuscitation protocols. The Drowning Chain of Survival emphasizes prevention, early recognition, safe rescue, and prompt resuscitation as critical elements in improving outcomes for pediatric drowning victims 1.