What is the immediate hospital management for pediatric drowning patients?

Hospital Management of Pediatric Drowning

Immediate hospital management of pediatric drowning must prioritize aggressive airway management and ventilation with high-concentration oxygen, followed by standard pediatric advanced life support protocols, as drowning-induced cardiac arrest results from severe hypoxemia rather than primary cardiac pathology. 1

Initial Assessment and Airway Management

Airway and breathing take absolute priority over circulation in drowning resuscitation—use the A-B-C sequence (Airway-Breathing-Compressions) rather than the standard C-A-B approach used for other cardiac arrests. 2 This fundamental difference exists because drowning progresses from respiratory arrest due to submersion-related hypoxia to cardiac arrest, making ventilation the critical intervention. 1

Immediate Respiratory Interventions

• Administer high-concentration oxygen immediately upon hospital arrival using the highest available FiO2, as cardiac arrest following drowning results from severe hypoxemia. 1, 2
• Provide immediate rescue breathing using any available means (mouth-to-mouth, pocket mask, or bag-mask ventilation) if not already initiated. 1
• Intubate and mechanically ventilate patients who remain unresponsive or have inadequate respiratory effort, as aspiration causes decreased lung diffusion capacity. 1, 3

Critical Pitfall to Avoid

Do NOT routinely perform cervical spine immobilization unless there are specific circumstances suggesting spinal injury (diving, water slide, signs of trauma). 2 Routine C-spine precautions delay critical airway management and are not indicated in simple drowning. 2

Cardiopulmonary Resuscitation Protocol

CPR Sequence for Drowning

• If no pulse is definitively felt within 10 seconds after initial ventilations, immediately begin chest compressions following standard pediatric BLS guidelines. 2
• Trained rescuers may initiate resuscitation with either breathing first (A-B-C) or compressions first (C-A-B)—both approaches are acceptable, though the hypoxic nature of drowning favors prioritizing ventilation. 1
• Provide rescue breaths as part of CPR rather than compression-only CPR, as ventilation is essential in hypoxic arrest. 1

Defibrillation Considerations

• Attach an AED/defibrillator and monitor cardiac rhythm once the patient arrives in the hospital. 1
• Attempt defibrillation if shockable rhythms are identified, though these represent a minority of drowning-related arrests. 1
• Shockable rhythms are uncommon in drowning because the primary pathology is hypoxic rather than primary cardiac. 1

Advanced Life Support Measures

Standard pediatric advanced life support (PALS) protocols form the cornerstone of in-hospital management once initial resuscitation is underway. 1

Diagnostic Evaluation

• Obtain blood glucose level, arterial blood gas, complete blood count, and electrolyte panel to assess metabolic derangements and guide resuscitation. 3
• Perform chest radiography to evaluate for aspiration, pulmonary edema, and pneumothorax. 3
• Maintain continuous cardiorespiratory monitoring with pulse oximetry and cardiac rhythm monitoring. 3

Hypothermia Management

For patients presenting with hypothermia (core temperature ≤28°C):

Rewarming Strategies

• Initiate conventional rewarming measures first (passive external rewarming, active external rewarming with warming blankets, warmed IV fluids). 4, 5
• Consider extracorporeal membrane oxygenation (ECMO) for rewarming only if conventional therapy fails to restore spontaneous circulation as core temperature approaches 34°C. 4
• Do NOT delay resuscitation efforts while rewarming—continue CPR during rewarming procedures. 6, 7

Evidence on Rewarming Outcomes

Recent analysis shows that 92% of children undergoing conventional rewarming survived compared to 41% undergoing ECMO, though ECMO patients were more severely affected (all pulseless on arrival). 4 This suggests conventional therapy should be the initial approach, with ECMO reserved for refractory cases. 4

Critical Management Pitfalls

What NOT to Do

• Never perform abdominal thrusts or the Heimlich maneuver as routine treatment for drowning victims. 2, 7 This delays critical ventilation and is not indicated.
• Never assume cervical spine injury without specific trauma indicators, as routine immobilization delays airway management. 2
• Never discharge patients without appropriate observation, even if they appear well initially. 2

Mandatory Observation and Disposition

ALL pediatric drowning victims who required ANY form of resuscitation (including rescue breathing alone) MUST be admitted to the hospital for evaluation and monitoring, even if they appear alert with effective cardiorespiratory function. 2

• Minimum observation period is 4-6 hours for all patients requiring any resuscitation intervention. 2
• This is non-negotiable because delayed pulmonary complications and neurological deterioration can occur. 6, 5

Prognostic Considerations

Long-term outcomes are primarily limited by pulmonary and neurological complications rather than the initial resuscitation success. 6 Factors that do NOT reliably predict mortality include mode of rewarming, age, sex, rectal temperature, or serum electrolytes. 6 The duration of submersion and severity of initial hypoxic insult remain the most important prognostic factors. 4, 5