What is the immediate in-hospital medical management for pediatric drowning patients?

Immediate In-Hospital Medical Management for Pediatric Drowning

Prioritize aggressive airway management and high-concentration oxygen delivery immediately upon hospital arrival, followed by standard pediatric advanced life support protocols, as drowning-induced cardiac arrest stems from severe hypoxemia rather than primary cardiac pathology. 1, 2

Initial Resuscitation Sequence

Airway and Breathing First (A-B-C Approach)

• Use the A-B-C sequence (Airway-Breathing-Circulation) rather than the standard C-A-B approach for drowning victims, as the pathophysiology progresses from respiratory arrest due to submersion-related hypoxia to cardiac arrest 1, 2
• Immediately establish airway patency and provide rescue breaths with the highest available oxygen concentration, as hypoxia is the primary injury mechanism 1
• If the child is in cardiac arrest, provide CPR with rescue breaths and chest compressions together after initial ventilations 1

Critical Pitfall to Avoid

• Do not routinely perform cervical spine immobilization unless specific circumstances suggest spinal injury (diving, water slide trauma, signs of head/neck trauma), as routine C-spine precautions delay critical airway management without evidence of benefit in simple drowning 2

Oxygen Administration Protocol

Maximal Oxygen Delivery

• Administer the highest available oxygen concentration immediately to reverse hypoxemia, which is associated with worse outcomes 1
• Optimize oxygenation aggressively because drowning causes decreased lung diffusion capacity from aspiration, and even effective CPR only achieves 12-42% of pre-arrest cerebral oxygenation 1
• Do not delay high-quality CPR to obtain supplemental oxygen, but provide it as soon as available 1

Cardiopulmonary Resuscitation Guidelines

If Cardiac Arrest is Present

• If no pulse is definitively felt within 10 seconds after initial ventilations, immediately begin chest compressions following standard pediatric BLS guidelines 2
• Continue CPR with rescue breaths included, as multiple large observational studies show improved outcomes when CPR includes rescue breaths in pediatric drowning 1
• Start CPR before applying an AED, as shockable rhythms constitute only 2-12% of drowning-related cardiac arrests 1

AED Considerations

• Apply an AED after initiating high-quality CPR if cardiac arrest is confirmed, but never delay CPR to obtain or apply an AED 1
• AED use is reasonable but secondary to immediate CPR with rescue breaths 1

Advanced Life Support Measures

Standard PALS Protocol

• Implement standard pediatric advanced life support (PALS) protocols as the cornerstone of in-hospital management once initial resuscitation is underway 1, 2
• Continue aggressive ventilatory support as the primary therapeutic intervention 2

Diagnostic Evaluation

• Obtain blood glucose level, arterial blood gas, complete blood count, electrolyte levels, chest radiography, and continuous cardiorespiratory monitoring with pulse oximetry 3
• Monitor for aspiration-induced noncardiogenic pulmonary edema, which is the most serious pathophysiologic consequence 4

Respiratory Support Options

Non-Invasive Ventilation

• Consider early application of bi-level positive airway pressure (BiPAP) in spontaneous/timed mode for children with pulmonary edema who are breathing spontaneously, as this can prevent progression to invasive mechanical ventilation 5
• Close monitoring during NIV is essential to detect any deterioration requiring intubation 5

Rewarming for Hypothermia

• If hypothermia is present, initiate passive external, active external, or active internal rewarming techniques depending on core temperature 3
• In severe cases with profound hypothermia and refractory respiratory failure, extracorporeal membrane oxygenation (ECMO) may be lifesaving 6

Mandatory Admission and Observation

Universal Admission Requirement

• Admit all pediatric drowning victims who required any form of resuscitation to the hospital for evaluation and monitoring, even if they appear alert with effective cardiorespiratory function 2
• Completely asymptomatic patients with normal vital signs, oxygenation, and chest radiographs require a minimum observation period of 4-6 hours 2, 4
• Most symptomatic drowning victims require at least 24 hours of observation 4

Prognostic Considerations

• Approximately 25% of victims presenting to the emergency department will die and another 6% will develop neurological sequelae despite optimal management 4
• Rapid reversal of hypoxemia through prompt resuscitation is associated with improved outcomes 1