Paediatrics: Immersion Update

Dr Fran LockieMedSTARPaediatric Emergency, WCH

Bedside Critical Care, September2013

Sydney Based Health practitionerPassion for female weight loss‘www.Hotfatchicks.com’

Sydney Based Health practitionerPassion for female weight loss‘www.Hotfatchicks.com’

Scope

• Case• Definitions/Guidelines• Epidemiology• Outcome• Management

A Nightmare..!

Case Study• Winter in the Blue Mountains:• 11:30am: mother and two children (2 and 4 yrs) lay down for a

nap• 11:50am: Neighbour accompanies 4-yr old to knock on the door

and wake mother; found outside on street with wet trousers. Says brother under water.

• Approx. 12:10pm: Mother spots 2-yr old under water in creek by the road, several minutes walk from the house

• Mother retrieves 2-year old from cold creek: Pale with circumoral cyanosis, apnoeic, pulseless and widely dilated pupils.

• Mother commences CPR at scene; ambulance called by neighbour at 12:13pm

• Paramedics arrive and assist CPR. GCS = 3. ?weak pulse; ?child moves one arm.

• Adult retrieval team:no pulse, pupils fixed and dilated and no signs of life– CPR continued– Intubated– IO sited– 3 x Adrenaline

• 1:18pm: Arrived ED– Spontaneous agonal respirations– Femoral pulse palpable– Closed chest compressions ceased

• Shut-down ++. Rectal temp <26.7 C• Arterial gas: pH 7.06, paO2 219, PaCO2 31, HCO3 8.8, BE

-21• GCS 3; pupils 4mm F&D• Rewarmed: humidified gas, overhead heater, gel pads,

bair-hugger, warm saline solution bladder irrigation and bags of warm normal saline solution to groins and axillae

• Measured temperature increased >26.7 C after 30 min• Active rewarming (except warm humidified insp gases)

ceased when temp 30 C

• Moves fingers prior to transfer to PICU• Temperature rose spontaneously to 36.7 C 6-hrs after

admission.• 48-hrs Hi-PEEP low volume Ventilation for pulmonary oedema /

ALI• Haemoglobin fell from 12.8 in ED to 9.8 g/dL 12-hrs later• Urine coloured red on Day 1. No RRT.• Eyes open Day 4• Generalised weakness; slow to wean from ventilator• 2-weeks later: Self-ventilating, weight-bearing and some

verbalisation• 23 days post immersion: Discharged home walking and talking• 6-months later: Mild speech delay

• ‘..respiratory impairment from submersion / immersion in liquid..’

• Outcomes defined• 388 000 deaths / year

• ‘..respiratory impairment from submersion / immersion in liquid..’

• Outcomes defined

National Drowning Report, RLSA, 2011

2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 20110

10

20

30

40

50

60PICU Admissions, Drowning, 2000-

2011

ANZPIC Registry

• Need more research: OHCA vs drowning• In water EAR if unresponsive 10-15 breaths• Early intubation with cuffed ETT• ECG, ET CO2 to confirm arrest. Keep going!• < 30 degrees: only 3 x defib attempts, no

drugs until temp > 30• Rewarm to 32-34 degrees. Avoid temp > 37

Patterns of Drowning in Australia 1992-1997

Mackie MJA 1999

Mackie MJA 1999

Bathtub Drownings

Age (years)

Mackie MJA 1999

Bathtub Drownings

Age (years)

Ocean/estuary(n=346)

Private pool(n=265)

Lakes/waterholes/lagoons(n=265)

Surfing beach(n=162)

Fishing (n=90)

Scuba(n=56)

Age (years)

Location

• 12.1% Overall survival to hospital discharge; 4% intact neurological survival

• Submersion injuries included in 30 of 41 studies and examined exclusively in 2 studies

• 22.7% (63 of 227) survived to hospital discharge

• 6% (7 of 117) had no neurological sequelae at discharge

Donaghue et al Ann Emerg Med. 2005

Resuscitation 2013

• 66716: 1300 children, 61000 adults• 1736 adults and 68 kids post drowning• One month survival, neurologically favourable

one-month survival• Better survival but no difference in good neuro

outcomes

Christensen et al Peds, 1997

92%

6%

Christensen et al Peds, 1997

‘Even fixed and dilated pupils, low GCS, need for CPR in ED have proven unreliable in individual cases’

‘Composite score based on ED physical exam (apnoea, coma) + need for CPR + lowest pH …..best available ……but even this 93% accurate in their hands’

Poor Prognostic Factors Include• Submersion time > 5 to 10 min• Fixed and dilated pupils (NB: Effect of severe hypothermia)• No or delayed bystander CPR• Time to first gasp > 40 min• Need for CPR >25 min• Need for CPR in ED• Initial pH < 7.00• Persistence of coma in ED and ICU 24 hrs after immersion• Abnormal CT within 36 hrs of submersion

Modell JH, Chest 1976

Suominen P, Resuscitation 1997

Quan L, Pediatrics 1990

Peterson B, Pediatrics 1977

Bratton SL, Arch Pediatr Adolesc Med 1994

ICU Prediction of Outcome ?• PE: GCS ≥ 6 or purposeful movement + intact

brainstem reflexes v likely good outcome• SEPS: absent SEPS 100% predictive of poor

outcome• Imaging:

Early (8h) abnormal CT strongly predictive for bad outcome; normal CT uninformative

MRI more specific but need 3-4 days to avoid inappropriate optimism

Is Cold Immersion Protective?

• Well documented and supported by animal studies1,2

• Hypothermia reduces oxygen consumption– approximately 7% per degree Celcius drop in body

temperature• Heat loss can be rapid

– Large SA to volume ratio. Cold fluid in lungs:excellent heat exchangers

• Unfortunately: – Diving refleximmersion induced apnoea and

layngospasm– Clothes

1. Kvittingen TT, Naess A, BMJ 19632. Orlowski JP, JAMA 1988

Suominen Resuscitation 1997, 2002

Impact of age, submersion time and water temperature on outcome in near drowning?

• Finland regional survey – most drownings occur in cold water

• 61 admissions to ICU Helsinki over 12 y: water temp, rectal temp, and estimated submersion time

• Median water temp 17C (range 0-33)…lower in survivors but much cross over

• 80% admission temp < 35C (no diff S & NS)• Est submersion time only independent predictor of

survival (5’ V 16’) but no clear cut off could be defined

04/20/99

Presentation of near drowning

2 types of presentation• 1. Awake alert after nil or brief Respiratory Arrest

– should do well with good care– may get serious lung pathology (ALI / ARDS /

pneumonia)– admit and observe CXR, ABG– good prognosis

04/20/99

Presentation of near drowning

2 types of presentation• 1. Awake alert after nil or brief Respiratory Arrest

– should do well with good care– may get serious lung pathology (ALI / ARDS /

pneumonia)– admit and observe CXR, ABG– good prognosis

04/20/99

Presentation of near drowning

• 2. Post Cardiac arrest – Need resuscitation, stabilisation and ICU

Pulmonary oedema, pneumonia (25-50%), ARDS < 10%

NeurogenicAltered capillary permeabilityForced inspiration against a

closed glottisSurfactant dysfunction

Fluid shifts Aspiration of debris pneumonitis Infection (rare) Surfactant depletion

Assessment and Managementof Immersion injury

• Primary survey ABC’s• Empty the stomach with a gastric tube• Early Intubation• PEEP, minimise VILI

Assessment and Management: Circulation

• Hypoxic, cold myocardiumProne to arrhythmias and arrestLikely to need inotropic supportActive rewarming essential

• Peripheral vasoconstrictionMay need vasodilators once blood pressure

restored

• Cold diuresis

Level Temp range TechniquesMild 35oC - 32oC Passive external re-warming

-overhead lights-remove wet clothing -warm blankets

Moderate 32oC – 30oC Active external re-warming-warmed IV fluids (microwave or fluid warmer)-warmed humidified gas for ventilation (humidifier)-warm saline bags to inguinal and neck areas (microwave)Warning: passive external re-warming may contribute to a drop in core temperature especially if applied to limbs

Severe 30oC – 25oC Active internal re-warming plus active external -bladder irrigation with warmed saline-peritoneal irrigation with warmed saline (pigtail catheter, fluid warmer), -pleural (right side) with warmed saline (pigtail catheter, fluid warmer)-discuss bypass for those in cardiac arrest with intensivist

Techniques of Warming

Resuscitation 2002

Artif Organs, Vol. 34, No. 11, 2010

Suominen Acta Anaesthesiol Scand 2010

Assessment and Management: Other issues

• No evidence– Anti-convulsants– Antibiotics (Wood, ADC, 2010) – Steroids (Foex, ADC, 2002)

• Continuous EEG monitoring • Hyponatraemia and electrolyte abnormalities• Coagulopathy (with hypothermia) and later thrombocytosis• Haemolysis or rhabdomyolysis

• Therapeutic Hypotherrmia “Cooling” ?

Pediatr Emer Care 2010

Pediatr Emer Care 2010

Lancet Neurol 2013

• 48-72 hrs therapeutic hypothermia with slow re-warming

• 77 patients• 39 cooled, 38 normothermia• No differences in adverse events• GOS almost identical• Terminated early due to futility

PaedOHCA

32-34C for 48h then 36-37.5C for 3d

36-37.5C for 5d

Within 6h of ROSC

* Drowning victims with core temp <32C on arrival specifically excluded

Kids Alive - Do the FiveWater Safety Programme

1. Fence the pool.

2. Shut the gate. 3. Teach your kids to swim-it’s great.

4. Supervise

5. Learn how to Resuscitate.

www.kidsalive.com.au

Summary

• Individualise care• Don’t make assumptions

– Opportunities to withdraw won’t go away• Kids are resilient (with unreliable parents!)• Re-warm• High quality neuro-ICU• Don’t forget the family and Resus team