1. Drowning & electrical injuries
Dr. Minoo Saeidi
Assisstant professor of pediatrics

2. drowning It is more common in children under 5 and 15 to 24 years old
Falling in to the swimming pool, open water, bathtub
Suicide, child abuse
Boys are four times susceptible than girls
Aspiration of small amount of water into the larynx, trigger breath holding and laryngospasm, after that aspiration of the larger volume of water or gastric content into the lung, destroying surfactant, pulmonary endothelial injuries, increased capillary permeability, impaired ventilation and oxygenation, hypoxia, circulatory collapse

3. Disorders associated with drowning

4. Prehospital care Rapid resuscitation after safe removal of the victim
Cervical spine injuries is rare (0.5%)
Use high flow oxygen
Warm the patient
Monitoring if possible
Establish IV access if possible
ED transfer is necessary if: Drowning amnesia for the event, Loss or depressed consciousness, Observed period of apnea, Who required a period of artificial ventilation

5. Emergency department care
Assess and secure the airway
Provide oxygen
Determine core temperature (warmed IV fluid, blanket, warmer)
Assist ventilation if needed
routine cervical immobilization and CT of brain is not necessary
GCS>13 and O2Sat >95% are low risk; observe them for 4 to 6 hours
Laboratory data and chest X ray are not valuable in deciding (don’t request)
When they should return; Fever, Pulmonary symptoms, Mental status changes

6. Emergency department care
GCS< 13; administer supplemental oxygen, ventilatory support
Intubate if: PaO2<80 with FIO2 40 to 60%
Request lab data, chest X ray
Monitoring PR, RR, T, BP, O2Sat
Don’t use prophylactic antibiotics for aspiration pneumonia
If the patient is normothermic on arrival and cardiac rhythm is asystole; discontinue prolonged CPR because of profound neurological complication

7. Continued management
Cardiac monitoring (infusion of Dopamine, echocardiography, CV line)
Neurologic monitoring (brain edema, neurologic deficit)
Monitor ICP (don’t improve outcome)
Hypothermia management
Avoid ventilator associated barotrauma
Consider Aeromonas when treat pulmonary infections

9. Poor prognostic factors in drowning
Bystander CPR at the scene (20% die later in hospital)
CPR in emergency department
Prolonged CPR in ED (longer than 30 minutes)
Asystole at the scene
Coma for more than 72 hours
GCS 5 or less
Fix dilated pupils
Seizure
Longer submersion time (more than 15 minutes, especially more than 60 minutes)

10. Prevention tips Parental vigilance during bathing
Never leave an infant in bath seats
Four sided pool fences
Use personal floatation devices
Education
Only swim in a lifeguarded area
Supervising in or near water

12. Electrical injury Low voltage < 1000 V (household)
High voltage > 1000 V (occupational)
Electric arc
Household electricity is AC (alternating current)
Electricity of batteries is DC (direct current)
Alternating current can cause ventricular fibrillation and tetany
Both of them can hurl the victim away, severe blunt injury
Better prognosis in children

13. Current flow in the body

14. Mechanism of damage Direct tissue damage due to electric power
Tissue damage due to thermal energy
Mechanical injuries due to falling or muscle contraction

15. High voltage/low voltage

16. Clinical features
Cardiac dysrhythmia (asystole, VF, QT prolongation, bradycardia)
Neurologic impairment (transient loss of consciousness, confusion, seizure, agitation, focal neurologic deficit, aphasia, quadriplegia, hemiplegia, visual disturbances, deep coma)
Spinal cord injury (compressive fracture of spine, direct injuries to spinal cord cells, vascular injury to the cord, late onset spinal cord injury, progressive demyelination, GBS like illness)
Peripheral nerve injury (Paresthesia even late onset)
Cutaneous involvement (entry and exit wounds, burn)
Orthopedic injuries (fracture, posterior shoulder dislocation)

17. Clinical features Inhalation injury (pulmonary hemorrhage and edema)
Ocular injuries (cataract, corneal scar, keratitis, retinal detachment, macular edema, uveitis, intraocular hemorrhage, optic nerve damage)
Auditory injuries (hemorrhage in the middle ear, TM, cochlea and vestibular system, late onset mastoiditis, early or late onset hearing loss)
Vascular damage (aneurysm, thrombosis)
Muscle damage (spasm, compartment syndrome)
Renal involvement (myoglobinuria, ATN)
Coagulation disorders (DIC)
GI injuries (ileus, intra abdominal hemorrhage, GI perforation)

20. Prehospital care tips Rescuer safety is very important
Stay at least 10 m from downed power line
Support structures may be electrically alive
Eliminate electrical source immediately
Don’t touch the victim until contact with the electrical source is eliminated
Consider neck immobilization
Do CPR as early as possible

21. Management in ED Consider ABC Maintain cervical immobilization
Cardiac monitoring in symptomatic and high voltage electrical injuries
Treat arrhythmia like you do in advanced life support
Do careful vascular and neurologic exam
Fluid administration (maintain diuresis until CPK level is less than 5 times normal)

22. Discharge/admission
Discharge to home: Voltage <600, Asymptomatic, Normal ECG on arrival, Normal complete examination
Observe for 6 hours: Voltage<600, Unwell, Any in ECG
Admit to the hospital: Voltage > 600 even there is no apparent injury, Beyond superfacial skin injury unrelated to the voltage, Any abnormal lab data or ECG unrelated to the voltage, Oral and lip burn in children because of scar separation and severe bleeding after 5 days, Child with unreliable parents

24. Prevention tips Put child-safety covers on all electrical outlets
Get rid of equipment and appliances with old or frayed cords and extension cords that look damaged
Position television and stereo equipment against walls so small hands don't have access to the back surfaces or cords
Don't run electrical wires under rugs or carpet
If an appliance appears faulty stop using it and have it checked at once

25. References Essentials of Nelson, Drowning, chapter 43
Tintinallis Emergency Medicine, Drowning, chapter 215
Tintinallis Emergency Medicine, Electrical and lightning injuries, chapter 218