Pediatric submersion injuries are one of the leading causes of preventable morbidity and mortality in the pediatric population. And while epidemiology of these cases varies by geographic location, the assessment and management are largely consistent regardless of patient population.^1,2

Clinical outcomes in submersion injuries are largely dependent on the degree of hypoxic injury experienced by the victim, making prehospital care of paramount importance. Optimally, bystander CPR, including the administration of rescue breaths, should be initiated prior to arrival of emergency medical services. Every effort should be made to restore adequate oxygenation, ventilation, and perfusion as soon as possible.³

Once the patient arrives in your emergency department, a rapid review of the patient’s status and results of resuscitative efforts should be performed. One question that is commonly raised is whether these patients should be trauma activations. One study demonstrated that the minority of the cases reviewed required surgical intervention or had identifiable traumatic injuries, making standard involvement of the trauma team unnecessary.⁴ Another study cited only 2.3 percent of pediatric drowning patients with clinically significant traumatic injuries, with intracranial injuries being the most common.⁵ As with any pediatric injury, however, non-accidental trauma should be in your differential.

ED treatment should focus on airway, breathing, and circulation with consideration for cervical spine protection depending on the circumstances surrounding the event. Oxygen administration, with or without ventilatory support, is the mainstay of treatment. Fluid resuscitation will likely be warranted, and with crystalloid solution is most appropriate. Although some of these patients will have acidosis, it is typically respiratory in nature, making sodium bicarbonate unnecessary.³

Hypothermia is commonly encountered in submersion episodes, regardless of geographic location and season, although case reports have hypothesized improved neurologic outcomes, possibly due to the protective effects of the lower body temperatures.^6,7 Hypothermia is classified as:

• Mild: Core body temperature less than 35 degrees Celsius (less than 95 degrees Fahrenheit)
• Moderate: Core body temperature 30 degrees Celsius–32 degrees Celsius (86 degrees Fahrenheit–89.6 degrees Fahrenheit)
• Severe: Core body temperature less than 30 degrees Celsius (less than 86 degrees Fahrenheit).⁷

Esophageal thermometers provide the most accurate estimation of core body temperature, but bladder or rectal measurements may be used if esophageal probes are not available. There are three main methods of rewarming utilized:

Passive External Rewarming

• Remove all wet clothing
• Warm blankets or forced air warming blanket

Active External Rewarming

• Hot packs and heat lamps to trunk of body

Active Internal Rewarming

(reserved for severe hypothermia)

• Warmed IV fluids
• Warmed humidified oxygen
• Peritoneal, thoracic, or bladder lavage
• ECMO3

While neurocognitive issues due to a hypoxic–ischemic event are the most commonly seen long-term complication of submersion injuries, lung injury can be seen in the acute phases. Aspiration of gastric contents is often the cause of the initial insult, but acute respiratory distress syndrome can develop, necessitating the use of positive pressure ventilation and admission to the intensive care unit.² All efforts should be made to maximize oxygenation and minimize barotrauma. Steroids have not been shown to be effective in lung injury secondary to submersion injuries and should be avoided. Additionally, there is not a role for prophylactic antibiotics.³

Until now, we have largely been discussing significant submersion injuries that require ongoing resuscitation and admission to the hospital, and although it has been suggested that all patients that have experienced a submersion injury should be admitted for observation, growing evidence suggests that some of these children can be safely discharged home. Much of the concern supporting admission for observation arises from the concept of “secondary” or “dry” drowning, which are not physiologically supported clinical entities.^3,8

Multiple studies have shown that children who are asymptomatic or mildly symptomatic at initial presentation have a high likelihood of being able to be safely discharged from the ED after an observation period. Findings leading to successful discharge included absence of respiratory distress, normal oxygen saturations and age-appropriate vital signs, and lack of need for prehospital intervention.^9,10,11 Blood gas analysis or chest X-ray findings did not contribute to disposition decisions and are largely unhelpful in this clinical subset. A pediatric submersion score was developed and validated in 2017 identifying five factors that, if present, suggest safe discharge from the ED after an eight-hour observation period. They include:

• Normal mentation
• Absence of dyspnea
• Normal respiratory rate
• Normal systolic blood pressure (no signs of hypertension)
• Absence of need for airway support¹²

At this time, a six- to eight-hour observation from the time of the submersion event is widely accepted, although future studies may prove that a shorter observation time is sufficient.^9,11

As with many pediatric issues, prevention is key. Several studies have identified common misperceptions and gaps in education. One study showed that only six percent of caregivers were able to correctly answer 10 water safety knowledge questions; more than 30 percent got the majority of answers wrong, including not understanding that submersion injuries are a leading cause of death in the toddler age group and that you may not hear splashing or calling for help when someone is drowning. In this same study, one-third of caregivers felt that children didn’t need to be supervised as closely after they had received swimming lessons.¹³ Another study showed that caregivers felt keeping children within arm’s length in the water would be less critical if they were wearing flotation devices or if older children were with the toddler.¹⁴ A third study demonstrated that children living in rental properties with pools, who have caregivers that cannot swim and whose caregivers do not speak English, are at higher risk. Making affordable, culturally appropriate, and accessible interventions available to this population is key.¹⁵ Other efforts should be aimed at education regarding bathtub and bucket drownings, as these are often overlooked.¹⁶

So, as we continue to care for the children who present to our emergency departments with submersion injuries, remember: Oxygen is vital, observation is essential, and prevention is key.

References

1. Webb AC, Wheeler A, Ricci A, et al. Descriptive epidemiology of pediatric drowning patients presenting to a large southern US children‘s hospital. South Med J. 2021;114(5):266-270.
2. Pellegrino F, Raffaldi I, Rossi R, et al. Epidemiology, clinical aspects, and management of pediatric drowning. Ital J Pediatr. 2023 Jun 14;49(1):74.
3. Semple-Hess J, Campwala R. Pediatric submersion injuries: emergency care and resuscitation. Pediatr Emerg Med Pract. 2022;19(6 Suppl):1-46.
4. Chotai PN, Manning L, Eithun B, et al. Pediatric near-drowning events: do they warrant trauma team activation? J Surg Res. 2017;212:108-113.
5. Kemal S, Ramgopal S, Macy ML. Traumatic injuries and radiographic study utilization among children with drowning presenting to U.S. pediatric hospitals. Acad Pediatr. 2024;24(4):677-685.
6. Kriz D, Piantino J, Fields D, et al. Pediatric hypothermic submersion injury and protective factors associated with optimal outcome: a case report and literature review. Children (Basel). 2017;5(1):4.
7. Bauman BD, Louiselle A, Nygaard RM, et al. Treatment of hypothermic cardiac arrest in the pediatric drowning victim, a case report, and systematic review. Pediatr Emerg Care. 2021;37(10):e653-e659.
8. Causey AL, Tilelli JA, Swanson ME. Predicting discharge in uncomplicated near-drowning. Am J Emerg Med. 2000;18(1):9-11.
9. Cohen N, Capua T, Lahat S, et al. Predictors for hospital admission of asymptomatic to moderately symptomatic children after drowning. Eur J Pediatr. 2019;178(9):1379-1384.
10. Cantu RM, Pruitt CM, Samuy N, et al. Predictors of emergency department discharge following pediatric drowning. Am J Emerg Med. 2018;36(3):446-449.
11. Brennan CE, Hong TKF, Wang VJ. Predictors of safe discharge for pediatric drowning patients in the emergency department. Am J Emerg Med. 2018;36(9):1619-1623.
12. Shenoi RP, Allahabadi S, Rubalcava DM, et al. The pediatric submersion score predicts children at low risk for injury following submersions. Acad Emerg Med. 2017;24(12):1491-1500.
13. Johnson MB, Lawson KA. Caregiver water safety knowledge and views of toddler water competency. Inj Epidemiol. 2023;10(Suppl 1):65.
14. Johnson MB, Boriack ED, McConnell CM, et al. Impact of caregiver swimming capability on perceptions of swimming pool supervision of toddlers. Inj Epidemiol. 2022;9(Suppl 1):40.
15. Awan B, Wicks S, Peden AE. A qualitative examination of causal factors and parent/caregiver experiences of non-fatal drowning-related hospitalisations of children aged 0-16 years. PLoS One. 2022;17(11):e0276374.
16. Siddiqui SA, Singh MV, Mishra N, et al. Buckets associated home drowning in Indian infants and toddlers: an analysis of 18 fatalities from 2016-2022. Trop Doct. 2023;53(4):416-418.