Exam III - Submersion Injury

Pathophysiology of Hypothermia

- Common after submersions - Children at increased risk because of their large surface area relative to body mass, decreased subcutaneous fat, and limited thermoregulation - Cold water decreases metabolic demands and activates the diving reflex - Causes blood to be shunted away from the periphery and concentrated to the brain and heart - Prolonged submersion in cold liquids can impair cognition, coordination and muscle strength, ultimately resulting in loss of consciousness, decreased cardiac output, and cardiac arrest

Pathophysiology of aspiration

- Fluid is quickly absorbed in the pulmonary circulation, resulting in pulmonary edema, atelectasis, and airway spasm, which aggravates the hypoxia - No difference noted among survivors submerged in salt water vs. fresh water

Pathophysiology

Aspiration Hypoxia, asphyxiation, hypothermia Impaired respiratory, neuro, cardiac function

Pathophysiology of Hypoxia

Hypoxia can cause damage to the brain, lung, heart, kidneys, liver and GI system - Cerebral hypoxia is the major component - Within minutes of a submersion, a lack of oxygen leads to coma and ultimately cardiac arrest - related to the duration of anoxia and asphyxia - Different cells tolerate variable lengths of anoxia, causing variations of cell damage - Neurons, especially cerebral cells, sustain irreversible damage after 4 to 6 minutes of submersion - Heart and lungs can survive up to 30 minutes - About 10% of drowning victims die without aspirating fluid, but succumb from acute asphyxia as a result of prolonged reflex laryngospasm

Therapeutic management of near drowning

KNOW Emergency resuscitative efforts at scene (CPR) Management based on the degree of cerebral insult KNOW First priority: restore oxygen delivery to cells and prevent further hypoxic damage A spontaneous breathing child will do well in an oxygen enriched atmosphere A more severely affected child will require endotracheal intubation and mechanical ventilation KNOW ALL children who have a submersion injury should be hospitalized for observation Almost half of asymptomatic or minimally symptomatic alert children experience complications (e.g., respiratory compromise, cerebral edema) during first 24 hours after incident ICU management - Prevent aspiration pneumonia - Frequent complication - Occurs 48-72 hours after the episode Prognosis Good outcome: - KNOW Submersion less than 5 minutes - Presence of sinus rhythm - Reactive pupils - Neurologic responsiveness at scene Worst prognosis: - KNOW Submerged more than 10 minutes - Not responding to advanced life support within 25 minutes - All children without purposeful movement and normal brainstem function 24 hours after a submersion injury have sustained severe neurologic deficits or death

Nursing Interventions for near drowning

Prevention of drowning Care depends on child's condition Vital signs Mechanical ventilation Tracheostomy Blood gas determination Chest physiotherapy IV infusion Emotional support for family Assist parents to cope with feelings of guilt Parental anxiety related to prognosis

What is submersion injury or near drowning?

Survival for at least 24 hours after water submersion Major cause of death in children greater than 1 year old Death occurs from asphyxia while child submerged Can occur in small quantity of water (e.g., a pail of water, toilet, or bathtub) Cases usually involve children who are helpless in water, such as inadequately attended children in or near swimming pools, bathtubs, ponds, streams and flooded excavations, boaters who fail to wear life preservers, children who have diving accidents, children who are able to swim but overestimate their endurance Accidental drowning occurs more commonly in toddlers, boys and African-Americans Children younger than 1 year old are most likely to drown in a bathtub Buckets willed with fluid cause a risk of drowning to top-heavy toddlers who can fall head first into the buckets Preschoolers at risk for drowning in swimming pools Drowning in school age children and adolescents most commonly occurs in natural bodies of water such as lakes, ponds and rivers Suction created at the outlet of pools, hot tubs or whirlpools spas is strong enough to trap any child, even larger children underwater