Prediction of childhood drowning and near-drowning morbidity and mortality

Objectives: (a) Evaluate the presenting hemodynamic status and neurologic function of a series of warm water submersion injuries. (b) To ascertain the importance of the timing of the neurologic examination. (c) To identify risk factors that predict which patients will not return to presubmersion status. Design: Retrospective review of all patients with a diagnosis of drowning/near-drowning responded to by the Children's Hospital pediatric transport service. Data were collected over a 24-month period regarding patient characteristics, submersion medium, rescue efforts, time out of sight, elapsed times to emergency department (ED) and pediatric intensive care unit (PICU) arrival, neurologic and hemodynamic status on arrival at the ED and PICU, reconstructed Conn-Modell category, and neurologic outcome. Setting: EDs of the referring hospitals and PICU of the Children's Hospital of Orange County (CHOC), California. Patients: Ninety-three submersion victims at an average age of 31 months. All patients were provided intensive care support. Interventions: None. Measurements and Main Results: Twenty-three percent (21/93) of patients died or survived vegetative. No patient arriving comatose and asystolic in the ED survived neurologically intact (n = 21, three patients expired in the ED). This group of patients had a mean duration of documented asystole = 41 minutes, range of 18 to 107 minutes, and time to ED arrival = 21 minutes. All patients with a detectable pulse and blood pressure (n = 72) on arrival to the ED, regardless of their neurologic status, recovered to their presubmersion status. Patients arriving comatose (decorticate, decerebrate, or flaccid posture) in the PICU (2 = 18, mean arrival = 192 minutes) all died or were vegetative. All patients with non-coma (n = 72, Conn-Modell category A or B) on arrival to the PICU recovered normally. Conclusions: Hemodynamic status in the ED and neurologic status in the PICU are highly predictive of outcome. On arrival to the ED, the cardiovascular status is more predictive of abnormal outcome than neurologic status. Poor neurologic outcome appears inevitable for warm water submersion victims who are asystolic at ED arrival and remain comatose for more than 200 minutes.