Episode 31: Pediatric Drowning – Prevention and Management

Emergency Medicine, Uncategorized

In this episode, host Jason Woods speaks with Emma Harding and Laura Bricklin about drowning in children. The discussion covers prevention (specifically parental and patient education) and management, as well as the current terminology and existing data.

This episode is produced in conjunction with Drs. Emma Harding and Laura Bricklin as part of their worth on an AAP CATCH grant.  

The following show notes were authored by Drs. Bricklin and Harding and provide a fantastic review.

Take-Home Points

  1. Drowning is the #1 cause of preventable death in children age 1-4
  2. You can’t drown-proof a child – multiple layers of protection help prevent drowning
  3. Providers are a major source of water-safety education for most families

Major Data Points

Drowning claimed the lives of nearly 1,000 children (under 20 years old) in 2017, and an estimated 8,700 children visited a hospital emergency department for a drowning.

Two age groups have the highest risk of drowning – toddlers, and teens. Teens of color are at especially high risk. 

The highest rate of drowning is among children under age 4, with children 12 to 36 months of age being at the highest risk. 

  • Most infants drown in bathtubs and buckets. 
  • Most preschool-aged children drown in swimming pools. 
  • CPSC found that 69% of children under 5 who drowned were not expected to be at or near a pool when the drowned. 

Teens ages 15-19 years have the second-highest fatal drowning rate. Every year, about 370 children ages 10-19 drown.

  • Among teens, half of all drownings occur in natural water settings like lakes, rivers or oceans. 
  • Among teens, drowning is due to a variety of factors, but alcohol is often involved. 

Layers of Protection

  • All children and adults should learn to swim. If swim lessons are suspended in your area due to coronavirus, it is important to add other layers of protection until your child can access lessons.
  • Close, constant, attentive supervision around water is important. Assign an adult ‘water watcher,’ who should not be distracted by work, socializing, or chores.
  • Around the house, empty all buckets, bathtubs, and wading pools immediately after use. If you have young children, keep the bathroom door closed, and use toilet locks to prevent access.
  • Pools should be surrounded by a four-sided fence, with a self-closing and self-latching gate. Research shows pool fencing can reduce drowning risk by 50%. Additional barriers can include door locks, window locks, pool covers, and pool alarms.
  • Adults and older children should learn CPR. 
  • Everyone, children and adults, should wear US Coast Guard-approved life jackets whenever they are in open water, or on watercraft.
  • Parents and teens should understand how using alcohol and drugs increase the risk of drowning while swimming or boating.

Pathophysiology

  • Fatal and nonfatal drowning typically begins with a period of panic, loss of the normal breathing pattern, breath-holding, air hunger, and a struggle by the victim to stay above the water. 
  • Reflex inspiratory efforts eventually occur, leading to hypoxemia by means of either aspiration or reflex laryngospasm that occurs when water contacts the lower respiratory tract
  • Results in decreased lung compliance, ventilation-perfusion mismatching, and intrapulmonary shunting, leading to hypoxemia that causes diffuse organ dysfunction

Management

  • Prehospital
    • Rescue and immediate resuscitation by bystanders improves the outcome of drowning victims
  • Ventilation is generally considered the most important initial treatment for victims of submersion injury. Rescue breathing should begin as soon as the rescuer reaches shallow water or a stable surface. Note that the priorities of CPR in the drowning victim differ from those in the typical adult cardiac arrest patient, which emphasizes immediate uninterrupted chest compressions. If the patient does not respond to the delivery of two rescue breaths that make the chest rise, the rescuer should immediately begin performing high-quality chest compressions.
    • In a large, population-based, observational study using a Japanese government registry, no significant difference in neurologic outcome at one month was found between drowning victims treated initially with compression-only CPR and conventional CPR with rescue breathing
  • According to the AHA Guidelines for Advanced Cardiac Life Support (ACLS), routine cervical spine immobilization can interfere with essential airway management and is not recommended
    • unless there are clinical signs of injury or a concerning mechanism (eg, dive into shallow water)
  • Pulses may be very weak and difficult to palpate in the hypothermic patient with sinus bradycardia or atrial fibrillation; a careful search for pulses should be performed for at least one minute before initiating chest compressions in the hypothermic patient because these arrhythmias require no immediate treatment.
  • Attempts at rewarming hypothermic patients with a core temperature <33ºC should be initiated, either by passive or active means as available. 
  • ED
    • If tracheal intubation is performed, an orogastric tube should be placed to relieve gastric distension, which occurs from passive passage of fluid and is common in nonfatal drowning patients.
  • A bedside glucose measurement should be obtained soon upon arrival.
  • Wet clothing should be removed and rewarming initiated in hypothermic patients. 
    • Methods include passive and active external rewarming (eg, application of warm blankets, plumbed garments, heating pads, radiant heat, forced warm air), and active internal core rewarming (eg, warmed humidified oxygen via tracheal tube, heated irrigation of peritoneal and pleural cavities). 
    • In addition, endovascular and several extracorporeal rewarming options are available in some centers.
  • Possibly because of the neuroprotective effects of hypothermia, complete recovery of some patients with accidental hypothermia and cardiac arrest, despite prolonged resuscitation, has been well documented 
    • Therefore, prolonged resuscitative efforts may be effective (in rare instances, even if continued for several hours) and should be continued until the patient’s core temperature reaches 32 to 35ºC (90 to 95ºF)
  • Most non-fatal drowning victims are hospitalized because of the severity of illness or concern for clinical deterioration. 
    • However, a review of 75 pediatric patients found that all who ultimately developed symptoms did so within seven hours of immersion
  • Asymptomatic patients should be closely observed for approximately eight hours and admitted if any deterioration occurs. 
    • If vital signs, pulse oximetry, and all studies, including a chest radiograph obtained close to the end of the observation period, are normal and no clinical deterioration develops during this period, the patient may be discharged with appropriate follow-up. 
    • Clear verbal and written instructions to return to the emergency department immediately for any respiratory or other problems must be given, and the patient must be accompanied by a responsible adult.

References:

Brenner, R. A., Taneja, G. S., Haynie, D. L., Trumble, A. C., Qian, C., Klinger, R. M., & Klebanoff, M. A. (2009). Association Between Swimming Lessons and Drowning in Childhood. Archives of Pediatrics & Adolescent Medicine, 163(3), 203. doi:10.1001/archpediatrics.2008.563

Causey, A. L., Tilelli, J. A., & Swanson, M. E. (2000). Predicting discharge in uncomplicated near-drowning. The American Journal of Emergency Medicine, 18(1), 9-11. doi:10.1016/s0735-6757(00)90039-1

Chandy, D., MD, & Weinhouse, G. L., MD. (2020). Drowning (submersion injuries). Retrieved August 01, 2020, from https://www.uptodate.com/contents/drowning-submersion-injuries

Denny, S. A., Quan, L., Gilchrist, J., Mccallin, T., Shenoi, R., Yusuf, S., . . . Weiss, J. (2019). Prevention of Drowning. Pediatrics, 143(5). doi:10.1542/peds.2019-0850

Hoek, T. L., Morrison, L. J., Shuster, M., Donnino, M., Sinz, E., Lavonas, E. J., . . . Gabrielli, A. (2010). Part 12: Cardiac Arrest in Special Situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation, 122(18_suppl_3). doi:10.1161/circulationaha.110.971069

Lavonas, E. J., Drennan, I. R., Gabrielli, A., Heffner, A. C., Hoyte, C. O., Orkin, A. M., . . . Donnino, M. W. (2015). Part 10: Special Circumstances of Resuscitation. Circulation, 132(18 suppl 2). doi:10.1161/cir.0000000000000264

Pratt, F. D., & Haynes, B. E. (1986). Incidence of “Secondary Drowning” after saltwater submersion. Annals of Emergency Medicine, 15(9), 1084-1087. doi:10.1016/s0196-0644(86)80133-0

Schmidt, A. C., Sempsrott, J. R., Hawkins, S. C., Arastu, A. S., Cushing, T. A., & Auerbach, P. S. (2016). Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning. Wilderness & Environmental Medicine, 27(2), 236-251. doi:10.1016/j.wem.2015.12.019

Tobin, J. M., Ramos, W. D., Pu, Y., Wernicki, P. G., Quan, L., & Rossano, J. W. (2017). Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning. Resuscitation, 115, 39-43. doi:10.1016/j.resuscitation.2017.04.004

Venema, A. M., Groothoff, J. W., & Bierens, J. J. (2010). The role of bystanders during rescue and resuscitation of drowning victims. Resuscitation, 81(4), 434-439. doi:10.1016/j.resuscitation.2010.01.005

Episode 30: Pediatric Stroke – A Primer with Dr. Megan Barry

Emergency Medicine, Neurology, Stroke

On this episode, host Jason Woods talks with Dr. Megan Barry, pediatric neurologist and stroke specialist, about pediatric stroke. This episode serves as a primer to pediatric stroke and a foundation for future discussion. We talk about diagnosis and initial management, risk factors, and places that can trip you if you aren’t careful

Of note, since recording, the International Pediatric Stroke Organization has been founded and has a number of great resources.
Guests

Megan Barry, DO. Assistant professor, Pediatric Neurohospitalist, Adult Vascular Neurologist, University of Colorado and Children’s Hospital Colorado

References

  1. Ferriero DM, Fullerton HJ, Bernard TJ, et al. Management of Stroke in Neonates and Children: A Scientific Statement From the American Heart Association/American Stroke Association. Stroke. 2019;50(3):e51-e96. doi:10.1161/STR.0000000000000183
  2. Shih EK, Beslow LA. Hemorrhagic stroke in children. UpToDate. Accessed: 5/28/19. https://www.uptodate.com/contents/hemorrhagic-stroke-in-children
  3. Kirton A, Deveber G, Pontigon AM, Macgregor D, Shroff M. Presumed perinatal ischemic stroke: vascular classification predicts outcomes. Ann Neurol. 2008;63(4):436-443. doi:10.1002/ana.21334
  4. Golomb MR, MacGregor DL, Domi T, et al. Presumed pre- or perinatal arterial ischemic stroke: risk factors and outcomes. Ann Neurol. 2001;50(2):163-168. doi:10.1002/ana.1078
  5. Lehman LL, Khoury JC, Taylor JM, et al. Pediatric Stroke Rates Over 17 Years: Report From a Population-Based Study. J Child Neurol. 2018;33(7):463-467. doi:10.1177/0883073818767039

Additional Resources

  1. Pediatric NIH Stroke Scale
  2. International Pediatric Stroke Organization

Episode 29: AHA Pediatric Post Cardiac Arrest Scientific Statement with Alexis Topjian

Cardiac Arrest, Critical Care, Emergency Medicine, Pediatric Emergency Medicine

On this episode, host Jason Woods talks with Alexis Topjian about the 2019 “AHA Pediatric Post–Cardiac Arrest Care Scientific Statement.” Dr. Topjian is the first author on the statement, which is the first pediatric post arrest care statement from the AHA (previously children had primarily been discussed as a special population within a primarily adult guideline). The document itself is long, but contains a large amount of useful information for bedside providers, health care administrators, and researchers.


Guests

Alexis Topjian MD, Associate Professor of Anesthesia and Critical Care Medicine, University of Pennsylvania School of Medicine, Children’s Hospital of Philadelphia

References

  1. Topjian AA, de Caen A, Wainwright MS, et al. Pediatric Post-Cardiac Arrest Care: A Scientific Statement From the American Heart Association. Circulation. 2019;140(6):e194-e233. doi:10.1161/CIR.0000000000000697

Additional Resources

  1. Previous Little Big Med podcast with Dr. Topjian on post arrest hypotension in children

Episode 28: Online Professionalism and Social Media in Medicine with Sarah Mojarad – Repost

Medical Education, Online Professionalism, Social Media

On this episode, host Jason Woods speaks with Sarah Mojarad, lecturer at USC with appoints in the schools of Medicine and Engineering. Professor Mojarad is an expert in online professionalism, social media use in STEMM (science, technology, engineering, mathematics, medicine), and science communication. This episode is all about how and why social media can be used in medicine (also the how not and why not!), strategies for successful communication to colleagues and patients, and mistakes to avoid.

Sarah has a number of online resources on these topics (listed below) and is a fantastic person to follow on social media. Her insights, topic highlights, and approach are invaluable to any health care practitioner looking to be involved on social media.

Guest

Sarah Mojarad, Lecturer of Engineering Writing, Viterbi School of Engineering and Keck School of Medicine, University of Southern California

Where to find Sarah:

Faculty bio

Twitter – @Sarah_Mojarad

Medium page

YouTube

Episode 27, Part 1: Gender Equity in Medicine with Nancy Spector

Medical Education

On this episode, host Jason Woods speaks with Dr. Nancy Spector, Professor of Pediatrics at Drexel University College of Medicine, and Executive Director of the Executive Leadership in Academic Medicine program, about gender equity issues in medicine. Dr. Spector is a frequent speaker on this issue and was the lead author on an article last year outlining the progress, barriers, and opportunities for women in pediatrics (see reference below).

This is part one of a two-part discussion. In part one, Dr. Spector focuses on outlining the scope of the issues and provides strategies for decreasing the equity gap and increasing opportunities for women at all levels of academic medicine.

I want to send out a big thanks to Kellen Vu, who serve as audio producer for this episode!

Guest

Nancy Spector MD, Professor of Pediatrics, Associated Dean for Faculty Development, Drexel University College of Medicine

References

  1. Spector ND, Asante PA, Marcelin JR, et al. Women in Pediatrics: Progress, Barriers, and Opportunities for Equity, Diversity, and Inclusion. Pediatrics. 2019;144(5):e20192149. doi:10.1542/peds.2019-2149.
  2. Cruz M, Bhatia D, Calaman S, et al. Senior author: Spector N. The Mentee-Driven Approach to Mentoring Relationships and Career Success: Benefits for Mentors and Mentees. MedEdPortal. 2015; Sept. doi:10.15766/mep_2374-8265.10201

Additional Resources – Things Dr. Spector mentioned for additional information

  1. ELAM Website
  2. Women Don’t Ask: The High Cost of Avoiding Negotiation – book from Linda Babcock and Sara Laschever
  3. Harvard Business Review – “What’s Holding Women in Medicine Back from Leadership”
  4. Be Ethical campaign

Episode 27, Part 2: Cross-gender Mentoring in Medicine with Nancy Spector

Education, Medical Education

On this episode, host Jason Woods speaks with Dr. Nancy Spector, Professor of Pediatrics at Drexel University College of Medicine, and Executive Director of the Executive Leadership in Academic Medicine program, about gender equity issues in medicine. Dr. Spector is a frequent speaker on this issue and is the lead author on an article published last year outlining the progress, barriers, and opportunities for women in pediatrics (see reference below).

This is part two of a two-part discussion. In part two, Dr. Spector focuses on mentoring across different genders. She provides strategies for successful mentorship, guidance on being a genuine ally without appropriating, and how to help your mentee seek out additional mentorship in areas where you may not have sufficient skill.

I want to send out a big thanks to Kellen Vu, who serve as audio producer for this episode!

Guest

Nancy Spector MD, Professor of Pediatrics, Associated Dean for Faculty Development, Drexel University College of Medicine

References

  1. Spector ND, Asante PA, Marcelin JR, et al. Women in Pediatrics: Progress, Barriers, and Opportunities for Equity, Diversity, and Inclusion. Pediatrics. 2019;144(5):e20192149. doi:10.1542/peds.2019-2149.
  2. Cruz M, Bhatia D, Calaman S, et al. Senior author: Spector N. The Mentee-Driven Approach to Mentoring Relationships and Career Success: Benefits for Mentors and Mentees. MedEdPortal. 2015; Sept. doi:10.15766/mep_2374-8265.10201

Additional Resources – Things Dr. Spector mentioned for additional information

  1. ELAM Website
  2. Women Don’t Ask: The High Cost of Avoiding Negotiation – book from Linda Babcock and Sara Laschever
  3. Harvard Business Review – “What’s Holding Women in Medicine Back from Leadership”
  4. Be Ethical campaign

Episode 26: EVALI

Emergency Medicine, Pulmonology, Uncategorized

On this episode, host Jason Woods speaks with Dr Heather Hoch DeKeyser, pediatric pulmonologist, about EVALI (e-cigarette or vaping product use-associated lung injury). This recently recognized condition has caused numerous people to suffer severe lung disease. We discuss the definition, current approach, remaining mysteries, and potential causes.

All treatment discussed is based on the most recent CDC EVALI guideline at the time of recording – available here

Guest:

Heather Hoch DeKeyser MD – Assistant Professor, Dept. of Pediatrics, Section of Pulmonary and Sleep Medicine, University of Colorado School of Medicine and Children’s Hospital Colorado

Additional Resources:

References:

  1. Layden JE, Ghana I, Pray I, et al. Pulmonary Illness Related to E-Cigarette Use in Illinois and Wisconsin – Preliminary Report. N Engl J Med. 2019 Sep 6. doi: 10.1056/NEJMoa1911614. [Epub ahead of print]
  2. Butt YM, Smith ML, Tazelaar HD. Pathology of Vaping Associated Injury. Letter to the Editor. N Engl J Med. 2019; 381:1780-1781. doin: 10.1056/NEJMc1913069
  3. Marsden L, Michalicek ZD, Christensen, ED. More on the Pathology of Vapid Associated Lung Injury. Letter to the Editor. N Engl J Med 2020; 382:387-39 doin: 10.1056/NEJMc1914980.
  4. Diaz CD, Carroll BJ, Hemyari A. Pulmonary Illness Related to E-Cigarette USe. Letter to the Editor. N Engl J Med 2020; 382-386. doi: 10.1056/NEJMc1915111

Episode 25: Sticky Education

Education, Uncategorized

On this episode, host Jason Woods speaks with Dr. Janet Corral, medical education expert, about some high yield tips to improve the success of your education! We also discuss the state of medical education as a whole and how to adjust the delivery for the needs of the current learners.

Guests

Janet Corral, Associate Professor, University of Colorado School of Medicine, PhD Educational Technology

Episode 24: Metabolic Resuscitation for Pediatric Septic Shock

Critical Care, Emergency Medicine, Sepsis

On this episode, host Jason Woods speaks with Dr Nelson Sanchez-Pinto, pediatric intensivist, about an article he co-authored that was just e-published in the last week! The article concerns a retrospective analysis of the use of HAT therapy (hydrocortisone, ascorbic acid, thiamine) at a single center PICU for the treatment of pediatric septic shock. The e-pub link is below and this post will update when it is published in print. This topic has caused significant controversy and strong emotions for the last several years, and I expect that to continue. Please take a look at the additional resources below, as well as Dr. Sanchez-Pinto’s twitter feed (@nelsonspinto), for even more information.

E-publication link: https://www.atsjournals.org/doi/pdf/10.1164/rccm.201908-1543LE

The highlights:

  • Study details
    • Single center, retrospective, propensity score matched
    • 557 septic shock patients in the PICU
    • 43 received HAT, 181 hydrocortisone alone, 333 neither
    • HAT patients matched 1:1 with the other groups
  • Results
    • HAT patients had lower mortality at 30-days (9 vs 28%, P=0.03) and 90-days (14 vs 37%, P=0.01) compared to no HAT or hydrocortisone
    • Similar results comparing mortality in HAT to those with hydrocortisone alone – 30-day (9 vs 30%, p=0.01) and 90 day (14 vs 37%, p=0.01)
    • No difference at 30 days in vasoactive free days or hospital free days

Guests

Nelson Sanchez-Pinto MD, Assistant Professor of Pediatrics and Preventative Medicine, Northwestern University, Feinburg School of Medicine

Pediatric Intensivist, Anne and Robert H. Lurie Children’s Hospital of Chicago

References

1.         Marik PE, Khangoora V, Rivera R, Hooper MH, Catravas J. Hydrocortisone, Vitamin C, and Thiamine for the Treatment of Severe Sepsis and Septic Shock: A Retrospective Before-After Study. Chest. 2017;151(6):1229-1238.

2.         Wilson JX. Mechanism of action of vitamin C in sepsis: ascorbate modulates redox signaling in endothelium. Biofactors. 2009;35(1):5-13.

3.         Fowler AA, 3rd, Syed AA, Knowlson S, Sculthorpe R, Farthing D, DeWilde C, et al. Phase I safety trial of intravenous ascorbic acid in patients with severe sepsis. J Transl Med. 2014;12:32.

4.         Spoelstra-de Man AME, Elbers PWG, Oudemans-van Straaten HM. Making sense of early high-dose intravenous vitamin C in ischemia/reperfusion injury. Crit Care. 2018;22(1):70.

5.         Zabet MH, Mohammadi M, Ramezani M, Khalili H. Effect of high-dose Ascorbic acid on vasopressor’s requirement in septic shock. J Res Pharm Pract. 2016;5(2):94-100.

6.        Wald EL, Sanchez-Pinto LN, Smith CM, Moran T, Badke CM, Barhight MF, Malakooti MR. Hydrocortisone-Ascorbic Acid-Thiamine Use Associated with Lower Mortality in Pediatric Septic Shock. Am Journal Respr and Crit Care Med. E-pub ahead of print. PMID: 31916841. DOI: https://doi.org/10.1164/rccm.201908-1543LE

7.        Fowler AA, Trust JD, Hite RD. Effect of Vitamin C Infusion on Organ Failure and Biomarkers of Inflammation and Vascular Injury in Patients With Sepsis and Severe Acute Respiratory Failure – The CITRIS-ALI Randomized Clinical Trial. JAMA. 2019;322(13):1261-1270. doi:10.1011/jama.2019.11825

Additional Resources

  1. SGEM discussion on the original Marik Trial
  2. PulmCrit on the recent CITRIS-ALI trial
  3. REBEL EM on the original Marik trial

Episode 23: Nephritis

Education, Emergency Medicine, Medical Education, Nephrology, Pediatric Emergency Medicine

What is it and why are there so many names?

On this episode, host Jason Woods speaks with Dr. Danielle Soranno, pediatric nephrologist, about nephritis in children. What is it, why are the terms so confusing, how do we diagnosis it, and when should we involve a nephrologist? Did the nephrologists invent terminology just to confuse us?

Guests

Danielle Soranno MD,  Assistant Professor, Pediatrics, Bioengineering & Medicine
University of Colorado and Children’s Hospital Colorado

References

  1. Floege J, Amann K. Primary glomerulonephritides. Lancet. 2016 May;387:2036-2048.
  2. Brogan P, Eleftheriou D. Vasculitis update: pathogenesis and biomarkers. Pediatr Nephrol. 2018 Feb;33:187-198.
  3. Chadban SJ, Atkins RC. Glomerulonephritis. Lancet. 2005 May;365:1797-1806.