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)