Asymptomatic Pediatric Fresh Water Drowning: How Long to Observe?

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Author: Megan Litzau, MD
Indiana University Emergency Medicine Resident PGY 2

This post was peer reviewed.
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Case:
A three-year-old female arrives after falling into a swimming pool. The patient did go underwater as witnessed by the patient’s siblings before the siblings pulled the patient out. The period of time underwater is unknown, however, she did not require any resuscitation at the scene. The patient arrived in a private vehicle in no apparent distress with normal vital signs for her age.


Introduction:
In pediatric drownings in which the patient is in cardiopulmonary arrest, the treatment and disposition is very clear as there are algorithms for treatment and the disposition is admission if return of spontaneous circulation (ROSC) is achieved. However, in a patient who presents asymptomatic after a fresh water near drowning incident as described above, what is the best treatment and disposition course for those patients? Do these patients need to be admitted or can they be observed and released from the emergency department? If the patients are going to be observed and released, how long do they need to be observed for in order to release them safely?


Discussion:
In order to answer this question, I reviewed the literature for asymptomatic fresh water near drowning in pediatric patients. There were two papers that were of interest. The first was published by Causey et al. This was a retrospective review at a single tertiary care children’s hospital over a 3 year period. Inclusion criteria were GCS greater than or equal to 13 with presentation for near drowning from fresh water. Exclusion criteria were GCS less than 13, those who required CPR less than 4 hours after presentation to the emergency department (ED), and patients with significant distracting injuries or significant past medical problems. There were 61 patients total in this study with 13 patient that were excluded. The remaining patients were divided into groups. Group A (39 patients): asymptomatic upon arrival and discharged within 48 hours, Group B (5 patients): were supplied oxygen for less than 6 hours and were discharged within 24 hours, Group C (4 patients): hospitalized longer than 24 hours but less than 48 hours. All patients in this study had a normal neuro exam at time of discharge. No patients who had a normal room air oxygen sat at 6 hours deteriorated while in the hospital. There were 3 patients in this study that did deteriorate during their ED course but they did so in less than 4 hours. The conclusion from this study is that a 4-8 hour observation period for patients who arrive with a GCS greater than or equal to 13 and have a room air oxygen sat greater than 95% at 4-6 hours can be discharged home from the ED.

The second paper was by Szpilman et al. This was a review article that was published looking at drowning cases in general. The article contains a grading system for drowning victims. If the patient can speak and has normal lung sounds, then the patient has a 100% chance of survival and can be released. If the patient can speak but has rales in some lung fields, the patient should be placed on low flow oxygen and if they are asymptomatic at 6 hours, can also be released from the ED. If the patient is higher grade (3-6 according to the chart in the paper) prolonged observation and higher levels of care are recommended.


Conclusion:
From the limited data that exists, for asymptomatic patients who present to the ED following a fresh water near drowning event, a 4-6- hour observation period does seem sufficient if they remain asymptomatic and have a room air oxygen saturation greater than 95%.

Sources:

1. Causey AL, Tilelli JA, Swanson ME. Predicting Discharge in Uncomplicated Near-Drowning. Am J Emerg Med. 2000;18:9-11. doi:10.1016/S0735-6757(00)90039- 1
2. Szpilman D, Bierens J, Handley A, Orlowski J. Current Concepts: Drowning. N Engl J Med. 2012;366:2102- 10. (10.1056/NEJMRA1013317)