Child drowning

Introduction to child drowning Drowning refers to the flooding of the face and the upper respiratory tract by various liquids, including water, resulting in a life-threatening state or death caused by suffocation of the respiratory function. The serious consequence of drowning is that even if life is revived, the nervous system damage caused by drowning is often enough to make the child lose normal living ability. Foreign data show that 60% of the drowning children who have undergone cardiopulmonary resuscitation in the emergency room and survived~ 100% have serious brain damage. The classification of drowning is mostly based on the time of drowning and the degree of hypoxia, the nature of drowning liquid (fresh water, seawater, sewage, etc.), and complications. Neardrowning generally refers to survival for more than 24 hours after drowning; drowning refers to death within 24 hours due to drowning. Secondary drowning refers to a patient who dies of complications shortly after drowning; the condition is not heavy at the beginning of drowning, but the condition worsens and eventually leads to death. Immersion syndrome (immersionsyndrome) refers to sudden death when falling into ice water, which is currently thought to be associated with over-excitation of the vagus nerve leading to cardiac arrest or ventricular fibrillation. Drowning can also be divided into pale and cyan. The former is due to heartbeat after drowning, respiratory reflex stop, rapid loss of consciousness, or accompanied by convulsions, craniocerebral trauma, intracranial hemorrhage, etc.; the latter is more common, because the child appears paddling and struggling during drowning, causing A large amount of catecholamines are released in the body. basic knowledge The proportion of sickness: 0.01% Susceptible people: children Mode of infection: non-infectious Complications: aspiration pneumonia, respiratory failure, hypoxic encephalopathy, arrhythmia, shock, acute renal failure

Causes of child drowning

(1) Causes of the disease

Most of the drowning patients are drowned by fresh water, including ponds, rivers, swimming pools, and even baths. The flooding rate of swimming pools accounts for 50% of freshwater drowning patients. The time of drowning is usually summer, and children may not The water is ripe or inadvertently dropped into the water by the floating plate. In the lakes, rivers and coastal waters, there are many older children such as school age. These children are drowning. There are usually some unexpected factors, such as swimming in the head and neck. The department was seriously injured, decompression sickness occurred during diving, low temperature paralysis or arrhythmia, abuse in water, convulsions, poisoning, etc.

Drowning can also occur in the home. If the child is inadvertent, the young child falls into the bath; the older child may be drowned by seizure in the bath or abused. Other children will enter the water tank during play. You can't pull out the water to cause drowning; or you can get drowning in the pool because the body is sucked by the drain in the pool or the hair is entangled.

In addition, hypothermia and exhaustion are also important causes of drowning in well-watered swimmers. Hyperventilation during swimming, photoflash stimulation, water immersion epilepsy and fatigue can induce seizures, epilepsy The incidence of drowning in children is 4 to 5 times higher than that of normal children, and even with antiepileptic drugs, complete protection cannot be achieved.

The cause of drowning caused by accidents is that the distressed person will not swim, cold, exhaustion and lack of ambulance support and life-saving supplies, while others are related to the subversion of the lifeboat. For example, the lifeboat is small and the personnel are overloaded. The driving force, etc., makes the lifeboat drift with the wind, can not quickly get out of danger, or overturn the wind and waves.

(two) pathogenesis

When drowning occurs, the drowning person can have two kinds of reactions: struggling and reflexive heartbeat respiratory arrest. The young child can show a reflective breath after entering the water, sinking directly into the water without struggling, and only after being rescued. Restoration of spontaneous breathing, part of the swimmer's head and face after exposure to cold water, due to excessive excitement of the vagus nerve, reflexive bradycardia or sudden arrest occurred and drowning, some people call this phenomenon "diving reflex", most drowning people in Struggling and breathing during drowning, with the struggle and lack of oxygen, a large amount of water is swallowed into the stomach, and some water can be inhaled into the airway while inhaling water. The liquid inhaled into the lungs is usually very small, and most drowning people inhale. The amount of water in the airway is less than 20ml/kg. After drowning, with the lack of oxygen, the consciousness of the sputum is quickly lost. If it is not rescued in time, the heartbeat will stop. After the drowning, there is no inhaled liquid in the airway called dry sputum. The cognac accounted for 7% to 10% of the total number of drowning. It was speculated that the cognac had water in the upper respiratory tract when drowning, but it caused a cough and swallowing reflex by stimulating the throat, causing a reflexive throat. Door closed Choking, suffocation result of hypoxemia and lead to loss of consciousness, and ultimately due to severe lack of oxygen the heart stops beating.

Low temperature is also a great hazard to drowning people. It is one of the important causes of drowning death. The body's heat loss rate in water is 33 times that of air. Children have larger body surface area and less subcutaneous fat, which is easier for adults. Low body temperature occurs, water temperature is too low, causing body temperature to drop, low body temperature can cause swimming movements, muscles are strong, feeling numbness and decreased breath holding capacity. When the central temperature is <32 °C, it can cause arrhythmia and hypotension, or even stop the heartbeat. When the Titanic ship sank, although the life jackets were sufficient, there were few lifeboats. Of the 2,201 passengers, 2/3 of them died within 2 hours of zero degrees Celsius, and only the passengers entering the lifeboat survived.

The primary damage of sputum is lung, and hypoxemia caused by lung gas exchange disorder is the main cause of secondary damage including brain injury. In the early stage after drowning, there is no obvious disturbance of body fluid and water and electrolyte metabolism. Animal experiments have shown that inhalation of 20 ml / kg of water does not lead to continuous water and electrolyte imbalance, and the instillation of 1-3 ml / kg of fresh water or sea water in the airway is enough to reduce the oxygen saturation of the animal.

Due to the difference in seawater and fresh water components, the pathophysiology caused by drowning and inhalation is also different. The osmotic pressure of seawater is about 14 times that of serum. The inhalation of hypertonic saline into the alveoli results in the infiltration of capillary plasma into the alveoli. Alveolar pulmonary edema occurs, plasma loss causes effective circulating blood volume reduction and blood concentration. At the same time, electrolytes such as sodium, chloride, magnesium, etc., which have higher concentrations in seawater, diffuse into the bloodstream, causing hyperosmolarity and hypernatremia, and freshwater osmotic pressure is lower than Plasma and body fluids, when a large number of hypotonic water osmotic gradients migrate toward the pulmonary interstitial and capillaries, cause interstitial pulmonary edema, intravascular hypotonic hemolysis and hyponatremia.

The mechanism of hypoxemia caused by fresh water and seawater is slightly different. Fresh water can inactivate pulmonary surfactant and collapse alveolar, and cause alveolar basement membrane damage, alveolar inflammation, protein exudation, alveolar hyaline membrane formation, extensive pulmonary edema With local bleeding, seawater drowning can transfer the fluid in the pulmonary blood vessels to the alveoli, so that the pulmonary surfactant is diluted and washed away, causing alveolar collapse. In animal rabbit experiments, the mitochondria of the pulmonary vascular endothelium and alveolar wall after drowning were found. Abnormal morphology, fluid inhalation can also cause blood shunt in the lungs, decreased lung compliance, ventilatory blood flow ratio imbalance and bronchospasm, all of which can aggravate hypoxemia.

Child drowning prevention

In most cases, drowning can be prevented. Strengthen the management and boat management of non-swim waters, strengthen the care of young children, prevent them from approaching the pool, and discharge the water in the pool after the bath. The older children should look after it. Swimming, or putting on a life jacket, and making it aware of the danger of diving in unfamiliar waters. For children who may have convulsions during swimming, it is not advisable to swim in the water, such as low intelligence, recent replacement of anti-epileptic drugs, and incomplete control of epilepsy. For children with epilepsy who have been stable for more than 2 years, they should be swimming under strict care to prevent accidents. In addition, training on cardiopulmonary resuscitation should be strengthened for adolescents and parents. First aid facilities should be provided in swimming areas and ships to make drowning. Patients can get timely recovery and rescue.

Child drowning complications Complications aspiration pneumonia respiratory failure hypoxic encephalopathy arrhythmia shock acute renal failure

Some children may have secondary aspiration pneumonia, respiratory failure, ARDS, hypoxic ischemic encephalopathy, hemolysis, arrhythmia, shock, acute renal failure and DIC, among which hemolysis, trauma caused by hemoglobinuria and myoglobin Urine can induce acute renal failure; significant water and electrolyte disturbances are more common in dripping with special liquids (such as sea water), or large amounts of liquids.

Children's drowning symptoms Common symptoms Hairy hypoxemia coma Vital signs Change bloating Breathing Irregular asphyxia Coughing ambiguity

The clinical manifestations of drowning are concentrated in the hypoxic damage of the lungs and central nervous system. In some cases, severe symptoms appear 2 to 6 hours after the drowning and resuscitation, and vital signs can be changed.

Clinical symptoms and drowning time, water absorption and whether it is timely rescue, the degree of disease varies greatly among individuals, lighter can have no obvious abnormal signs, severe cases need to carry out cardiopulmonary resuscitation, drowning 1-2 minutes can be blurred, breathing is not Rules, blood pressure drop and slow heartbeat; may have cough, vomiting, or suffocation due to reflex throat, but also suffocation due to vomit inhalation into the respiratory tract, sputum 3-4 years or more often coma, convulsions, face bruising , edema, bloody liquid through the mouth and nose, cold limbs, blood pressure, lungs have a voice, arrhythmia or breathing, heartbeat stop, drowning and struggling when swallowing a large amount of liquid can occur abdominal distension, some patients can also be flooded Brain trauma, fractures, etc. occur when you are paralyzed.

Hypoxemia, acidosis, and hypoperfusion of blood flow after drowning can affect various organs throughout the body.

Child drowning check

The most important test is blood gas analysis, which can directly understand the acid-base balance state of the patient. If you need to check blood gas frequently, you can place an artery cannula; or supplement with pulse oximetry monitoring. The necessary laboratory tests also include whole blood. Conventional, hematocrit, blood electrolytes, blood sugar (low temperature can cause hypoglycemia or hyperglycemia), blood osmotic pressure, liver and kidney function, diagnostic DIC indicators (including prothrombin time, partial thromboplastin time, platelet count) , plasma fibrinogen, fibrin degradation products), urine routines, etc., for other cases can also be given other corresponding laboratory tests.

X-ray examination is used to understand whether the patient has aspiration pneumonia and pneumothorax, observe the placement of tracheal intubation, gastric tube and central venous catheter. For patients with suspected fracture, cervical or head trauma, bone radiographs can be given.

Diagnostic identification of children drowning

diagnosis

1. History should carefully understand the relevant medical history, such as drowning time, location, whether sinking into the water, awareness of rescue, spontaneous breathing and cyanosis, and the nature of water temperature and water (fresh water, sea water, dirty water), and cardiopulmonary resuscitation The response to rescue, combined with physical examination, to determine the nature and extent of drowning, while paying attention to identify whether there are abnormal factors such as trauma, convulsions, poisoning, excessive fatigue.

2. The physical examination should be detailed. During the rescue, the following items should be observed:

(1) Center temperature and cyanosis.

(2) Whether there is autonomous heartbeat breathing, shortness of breath, three concave signs and wheezing.

(3) The state of consciousness, the pupil responds to light, whether there is a brain position and pain response.

(4) Are there neck injuries and other organ damage?

After resuscitation, the corresponding laboratory and auxiliary examinations may be considered to understand the extent of the disease and the complications.

3. Intracranial pressure monitoring is helpful to understand the state of cerebral edema and guide treatment. Continuous intracranial pressure higher than 20mmHg indicates severe brain injury, while intracranial pressure is lower than 20mmHg, and cerebral perfusion pressure is higher than 50mmHg, indicating a better prognosis.

Differential diagnosis

There are many types of accidental injuries. According to the history and performance, it is easy to diagnose drowning, but it must be identified as simple drowning, or combined with other diseases before drowning, such as epilepsy (determine whether it is epilepsy, ask the patient and his relatives or colleagues and other witnesses in detail, Getting a detailed and complete history of seizures is the key to accurate diagnosis of epilepsy. EEG is the most important means of diagnosing seizures and epilepsy, and contributes to the classification of seizures and epilepsy. EEG should be performed. It should be noted that the abnormal rate of general EEG is very low, about 10 to 30%. The standardized EEG, due to its appropriate extension of the tracing time, guarantees various induced tests, especially It is induced by sleep, and if necessary, it is added as a sphenoid electrode. Therefore, the detection rate of epileptic discharge is obviously improved, the positive rate can be increased to about 80%, and the accuracy of diagnosis of epilepsy can be significantly improved.), heart disease, etc. And whether there is fracture damage when falling into the water.

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