Near Drowning

case presentation
A 2-year-old child was found face down in his family’s
backyard pool. The family lives in Boracay and the
estimated pool temperature at the time of the near-
drowning incident was 85°F. The parents estimate that their
son was in the water for 6 to 8 minutes before being pulled
out. His father began CPR immediately and Emergency
Medical Services (EMS) was called. When EMS arrived,
CPR was continued, but intubation was unsuccessful. The
patient’s heart stopped three separate times before he was
eventually stabilized in the emergency department. His
body temperature in the emergency room was 94°F.
He was unresponsive to painful and verbal stimuli and was
reliant on mechanical ventilation. His pupils were fixed and
dilated at 4 mm. On admission, he had a PGCS score of 3.
Two days later, he had an NSE level of 38. Both parents
were emphatic that their child be “saved.” The patient is
currently in the pediatric intensive care unit (PICU) 10 days
after the near-drowning episode. His PGCS score is now 11.
His eyes open spontaneously and he is beginning to focus
on people. He is groaning and beginning to respond to
tactile input by pulling the touched body part away. He is still
intubated but the plan is to begin weaning him over the next
few days.
PATHOPHYSIOLOGY
Buildup of
lactic acid

Metabolic
acidosis
MEDICAL PROCEDURES/ INTERVENTIONS
History
-Assess the situation and provide the right interventions
Data: 2 year old toddler estimated 6-8 mins drowned in
freshwater with temp of 85°F
Insertion of rectal probe
-measures degree of hypothermia/ core body
temperature.
-best for toddlers up to 3 yrs old
-Data: Pt is 94°F –Considered Hypothermic ~Normal:
98.6°F
ECG Monitoring
-Monitor heart rhythms and abnormalities
-Cardiac: Tachycardia, dysrhythmia
Blood culture for both aerobic and anaerobic
organisms
-to test for possible septicemia. Used if client is
exposed to murky waters.
Lab Values Monitoring
Serial arterial blood gas measurement-
Measures levels of pH and levels of O2 and
CO2. Increased CO2 and insufficient O2 in the
body causes respiratory acidosis.
ICP measurement- Anoxic Brain injury (ABI)
can cause brain swelling, increasing ICP
Serum Electrolyte levels- Can cause lactic
acidosis due to tissue hypoxia.
Input and output- Metabolic acidosis can cause
changes in renal output.
Serial Chest Xrays- can show pneumothorax,
pneumonia, acute respiratory distress
syndrome (ARDS), pulmonary edema and the
aspirated fluids.
Pupil dilation
-Dilated pupils can be a sign of severe brain
injury
Data: Pt has dilated pupils of 4mm (full dilation)
indicating severe brain injury and requiring
emergency assistance.
Pediatric Glasgow Coma Scale
(pGCS)
-Assess mental status and levels of
consciousness for toddlers ages 2 and
above.
Data: 3, indicating having severe brain
injury (3-8)~Normal: 9 and above.
Unresponsive to painful stimuli and
eyes fully dilated at 4mm PTA.
After 10 days: pGCS of 11, Eyes open
spontaneously, groaning, and responds
to tactile stimuli by shrugging the
hands touching the pt.
CPR- Cardiopulmonary Resuscitation
Goal- maintain cerebral perfusion and
oxygenation to prevent further damage to
vital organs.
Top priority of CPR- manage hypoxia,
acidosis, and hypothermia.430 pumps with
speed of 100 pumps/min followed by 2
rescue breaths (CAB)
Nasogastric intubation
-used to decompress the stomach and
prevent aspiration of gastric contents.
Endotracheal intubation with positive
end-expiratory pressure (PEEP)

Rewarming -PEEP increases alveolar pressure and

1 ex: Extracorporeal circulation rewarming alveolar volume, prevent alveolar collapse.
(expensive method)
-Provides efficient rewarming to correct
hypothermia.

Indwelling urinary catheterization

-measures urine output.
-Hypothermia and acidosis may
compromise renal functioning.
MEDICATIONS
inhaled beta-agonist bronchodilator
-used for bronchospasm due to cold-induced bronchorrhea or irritation of the tracheobronchial tree by
inhaled water or particulate material
Albuterol
Dose: For 2-6 y/o, 0.1-0.2mg/kg t.i.d (Max: 4 mg/dose)
Side effects: Hypertension/ hypotension, bradycardia, nervousness, headache, hallucinations,
hypersensitivity reactions.

Antibiotic prophylaxis
-used when pt is submerged in grossly contaminated water or sewage.
-Not necessary to be given to the pt since pt is in freshwater pool.
Cefuroxime Na
Dose: For 3 mo-12y/o, PO 10-15 mg/kg q12h, IV/IM 75-100 mg/kg/d divided q8h (Max: 6g/d)
Side Effects: Diarrhea, nausea, pruritus, urticarial, dec. creatinine clearance.

Sodium Bicarbonate
-to correct metabolic acidosis
Dose: for infant: IV 2-3 mEq/kg/d of a 4.2% solution over 4-8 h
Side Effects: gastric distention, flatulence, metabolic alkalosis, electrolyte imbalance: sodium overload
(Pulmonary edema), hypokalemia, dehydration, dec. CSF pressure, impaired kidney function.
Diuretics
-Removes excess volume of fluids in the body, can also be used for pulmonary edema.
Furosemide
Dose: Child IV/IM 1mg/kg, may be increased by 1 mg/kg q2h if needed
Side Effects: Acute hypotensive episodes, dizziness, dehydration, hyponatremia, hypokalemia,
NSVD.

Nitrates
-Vasodilators to help blood flow to the heart. Treatment for acute pulmonary edema.
Nitroglycerin
Dose: Child IV 0.25-0.5 mcg/kg/min, titrate by 0.5-1mcg/kg/min q3-5 min
Side Effects: vertigo, dizziness, weakness, palpitations, tachycardia, NSVD, cutaneous
vasodilation with flushing, rash
NURSING OUTCOMES
(nursing diagnosis)
List of Possible Nursing Diagnosis

• Impaired gas exchange related to aspiration of freshwater

Expected Outcomes:
Patient will:
Maintain optimal gas exchange, as evidenced by arterial blood gases (ABGs) within client’s usual
range, oxygen saturation of 90% or higher, alert, responsive mentation or no further decline in the
level of consciousness, relaxed breathing, and baseline heart rate for the client.

• Hypothermia related to near drowning experience as evidenced by a body temperature of

94°F.
Expected Outcomes:
Patient will:
Display core temperature within normal range
Be free of complications such as respiratory infections, thromboembolic phenomena
•Ineffective Airway Clearance related to altered level of consciousness as evidenced by
PGCS score of 3 and pt is reliant to mechanical ventilation
Expected Outcomes:
Patient will:
•Maintain airway patency
•Demonstrate absence/reduction of congestion with breath sounding clear, noiseless
respirations, and improved oxygen exchange (e.g., absence of cyanosis and arterial
blood gas [ABG]/pulse oximetry results within client norms).

•Ineffective Cerebral Tissue Perfusion related to gas exchange insufficiency as evidenced

by altered level of consciousness with PGCS score of 3
Expected Outcomes:
Patient will:
•Maintain optimal cerebral tissue perfusion, as evidenced by alert, responsive
mentation; absence of neurological deficits; normoreactive pupils; normal or baseline
motor function.
•Risk for Injury related to decreased level of consciousness with PGCS score of 11, 10
days after the near-drowning episode
Expected Outcomes:
Patient will:
•Be free of injury.

•Risk for Impaired Skin Integrity related to prolonged immobility as evidenced by 10 days
of stay in PICU after the near-drowning episode
Expected Outcomes:
Patient will:
•Maintain normal skin integrity.
EMERGENCY NURSING INTERVENTIONS/
MANAGEMENT
•Right after the patient is being pulled out from the pool, check first the breathing of the patient
by tilting their head backwards and looking and feeling for breaths.

•Perform ABC assessment (Airway, Breathing, Circulation). Airway: Any patient with respiratory
distress, inability to protect their airway or with traumatic injuries should have their airway
secured by endotracheal intubation. Breathing: Continue the ventilations initiated on the
scene, providing supplemental oxygen, with the goal of keeping the oxygen saturation above
92%. Circulation: Do CPR on a patient without a pulse.

•Perform cardiopulmonary resuscitation (CPR) to manage immediately the hypoxia, acidosis,

and hypothermia.
•Check the patient's vital signs.

•Assess patient's neurologic status using Glasgow Coma Scale.

•Assess respiratory effort or adventitious breath sounds to determine if there is a presence of

pulmonary edema.
•Remove the patient's wet clothing and wrap the patient in a warm blanket; rewarm slowly.

•Monitor arterial blood gases to evaluate oxygen, carbon dioxide, bicarbonate levels, and pH.
These parameters determine the type of ventilatory support needed for the patient.

•The use of endotracheal intubation with PEEP improves oxygenation, prevents aspiration,
and corrects intrapulmonary shunting and ventilation–perfusion abnormalities (caused by
aspiration of water). If the patient is breathing spontaneously, supplemental oxygen may be
given by mask. However, an endotracheal tube is necessary if the patient does not breathe
spontaneously.

•Monitor patient's ECG because dysrhythmias may frequently occur.

DISCHARGE PLAN