1342 SECTION XII Pediatric Critical Care Environmental Injury and Trauma mouth to mouth resuscitation could be life saving 47 Clinical studies involving children and adults have failed to demonstrate[.]
1342 S E C T I O N X I I Pediatric Critical Care: Environmental Injury and Trauma mouth-to-mouth resuscitation could be life-saving.47 Clinical studies involving children and adults have failed to demonstrate an efficient diving reflex in response to cold-water submersion.48,49 Preexisting Associated Conditions An underlying etiologic mechanism should be explored depending on a given clinical scenario involving unexplained drowning Children with seizure disorders are at greater risk for submersion accidents Similarly, an occurrence of vasovagal syncope or a hypoglycemic episode during swimming may be the underlying factor responsible for drowning Occult cardiomyopathy or a cardiac arrhythmia should also be considered in an unexplained drowning event An episode of drowning might be the first manifestation of LQTS Ackerman et al studied blood samples or archived autopsy tissue samples in 35 cases of autosomal-dominant LQTS Six of these patients had a personal history or extended family history of near-drowning All of these patients were found to have LQTS causing mutations in KVLQT1, whereas such an abnormality was found in only of the remaining 29 patients who did not have a personal history of submersion episode.50 Thus, swimming appears to be a gene-specific (KVLQT1) arrhythmogenic trigger for LQTS Diagnosis of inherited LQTS allows for identification of other family members with similar affliction.7 Yoshinaga et al showed that face immersion in cold water results in abnormal lengthening of the QT interval in children identified with nonfamilial LQTS and that such children could potentially be at risk of a life-threatening arrhythmia during swimming.51 More recently, Albertella et al described the presentation of outcome of water-related events in children with LQTS.20 Of the 10 children identified with LQTS and who had a documented history of water-related syncope, nine had LQTS type Seven were swimming at the time of the syncopal event Factors leading to arrhythmias during swimming in patients with LQTS are thought to include facial immersion in cold water and the dive reflex, which causes a fall in heart rate, competing with epinephrine release from exercise Patients with LQTS should avoid swimming and diving and any medications that can prolong the QT interval It has been shown that b-blockers reduce the risk of sudden death in LQTS by 75%.52 A significant risk factor for drowning is epilepsy Accidental drowning causes 8% of all deaths in children and young adults with epilepsy.53 These patients have a four-fold higher prevalence of drowning than those without the condition.54 Unwitnessed bathtub drownings occur in roughly 30% of these cases and are more common in children age years and older.54,55 In older children and adolescents with epilepsy who are able to bathe independently, showers are advised over baths to reduce this risk Children with intellectual delays may be at reduced risk of drowning because they are more likely to be supervised in pools and tubs.54 However, there remains the risk of ambulatory children wandering off One study of children with autism spectrum disorder who drowned found that 74% of these deaths occurred in natural bodies of water (pond, river, lakes) in close proximity to home.56 Cold Water Drowning Proposed protective mechanisms of hypothermia for the injured brain include a decrease in cerebral metabolic rate, ICP, excitotoxic neurotransmission, cytotoxic edema, generation of deleterious O2-derived free radicals, and cerebral hyperemia, which can cause ischemia/reperfusion injury and further increase ICP The effects of hypothermia may apply to drowning injury, as good outcomes have been reported in children submerged in ice water (,5°C) for prolonged periods.22,57 It appears that if hypothermia is protective in drowning, rapid cooling in ice water is necessary, as a lesser degree of hypothermia in warmer water does not offer cerebral protection.58 It is also possible that a publication bias exists in reporting of cold water drowning, as cases with good outcome are more likely to be published than cases with poor outcome.59 Indeed, more recent studies call into question the protective effects of hypothermia in drowning Quan et al studied more than 1000 child and adult open-water drowning victims and did not find a protective effect of cold water but rather estimated that submersion duration was the most powerful predictor of outcome.60 In this study, young age was also a predictor of good outcome, which may reflect the capacity of children to become hypothermic faster and possibly benefit from its neuroprotective effects A meta-analysis of 24 cohort studies by the same author again reported no change in outcome based on water temperature Children who were submerged for less than minutes generally had good outcome, and those submerged for more than 25 minutes invariably died Shorter emergency medical services arrival time was also associated with favorable outcome This meta-analysis, however, found no correlation between age and outcome Management Because the full extent of CNS injury cannot be adequately determined immediately after the rescue, all drowning victims should receive aggressive basic and advanced life support at the site of the accident and in the emergency department It cannot be overemphasized that the major determinant of survival and maximal brain salvage is prompt and effective management of hypoxemia and acidosis In this context, the management in the immediate post-drowning period is of paramount importance The success or failure of cardiopulmonary resuscitation (CPR) at the site of the accident often determines the outcome.61,62 In a study of more than 900 drowning victims, neurologically favorable survival was associated with bystander-administered CPR as well as witnessed drowning.63 The issue of the duration of submersion in relation to the success of resuscitation is often raised Although asphyxia for longer than minutes frequently results in significant brain injury, this should not be a consideration in deciding whether or not to initiate on-site resuscitation The emotional excitement surrounding the accident makes it difficult to accurately estimate the duration of hypoxia Management at the Scene Ensuring the adequacy of the airway, breathing, and circulation is the goal of basic life support after the initial rescue In cases of inadequate airway and cardiopulmonary status, CPR must be instituted immediately The fundamentals of basic life support are the same after drowning as for any other situation requiring CPR; however, some practical aspects are worth considering Unlike the out-of-hospital cardiac arrests in adults, cardiac arrests from drowning in children are initiated by hypoxia due to disconnection of atmosphere from the airways and lungs Therefore, it is important that CPR is performed in the traditional airwaybreathing-circulation (ABC) rather than circulation-airwaybreathing (CAB) sequence.64 Although in recent years there has CHAPTER 115 Drowning been a push for chest compression–only CPR for out-of-hospital cardiac arrests, rescue breathing as well as chest compressions is essential for successful resuscitation.65 The aim of resuscitation at the scene is to prevent irreversible tissue injury from prolonged hypoxia and ischemia.66 After ensuring a safe environment for a rescue attempt and calling for help, the victim should be removed from the water as soon as possible Wet clothing should be removed to prevent heat loss Less than 0.5% of drowning victims sustain cervical spine injuries; thus, application of cervical spine precautions is not routinely indicated Cervical spine immobilization in the water is indicated when head and neck injury is strongly suspected, such as in accidents involving diving, waterskiing, and surfing.67 In such situations, the preferred airway opening maneuver is anterior displacement of the jaw, rather than extension of the neck If breathing is either absent or agonal, rescue breathing should be performed even while the victim is in the water if possible, either via bag-valve-mask if available or by mouth-to-mouth Chest compressions should not be attempted in water because they are ineffective and waste valuable time.68 After the victim is removed from the water and placed on a hard board, chest compressions should be given at a rate of 100 per minute with a ratio of 15:2 If available, an automatic defibrillator should be applied to detect a shockable rhythm and defibrillate if necessary Prolonged attempts to remove water from the lungs are futile and may hinder ongoing ventilatory support Heimlich and Patrick have recommended the use of subdiaphragmatic pressure in drowning victims to remove water from the airway,69 but this practice is ill advised In addition to the fact that most drowning victims aspirate relatively small amounts of water, there is no evidence to suggest that the Heimlich maneuver can remove aspirated fresh water or pulmonary edema fluid.62 On the other hand, such patients frequently swallow large amounts of water Consequently, increased abdominal pressure may result in regurgitation of gastric contents into the oropharynx and aspiration into the tracheobronchial tree.70 Any debris observed in the oropharynx should be removed before initiation of mouth-to-mouth breathing Presence of airway obstruction caused by a foreign body should be suspected if effective chest expansion cannot be accomplished with appropriate ventilatory technique A subdiaphragmatic thrust in such a situation would be indicated As soon as the equipment becomes available, ventilation with 100% oxygen via bag-valve mask device should be initiated for patients who are not breathing adequately Pressure used during resuscitation to inflate the lungs of drowning victims may have to be higher than anticipated because of reduced compliance of the edematous lungs A PEEP valve should be used if available Overinflation should be avoided, however, because this can lead to pulmonary barotrauma and overdistention of the stomach with regurgitation and aspiration of gastric contents In patients who are too obtunded to maintain airway protection, exhibit hypoxia, or otherwise unable to maintain oxygenation despite bag-valve mask ventilation, endotracheal intubation should be performed Emergency Department Evaluation and Stabilization As with any form of accidental injury, other forms of associated trauma must be considered Children who slip and fall into the pool may sustain external head injury, such as abrasions, lacerations, and contusions Occasionally, profuse bleeding from scalp lacerations may be sufficient to aggravate hypovolemic shock In bathtub drowning, or in instances in which child abuse is 1343 suspected, fractures and other evidence of previous injury should be looked for In adolescent victims, drowning is frequently associated with illicit drug or alcohol use When appropriate, urine and blood toxicology tests should be performed Spinal injuries should be suspected in diving, water-skiing, and surfing accidents involving young adults.62 The need for hospitalization should be determined by the severity of the drowning episode and clinical evaluation All patients with a history of drowning should be observed in the emergency department for at least to hours in case they were to develop respiratory distress Those with insignificant history and normal physical examination may be safely released.71 Patients with respiratory symptoms, decreased O2 saturation indicated by pulse oximetry or blood gas determination, and altered sensorium should be hospitalized Although the Glasgow Coma Scale was originally designed for use in head trauma, it has been routinely used to assess hypoxic encephalopathy in drowning Maintaining adequate airway, respirations, and peripheral perfusion with continued attention to oxygenation, ventilation, and cardiac performance should take priority Electrocardiographic monitoring and arterial blood gas determination should be performed as soon as possible Ventricular dysrhythmias, asystole, and hypotension may be encountered during the early resuscitation phase The standard CPR techniques also apply to the drowned child Patients with respiratory acidosis and hypoxemia, and those who are unconscious with significant respiratory distress or poor respiratory efforts, require intubation and mechanical ventilation Early use of PEEP is effective in reversing hypoxemia Because pulmonary edema is not caused by hypervolemia in drowning, diuretics are not helpful In addition, they may exacerbate the prevalent hypovolemia Therefore, pulmonary edema after near-drowning is best treated mechanically with positivepressure breathing and PEEP rather than diuretics Hypovolemia is commonly encountered in the early resuscitation phase Isotonic crystalloids (20 mL/kg) or colloids (10 mL/kg) infused over 15 to 20 minutes should be used for intravascular volume expansion Additional volume expansion can be carried out based on clinical and hemodynamic status Administration of large amounts of hypotonic fluid is contraindicated because such solutions are ineffective for intravascular volume expansion Furthermore, the resultant decrease in serum osmolality may exacerbate cerebral edema In the face of continued hypotension and/or impaired peripheral perfusion after appropriate intravascular volume expansion, inotropic/vasopressor support may be necessary Central venous pressure monitoring is extremely helpful for ongoing assessment and management of intravascular volume Metabolic acidosis resolves with improvement of oxygenation and tissue perfusion Radiologic studies should include a chest radiograph to determine the presence or absence of pneumothorax or pneumomediastinum Unless head injury is suspected, a computed tomography scan of the head is usually not necessary because early findings are often normal even in the face of severe hypoxic damage.72 Prevention and treatment of hypoglycemia is extremely important It is reasonable to maintain blood sugar between 80 and 160 mg/dL The issue of controlling body core temperature also deserves mention Therapeutic hypothermia after pediatric cardiac arrest has been proven to be of no benefit.73 However, there may be special considerations in drowning victims since most are relatively hypothermic at the time of rescue After return of spontaneous circulation, a reasonable approach is to not rewarm the victim aggressively as long as the core temperature is between 32°C and 1344 S E C T I O N X I I Pediatric Critical Care: Environmental Injury and Trauma 34°C Rewarming should occur at a rate no greater than 0.5°C per hour Hyperthermia (.37°C), on the other hand, must be prevented or treated aggressively if present.74,75 Severe bradycardia and intense vasoconstriction associated with marked hypothermia (,32°C) may make drowning victims appear dead However, resuscitative efforts should be continued while normalizing body temperature Management in the Intensive Care Unit The drowning victim can sustain insults to many organ systems, including the brain, lungs, cardiovascular system, liver, and kidneys Since the major contributor to mortality and long-term morbidity is cerebral hypoxic-ischemic injury, management in the ICU should focus on supporting these organ systems as they relate to the brain Continued attention to oxygenation and ventilation status and cardiac performance is essential ARDS can occur as a result of aspiration injury, pneumonia, and surfactant deficiency or dysfunction Both hypoxemia and hyperoxemia have been associated with poor outcome after cardiac arrest Maintenance of O2 saturation between 94% and 98% and Pao2 between 70 and 100 are reasonable goals The cerebral vasculature of the injured brain is reactive to changes in Paco2 Hypercapnia increases cerebral blood volume and can raise ICP Conversely, arterial hypocapnia decreases CBF and therefore cerebral O2 delivery Thus, ventilation should be titrated to achieve Paco2 around 40 torr To monitor these effects, arterial and central venous pressure monitoring are necessary in most patients who require intensive care A useful parameter to monitor is mixed venous O2 saturation (Svo2) Provided that arterial O2 content and O2 consumption remain constant, Svo2 is a useful indicator of changes in cardiac output The need for endotracheal intubation and different ventilatory strategies should be determined on an individual basis and by clinical judgment Respiratory acidosis, PaO2 less than 60 torr in Fio2 greater than 0.5, clinical signs of impending respiratory fatigue, and depressed level of consciousness are the most common indications for mechanical ventilation Lung injury may not peak until at least 24 hours; thus, weaning from mechanical ventilation should not occur before then Early use of PEEP and supplemental O2 are extremely effective in reversing hypoxemia The goal of mechanical ventilation is to provide adequate gas exchange to ensure tissue viability while minimizing the inevitable ventilator-associated injury from oxytrauma, barotrauma, volutrauma, and ineffective tracheobronchial toilet Ventilatory strategy should take into account the major alterations in pulmonary mechanics As noted earlier, most children who drown have decreased FRC, compliance and time constant and increased critical opening pressure Salutary effects of PEEP are from maintaining alveolar stability, alveolar recruitment, and increasing FRC It stabilizes the relatively softer chest wall of a child, thus minimizing chest wall recoil and further decrease in FRC PEEP also displaces intraalveolar water into interstitial and perilymphatic spaces, resulting in decreased venous admixture and improved compliance Excessive PEEP can result in decreased venous return and cardiac output, pulmonary overdistension and decreased compliance, and barotrauma Maintenance of normovolemia is an important consideration in patients receiving PEEP Furthermore, excessive PEEP can decrease cerebral venous drainage and increase cerebral blood volume and ICP Overdistention can also impair ventilation, and the subsequent increase in partial pressure of carbon dioxide (Pco2) can increase ICP Thus, PEEP should be titrated to maintain lung recruitment, ventilation, and oxygenation while maintaining hemodynamics The pulmonary management of pediatric drowning victims should follow the same standard approach as in other children with acute lung injury and ARDS: low Vt (6–7 mL/kg), lung recruitment with PEEP, and titration of Fio2 to achieve adequate O2 delivery We recommend pressure-controlled ventilation with a relatively low peak airway pressure and prolonged inspiration while still allowing adequate time for complete exhalation Alternatively, pressure-regulated volume control mode can also be used to deliver a preset Vt with minimum possible inflation pressure The level of PEEP can be optimized by gradual increments depending on its effects on increasing Pao2/Fio2 ratio Optimal PEEP as evidenced by improvement in dynamic compliance can be determined by measuring exhaled Vt at varying levels of PEEP When PEEP exceeds critical opening pressure or the lower inflection point on the pressure/volume curve, dynamic compliance improves Ventilatory rate, inspiratory/expiratory times, and peak airway pressures can also be adjusted according to their effects on dynamic compliance and by ascertaining the return of expiratory flow to baseline In patients without CNS injury and intracranial hypertension, the technique of permissive hypercapnia can be used to minimize barotrauma in a patient with ARDS This involves using lower inflation pressures or Vt and accepting higher levels of Pco2 as long as pH remains near normal High-frequency ventilation is another strategy that can be used in the management of hypoxic respiratory failure This mode of ventilation uses a relatively high mean airway pressure while minimizing excessive fluctuations in pressures during the respiratory cycle High-frequency ventilation is a safe and effective modality in the treatment of severe acute respiratory failure that is unresponsive to conventional mechanical ventilation.76,77 While extracorporeal life support (ECLS) has been used for rewarming in patients with severe hypothermia following drowning in cold water, the routine use of ECLS for the treatment of ARDS associated with drowning is less clear The presumed benefit of ECLS is the provision of lung rest to mitigate barotrauma and O2 toxicity in patients who not improve despite maximum ventilatory support Criteria for ECLS in drowning with refractory cardiovascular or respiratory dysfunction should be similar to other disease states There is no evidence to suggest that “prophylactic” antibiotics help prevent drowning-associated pneumonia; in addition, they may lead to the selection of resistant organisms.78 Furthermore, drowning in swimming pools rarely results in pneumonia.79 However, fulminant S pneumoniae bacterial sepsis and pneumonia have been described shortly after a severe drowning injury Therefore, it is reasonable to institute broad-spectrum antibiotic therapy in patients with positive sputum cultures, fever, sepsis, or severe cardiopulmonary deterioration, especially when this occurs after a period of stability.80 CNS injury is by far the most important cause of death and long-term functional impairment among the immediate survivors of drowning accidents Studies have failed to demonstrate beneficial effects in improving outcome of various cerebral protective strategies, such as therapeutic hypothermia, ICP control, corticosteroids, and barbiturate coma Our experience suggests that significant intracranial hypertension is not commonly encountered in the early postdrowning period, whereas late, uncontrollable intracranial hypertension carries an unfavorable prognosis.81 Additionally, satisfactory control of intracranial hypertension is not necessarily associated with improved outcome.81–83 It appears that CHAPTER 115 Drowning the occurrence of cerebral edema and intracranial hypertension to days after drowning is a reflection of the early hypoxic injury rather than a manifestation of a reversible process Late, persistent intracranial hypertension associated with a comatose state is of ominous significance and is almost always associated with an unfavorable outcome.81 The most practical tool of neuromonitoring is the standard neurologic examination The vast majority of patients who are awake and interactive in the emergency department survive neurologically intact Admission neurologic examination by itself is not predictive of outcome However, persistent absence of cognitive function 48 to 72 hours after the drowning episode is of grave prognostic significance Large and unreactive pupils portend a severe hypoxic ischemic injury and a poor neurologic prognosis Components of the examination that should be performed serially include pupillary reactivity, level of consciousness, brainstem reflexes, and motor function The use of ICP monitoring in children with hypoxic-ischemic encephalopathy after drowning is not recommended The emphasis of management of a comatose child in the immediate post-drowning period should be on maintaining adequate oxygenation/ventilation, O2 delivery, and avoidance of hypotonic fluid overload Pathophysiologic changes from asphyxia—as well as various nonindicated therapies aimed at cerebral salvage, such as barbiturates and osmotic diuresis—adversely affect myocardial performance.84 Cardiovascular support with maintenance of intravascular volume and the use of inotropic agents is often necessary to maintain optimum organ perfusion in patients who have sustained a significant hypoxic-ischemic insult The neuroprotective properties of hypothermia that have been extensively demonstrated in laboratory studies suggest potential merits as a therapy in some children, including victims of drowning A randomized controlled trial of therapeutic hypothermia has shown benefits in neonatal hypoxic-ischemic encephalopathy.85 Although therapeutic hypothermia has been shown to be effective in neonatal hypoxic-ischemic injury, studies in pediatric drowning showed that not only did hypothermia not improve outcome, it increased infectious complications, and improved survival to merely a vegetative state.82,86,87 In cases of cold-water drowning, although the patient should be actively warmed to prevent arrhythmias and secondary infections, once a core body temperature of 30°C is achieved, warming should not exceed 0.5°C per hour to prevent rises in CBF and ICP, ischemia/reperfusion injury, and fever Prognosis The outcome of drowning victims depends largely on the success of resuscitative measures at the scene of injury and the duration of submersion Survival is extremely poor among drowning victims who have sustained cardiac arrest and is comparable to other causes of out-of-hospital cardiac arrest.88 Other markers of poor outcome in pediatric drowning victims include generalized edema89 and respiratory arrest.90 Patients who are successfully resuscitated and who are conscious on arrival at the hospital have an excellent chance of intact survival.61,91,92 Patients who have a witnessed arrest are more likely to survive, presumably due to more rapid resuscitation A recent observational study of 131 children admitted to an ICU after drowning found an excellent recovery rate of 96% after witnessed drowning versus 69% when unwitnessed Of children who required CPR, epinephrine, and intubation, 96% had poor outcomes Other predictive factors were pH less than 7.1 and initial Glasgow Coma Scale score of less than 5.93 1345 A secondary analysis of children of the Therapeutic Hypothermia after Pediatric Cardiac Arrest (THAPCA) trial who experienced out-of-hospital cardiac arrest due to drowning found significant decreases in all aspects of behavioral and cognitive testing at 1-year follow-up.86 In this study, enrolled children were comatose on presentation and had received at least minutes of chest compressions Patients were randomly assigned to either a normothermia or hypothermia group There was no difference between groups in mortality or neurobehavioral testing at 1-year followup, presenting the strongest evidence to date that therapeutic hypothermia does not improve outcome after drowning All patients enrolled who required CPR more than 30 minutes either died or had severe disability, consistent with published literature.94 Our experience suggests that the absence of cognitive function 72 hours after the hypoxic episode is strongly associated with either death or survival in a persistent vegetative state.81 Because the majority of children who drown are previously healthy, they may represent a subpopulation of children who have better outcome after cardiac arrest.39,95 Another secondary analysis was done using data from the previously described THAPCA trial, comparing drowning victims to children who had been in cardiac arrest from other respiratory causes.96 The children who drowned had a significant decrease in neurobehavioral and cognitive function However, loss of function was less than that experienced by children who had been in hypoxic arrest from other causes These differences were present in categories of cognition, adaptive behavior composite scores, communication, and motor function There was a broad range of function and some positive results, with 28% of drowning victims having average or above cognitive scores Children overall of younger age and who received few doses of epinephrine scored higher on functional and cognitive testing The children in the “other” group had more premorbid conditions that likely affected their outcome A study of long-term follow-up to 14 years after drowning of 21 drowned and resuscitated children admitted to the PICU found that 57% had neurologic dysfunction and 40% had low full-scale intelligence quotient.97 This study included children who had both prolonged submersion more than minutes and those with briefer submersion times who were revived on the scene Children who had normal IQ had an average submersion time of minutes versus 7.5 minutes for those with low IQ The most common motor disturbances were coordination and fine motor skills Length of submersion, need for ongoing CPR, mechanical ventilation, and longer PICU stay were associated with worse outcome Though there have been several case reports of patients receiving ECLS and rewarming who have recovered with good neurologic outcome,98,99 most drowned children with prolonged cardiac arrest and hypothermia have poor chance of functional recovery The data are scarce, consisting of small retrospective studies of to 13 children, with reports of good long-term neurologic recovery ranging from 11% to 16%.100–102 A large retrospective study using the Extracorporeal Life Support Organization (ELSO) registry measured survival of drowned patients who required ECMO Of the 247 patients, most (198) were children and overall survival was 51% This encompassed all indications for ECMO, including those patients who had not been in cardiac arrest but required venovenous cannulation for respiratory failure When looking at the group required that ECLS for refractory cardiac arrest (extracorporeal cardiopulmonary resuscitation [ECPR]), the survival was still an encouraging 23%, much higher than previous reports.103 However, functional recovery was not 1346 S E C T I O N X I I Pediatric Critical Care: Environmental Injury and Trauma evaluated and it is unclear what the neurologic outcome was for survivors Patients who required ECPR were more likely to be hypothermic and had a higher mortality rate ECLS may be a life-saving option for select patients with hypothermia, which in and of itself may cause cardiac arrhythmias and coagulopathy Shock and disseminated intravascular coagulopathy may further complicate transitioning to extracorporeal support In centers experienced with extracorporeal cannulation in children, ECLS may be considered as a salvage therapy However, the risk of bleeding complications and severity of organ dysfunction must be carefully weighed prior to cannulation Key References Burke CR, Chan T, Brogan TV, et al Extracorporeal life support for victims of drowning Resuscitation 2016;104:19-23 El Sibai R, Bachir R, Sayed M El Submersion injuries in the United States: patients characteristics and predictors of mortality and morbidity Injury 2018;49(3):543-548 Franklin RC, Pearn JH, Peden AE Drowning fatalities in childhood: the role of pre-existing medical conditions Arch Dis Child 2017;102(10): 888-893 Idris AH, Bierens Joost JLM, Perkins GD, et al 2015 revised Utsteinstyle recommended guidelines for uniform reporting of data from drowning-related resuscitation: an ILCOR advisory statement Resuscitation 2017;118:147-158 Moler FW, Hutchison JS, Nadkarni VM, et al Targeted temperature management after pediatric cardiac arrest due to drowning: outcomes and complications Pediatr Crit Care Med 2016;17(8):712-720 Mtaweh H, Kochanek PM, Carcillo JA, Bell MJ, Fink EL Patterns of multiorgan dysfunction after pediatric drowning Resuscitation 2015;90:91-96 Quan L, Mack CD, Schiff MA Association of water temperature and submersion duration and drowning outcome Resuscitation 2014; 85(6):790-794 Quan L, Bierens Joost JLM, Lis R, et al Predicting outcome of drowning at the scene: A systematic review and meta-analyses Resuscitation 2016;104:63-75 Salas Ballestin A, de Carlos Vicente JC, Juan GF, et al Prognostic factors of children admitted to a pediatric intensive care unit after an episode of drowning Pediatr Emerg Care 2018 Epub ahead of print Tobin JM, Ramos WD, Pu Y, Wernicki PG, Quan L, Rossano JW Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning Resuscitation 2017;115:39-43 Topjian AA, Berg RA, Bierens Joost JLM, et al Brain resuscitation in the drowning victim Neurocrit Care 2012;17(3):441-467 The full reference list for this chapter is available at ExpertConsult.com ... anterior displacement of the jaw, rather than extension of the neck If breathing is either absent or agonal, rescue breathing should be performed even while the victim is in the water if possible,... attempt and calling for help, the victim should be removed from the water as soon as possible Wet clothing should be removed to prevent heat loss Less than 0.5% of drowning victims sustain cervical... Drowning been a push for chest compression–only CPR for out-of-hospital cardiac arrests, rescue breathing as well as chest compressions is essential for successful resuscitation.65 The aim of resuscitation