The signs and symptoms of near-drowning can differ widely from person to person. Some victims are alert but agitated, while others are comatose. Breathing may have stopped, or the victim may be gasping for breath. Bluish skin (cyanosis), coughing, and frothy pink sputum (material expelled from the respiratory tract by coughing) are often observed. Rapid breathing (tachypnea), a rapid heart rate (tachycardia), and a low-grade fever are common during the first few hours after rescue. Conscious victims may appear confused, lethargic, or irritable.

Diagnosis

Diagnosis relies on a physical examination of the victim and on a wide range of tests and other procedures. Blood is taken to measure oxygen levels and for many other purposes. Pulse oximetry, another way of assessing oxygen levels, involves attaching a device called a pulse oximeter to the patient's finger. An electrocardiograph is used to monitor heart activity. X rays can detect head and neck injuries and excess tissue fluid (edema) in the lungs.

Treatment

Treatment begins with removing the victim from the water and performing cardiopulmonary resuscitation (CPR). One purpose of CPR--which, of course, should be attempted only by people trained in its use--is to bring oxygen to the lungs, heart, brain, and other organs by breathing into the victim's mouth. When the victim's heart has stopped, CPR also attempts to get the heart pumping again by pressing down on the victim's chest. After CPR has been performed and emergency medical help has arrived on the scene, oxygen is administered to the victim. If the victim's breathing has stopped or is otherwise impaired, a tube is inserted into the windpipe (trachea) to maintain the airway (this is called endotracheal intubation). The victim is also checked for head, neck, and other injuries, and fluids are given intravenously. Hypothermia cases require careful handling to protect the heart.

In the emergency department, victims continue receiving oxygen until blood tests show a return to normal. About one-third are intubated and initially need mechanical support to breathe. Rewarming is undertaken when hypothermia is present. Victims may arrive needing treatment for cardiac arrest or cardiac dysrhythmias. Comatose patients present a special problem: although various treatment approaches have been tried, none have proved beneficial. Patients can be discharged from the emergency department after four to six hours if their blood oxygen level is normal and no signs or symptoms of near-drowning are present. But because lung problems can arise 12 or more hours after submersion, the medical staff must first be satisfied that the patients are willing and able to seek further medical help if necessary. Admission to a hospital for at least 24 hours for further observation and treatment is a must for patients who do not appear to recover fully in the emergency department.

Prognosis

Neurological damage is the major long-term concern in the treatment of near-drowning victims. Patients who arrive at an emergency department awake and alert usually survive with brain function intact, as do about 90% of those who arrive mentally impaired (lethargic, confused, and so forth) but not comatose. Death or permanent neurological damage is very likely when patients arrive comatose. Early rescue of near-drowning victims (within 5 minutes of submersion) and prompt CPR (within less than 10 minutes of submersion) seem to be the best guarantees of a complete recovery. An analysis of 715 patients admitted to emergency departments in 1971-81 revealed that 69% recovered completely, 25% died, and 6% survived but suffered permanent neurological damage.

Experts are constantly warning parents to be vigilant when their kids are near water of any kind. A moment of inattention is all it takes for disaster to strike. Here's a look at what you should be aware of when your young child is in the tub.

Presence Of Mind
Never leave a baby alone in a bathtub for even a second. Always keep the baby in arm's reach. Don't leave a baby in the care of another young child. Never leave to answer the phone, answer the door, to get a towel or for any other reason. If you must leave, take the baby with you.

Don't Trust The Devices
A baby bath seat isn't a substitute for supervision. A bath seat is a bathing aid, not a safety device. Babies have slipped or climbed out of bath seats and drowned.

Be Careful Of The Surfaces
Never use a baby bath seat in a non-skid, slip-resistant bathtub because the suction cups won't adhere to the bathtub surface or can detach unexpectedly. Babies could tip over and drown.

It's Not Just The Tub
Never leave a bucket containing even a small amount of liquid unattended. When finished using a bucket, always empty it immediately. Don't leave buckets outside where rainwater can collect in them. Young children can drown in a small amount of water. Keep entrances to swimming pools and hot tubs locked and keep infants away from the areas.

Watch The Other Hidden Hazards
Keep the toilet lid down to prevent access to the water and consider using a toilet clip to stop young children from opening the lids. Consider placing a latch on the bathroom door out of reach of young children.

Brain injury - Dysautonomia

Our bodies have many automatic functions that are controlled by the brain. After a severe brain injury, our ability to control these automatic functions can be reduced.

What is it?

Automatic functions include breathing, temperature control, heart rate and blood pressure. There is a delicate balance between all of these functions, and they are usually adjusted automatically. We are only aware of it when something unusual happens (eg when we are sick we can get a high temperature).

Sometimes, after a severe brain injury, our ability to control these automatic functions is disturbed. There can be under or over-activity. The brain can respond to a gentle stimulus, like being touched or hearing a noise, with an exaggerated reaction (eg lots of body movement, high temperature, high blood pressure or severe sweating etc). This may occur 'out of the blue' without any obvious cause. This is called dysautonomia, meaning disordered autonomic function.

Quite often the signs of dysautonomia may not show until after ventilation in Intensive Care has been ceased, and sedation such as morphine has been stopped. Sedatives can help treat the syndrome, but often other treatment is needed. Children cannot stay heavily sedated for very long periods or other complications will also develop.

The over-activity often occurs in episodes or 'bursts' and there may be an obvious trigger to start them, such as a painful stimulus like taking blood tests, or there may be no trigger at all that we can identify. These episodes usually start suddenly and stop suddenly, like turning a tap on and off. Several or many episodes may occur in one day (this is sometimes called 'storming'). The bedside charts and parents observations may help to work out some triggers.

What are the features?

• Elevated temperature
• Profuse sweating
• Increase in heart rate
• Increase in respiratory rate and laboured breathing
• Agitation
• Increased muscle stiffness (spasticity)
• Large pupils

What is the treatment?

A variety of actions may be useful in treating dysautonomia.

• Provide a quiet and calm environment for the child, with soft lighting and little stimulation.
• Allow them plenty of rest and sleep.
• Restrict visitors - with few people allowed in the room at any one time (usually a maximum of 3-4 people).
• Placing the child in a comfortable position (often bent a little at the hips and knees).
• Give them plenty of fluids to prevent dehydration and provide nutrition (this may need to be given via a tube or through an intravenous drip).
• Appropriate treatment of pain, fractures, skin wounds, urine infections or constipation.

Medications

One or more drugs are often needed. It takes quite a long time to achieve the right combination of drug treatments before the dysautonomia is controlled. Then with time, the body learns to control the automatic responses. Medicines usually have to be reduced slowly once control seems reasonably good, as stopping too quickly may lead to a relapse. During this time careful fluid and nutrition balance are very important.

• Valium (Diazepam) to help with muscle stiffness and used as a mild sedative.
• Propranolol, Clonidine, or Bromocriptine can help control pulse, sweating, blood pressure and high temperatures.
• Baclofen or Dantrolene may be useful to treat the muscle stiffness (spasticity).

All drugs have some side effects and the effects of any drug combination must be carefully checked, by looking at blood test results. Dysautonomia usually settles with time, as the child's brain injury symptoms settle. This can take many weeks or a few days. The problem does not recur later in the child's life.

Key points to remember

• Dysautonomia occurs when our ability to control automatic body functions is disturbed.
• Dysautonomia can occur after brain injury.
• Medications and other treatments can be used to reduced dysautonomia.
• Dysautonomia usually settles with time.

For more information

Paediatric Rehabilitation Service, Royal Children's Hospital
Ph:  61-3-9345-5283
Fax:  61-3-9345-5913

rehab.service@rch.org.au