1. Pediatric Submersion
Peter Antevy MD
Davie Fire Rescue, Medical Director
American Ambulance, Medical Director
Miramar Fire Rescue, Asst. Medical Director
Broward College EMS, Medical Director
JDCH, Pediatric Emergency Medicine

2. Pediatric Submersion
Disclosure
• Pediatric Emergency Standards, Inc.
– Founder and CEO
– Consulting
– Pediatric Resuscitation System

3. Pediatric Submersion

4. Pool Danger
4

5. Pediatric Drowning
Objectives
• Allan’s Story
• Broselow Demo
• Where are kids resuscitated
• Epinephrine administration
• Hypothermia?
• Oxygen (too much vs. too little)
• ABC vs. CAB

6. A Day at the Beach

7. Pediatric Submersion
Prevention
Rescue
Medical

8. A Similar Story
Pregnancy Delivery Life

9. Pediatric Drowning
Allan’s Story

10. Pediatric Drowning
Allan is down
• Recognize - Understand - React
• Will you step in?
• Can you control your adrenaline surge?
• Will you do something wrong?
Do you know the physiology?

11. Pediatric Drowning
Allan is down
• Rescue arrives in 4 minutes
• Child found blue and without a pulse
• CPR ensues
• Child transported rapidly to Joe DiMaggio
Children’s Hospital
He is unconscious

12. Pediatric Drowning
Allan is down
• ED Arrival
– Copious amounts of emesis
– Moderate respiratory distress
– O2 Sat of 92% on 100% non-rebreather
– Minutes later he vomits a frothy pink fluid
What is happening?

13. Pediatric Drowning
ED Management
• Placed on a ventilator
• Labs suggest significant illness
– Oxygen starvation
– Elevated Acid levels
• IV medications & fluid
• Transferred to PICU

14. Pediatric Drowning
PICU Course
• Severe lung swelling at 12 hours
• Significant brain swelling over 24 hours
• Tracheostomy and Gastrostomy tubes
• Multiple specialists involved
• 3 month hospitalization

15. Pediatric Drowning
A Mothers Reflection
• Initial explanation did not sink in
• I was told he didn’t drown, so I thought he’d be
OK
• They asked if I want to disconnect the
ventilator at 48 hours
• Things sunk in at 3 weeks

16. Pediatric Drowning
Allan’s Story

17. Pediatric Drowning
Allan

19. “Pool’s Gold”
• 3 year old male
• Submerged in pool

20. Pediatric Drowning
Let’s Start from the Beginning
You are the Paramedic

21. Pediatric Drowning
Timeline
Child
Child falls poolside EMS ED
into pool No Pulse Arrival Arrival The Variables
- CPR on Scene
- Resus location
- Epinephrine
911 Call - when & where
0 5 min 13 min 22 min
Why is Epinephrine Important?

22. PALS UPDATE
Epinephrine
10 mL

23. PALS UPDATE
Epinephrine
• CPR
• Epinephrine
10 mL

24. Epi in Cardiac Arrest

25. Epi in Cardiac Arrest
11.3
6
1.3
0.6
Epi No Epi Epi No Epi

26. Pediatric Drowning
Critical Minutes
Early
• CPR
• Epinephrine
10 mL

27. Pediatric Drowning
Submersion Time

28. Pediatric Drowning
CPR Duration

29. Pediatric Drowning
ER Resuscitation
• Prolonged resuscitation (ACLS >25 min) of warm
water pediatric drowning victims is NOT indicated
• The longest ED CPR with a good neurologic outcome
was 12 minutes

30. Pediatric Drowning
Bystander CPR
• Family members performed CPR in 20%
of cases
• 65 received bystander CPR prior to
paramedic arrival
• 41/63 breathing and with pulses when
EMS arrived
• All 41 survived to hospital discharge
Sirbaugh (Ann Emerg Med, 1999)

31. Pediatric Drowning
Timeline
Child
Child falls poolside EMS ED
into pool No Pulse Arrival Arrival
911 Call
0 5 min 13 min 22 min
9 Minutes

32. Pediatric Drowning
Back to the Scene
Paramedic Arrival

33. Putting the Tape to the Test
What Really Happens?

34. ACADEMIC EMERGENCY MEDICINE 2012; 19:37–47
• Incorrect Weight Estimates
• Incorrect Broselow Tape Use
• Drug Calculation Errors
- mg to mL conversion
- Wrong mg/kg dose for route
- Math difficult under stress
• IV/IM/IN doses of same drug
different depending on route

35. Ambulance Personnel Perceptions of Near
Misses and Adverse Events in Pediatric
Patients
Cushman October/December 2010, Volume 14 Number 4.
61 Events
12
Peds
8 2 2
Normal Injury Death

36. Family Presence
IT’S NOT THEM
IT’S YOU

37. Is Epinephrine 1:10,000 IV
given to pediatric patients
during out of hospital cardiac
arrest?

38. Epinephrine
Pediatric Cardiac Arrest
100.0
75.0
50.0
25.0 32% 28% 0%
EPI EPI EPI
0
Region 1 Region 2 Region 3
n = 2500 n = 100 n = 200

39. Customizing Resuscitation

41. Pediatric Drowning
Back Even Further
The 911 Phone Call

42. Early
• CPR
• Epinephrine

43. If a 6 Year Old Can Do It
KILOGRAMS

44. Pediatric Drowning
Allan’s Story

45. Bondi Beach Rescue
“Not So Good” CPR on Scene

46. Pediatric Drowning
Treatment
This could be you!

47. PALS UPDATE
Infant CPR

48. PALS UPDATE
Child CPR

49. Pediatric Drowning
CPR
• Lift chin Give 2 breaths
• Check for a pulse
• Chest compressions : 100 times per minute
– 30:2 if one rescuer
– 15:2 if 2 rescuers
• Remember the BeeGees….or Queen

50. CPR “to the beat”

52. Pediatric Drowning
Hypothermia

53. Pediatric Drowning
Hypothermia Update
What is the latest research on
hypothermia in pediatrics?

54. Pediatric Drowning
Oxygen
It’s Good, Right?

66. Pediatric Drowning
ABC or CAB
A B C D
O2 O2

67. 5170 Peds
Non-Cardiac Cardiac OK
Cause of Cause of
Arrest Arrest Hands
Only
8.9% vs 9.9%
71% Totals 29%

68. 5170 Peds
Conventional Hands Only
CPR CPR
7.2% Survival 1.6%

69. Pediatric Drowning
Take Home Points
• Look at Every Step With a Microscope
– 911 Call
– CPR Early (Family and EMS)
– Resuscitation ON SCENE (2 minutes then move)
– Epinephrine ON SCENE (My 6 YO knows the dose!)
– Customize Resuscitation
– Limit Oxygen Toxicity
– Airway Breathing Circulation (NOT CAB)
• Waiting on Hypothermia Data

70. Thank You!
Peter Antevy MD
954-707-2692
pantevy@mhs.net
Handtevy.com

71. Pediatric Submersion
Peter Antevy MD
Davie Fire Rescue, Medical Director
American Ambulance, Medical Director
Miramar Fire Rescue, Asst. Medical Director
Broward College EMS, Medical Director
JDCH, Pediatric Emergency Medicine