Snapshot A 5-year-old previously healthy male is brought to the ED after falling into a freshwater lake while hiking with his father. He was unaccounted for 15 minutes until his body was found floating face down in the water. He is cyanotic, pulseless, and apneic with fixed and dilated pupils. Temporal temperature is 80°F (26.7°C). Active passive and active rewarming protocols are employed. CPR has been ongoing since he was found. The patient is intubated and mechanically hyperventilated for reduction of intracranial pressure and with high PEEP settings for maximal alveolar recruitment. Chest radiograph reflects no evidence of pulmonary edema. ABG measurements reflect gradually correcting hypoxemia but persistent lactic acidosis. Intraosseous access is established for fluid administration. The patient is admitted to the PICU. Introduction 3rd most common cause of accidental death in United States most common in children < 4 years and teenagers Risk factors inability to swim/inadequate supervision substance use hypothermia seizure disorder known/unknown cardiac arrhythmia Presentation Physical exam vital signs: hypotension, hypothermia lungs: rales (ARDS, pulmonary edema), decreased breath sounds (pneumothorax) CV: murmurs, dysrhythmia neuro: GCS score, pupil size, focal deficits hypoxemia can easily lead to hypoxic encephalopathy C-spine injuries (especially with history of diving into shallow water) scuba-related injuries barotrauma air emboli Evaluation and Management Primary and secondary survey with resuscitation best next step: rescue breaths before chest compressions deviates from compression-only rescue because ventilation is most important initial treatment if pulseless and hypothermic, rewarm body first search pulse for full 1 minute before commencing ACLS algorithm intubate and mechanically ventilate early in apneic/unconscious patient dysrhythmia usually corrected with resolution of hypoxemia, hypothermia, acidosis vomiting very common NG suction to prevent aspiration convulsions usually corrected with oxygen support if refractory, use benzodiazepine (diazepam) Investigations labs: CBC, electrolytes, BUN/Cr, ABG, urinalysis imaging: CXR cardiac: EKG Disposition non-significant immersion: observation in ED, then discharge significant but asymptomatic immersion: admit for observation due to potential delayed onset of pulmonary edema CNS symptoms +/- hypoxemia: admit severe hypoxemia, loss of consciousness: ICU References