A 3-year-old girl is brought to the emergency department by ambulance after being found unresponsive in her family's pool. She and her mother had been playing on the back porch until the mother went inside "for less than 1 minute" to answer the phone. When the mother came back outside, she found the girl floating face down in the pool. The mother immediately pulled her out and began rescue breathing, and the neighbor called an ambulance. The emergency medical team arrived 5 minutes later, at which time the patient was awake, alert, and coughing. She is an otherwise healthy girl with no prior hospitalizations. The patient lives at home with her parents and 16-year-old brother. On arrival, temperature is 36.7 C (98 F), blood pressure is 90/50 mm Hg, pulse is 104/min, and respirations are 20/min; pulse oximetry is 99% on room air. Physical examination shows a smiling, alert young girl running around the room. Heart rate and rhythm are regular, and the lungs are clear to auscultation with no adventitious sounds or increased work of breathing. Which of the following complications is this patient at greatest risk of developing?

Question

A 3-year-old girl is brought to the emergency department by ambulance after being found unresponsive in her family's pool.  She and her mother had been playing on the back porch until the mother went inside "for less than 1 minute" to answer the phone.  When the mother came back outside, she found the girl floating face down in the pool.  The mother immediately pulled her out and began rescue breathing, and the neighbor called an ambulance.  The emergency medical team arrived 5 minutes later, at which time the patient was awake, alert, and coughing.  She is an otherwise healthy girl with no prior hospitalizations.  The patient lives at home with her parents and 16-year-old brother.  On arrival, temperature is 36.7 C (98 F), blood pressure is 90/50 mm Hg, pulse is 104/min, and respirations are 20/min; pulse oximetry is 99% on room air.  Physical examination shows a smiling, alert young girl running around the room.  Heart rate and rhythm are regular, and the lungs are clear to auscultation with no adventitious sounds or increased work of breathing.  Which of the following complications is this patient at greatest risk of developing?

Quizplus · Accepted Answer

11ec25c8_d1f7_12c8_bc81_6d0412b5fd9d_MD0003_00 Drowning, defined as respiratory impairment due to submersion in liquid, is a leading cause of accidental death in children. Children age <5 are at increased risk due to inadequate supervision around pools/bathtubs, and males age 15-25 are also at high risk due to risk-taking behaviors and concomitant drug or alcohol use. Complications of drowning are a result of hypoxemia from fluid aspiration. The aspirated liquid washes out alveolar surfactant, causing pulmonary edema, respiratory insufficiency, and acute respiratory distress syndrome (ARDS). Although this patient has a good prognosis because she was submerged briefly, resuscitated quickly, and is now back to baseline activity, she is still at risk for ARDS despite currently being asymptomatic. ARDS can develop insidiously over the next 72 hours. She should be admitted to the hospital and monitored closely for dyspnea, cough, cyanosis, and crackles. (Choice A) Arrhythmias (eg, sinus tachycardia, sinus bradycardia, atrial fibrillation) can occur in response to hypothermia and hypoxemia but are typically present on initial presentation. This patient has a normal cardiac examination and low risk of developing an arrhythmia. (Choice B) Cerebral edema and increased intracranial pressure from hypoxic brain injury due to drowning are more likely with a prolonged submersion time (>5 min) or when resuscitative efforts are delayed or prolonged. This patient's submersion time and resuscitation were brief. (Choice C) Hypothermia triggers peripheral vasoconstriction, leading to perceived volume overload and decreased antidiuretic hormone production; the resultant diuresis leads to hypotension and hypovolemic shock. This patient has normal blood pressure, pulse, and temperature. (Choice D) Pneumonia can complicate drowning when the patient is submerged in contaminated water (eg, lake) but is less likely following submersion in a swimming pool. Educational objective: Drowning is defined as respiratory impairment after submersion in liquid. Aspirated liquid causes hypoxemia and can wash out pulmonary surfactant, leading to insidious onset of acute respiratory distress syndrome. References: Patterns of multiorgan dysfunction after pediatric drowning. (http://www.ncbi.nlm.nih.gov/pubmed/25703785)

A 3-Year-Old Girl Is Brought to the Emergency Department by Ambulance