CAYD - Olgu 2

A RARE CAUSE OF ARDS: near drowning in detergent and sodium hypo chloride containing solution
Yaratılış Tarihi : 2007-01-22 22:36:25

Yazar : Soysal D*, Yekeler E**, Biçer S***, Çıtak A*, Uzel N*, Uçsel R*, Karaböcüoğlu M*

* Istanbul University, Istanbul Medical Faculty Division of Pediatric Emergency and Intensive
** Istanbul University, Istanbul Medical Faculty, Radiodiagnositic Department
*** Bakırköy Social Security Hospital

Near-drowning continues to be associated with high mortality and morbidity in both children qand adults. With the availability of sophisticated technologies and pediatric ICUs, victims of near-drowning are now more likely to survive. However this improvement in short-term survival of near-drowning, victims after an acute submersion episode has also resulted in an increase of acute respiratory distress syndrome (ARDS) and persistent hypoxic-ishcemic central nervous system (CNS) injury. Therefore, it isimportanat for the acute ICU management of victims of near-drowning but also understqnd the progression of the disease.

We report a patient who had been near-drowned in bucket filled with sodium hypochlorite and detergent containing water.

CASE REPORT:

An 11-months old boy who had been pulled from bucket filled with sodium hypochlorite and detergent containing water. Her mother left the child was behind the bucket. The bucket was approximately one-half full of water. The mother was gone approximately five minutes, nad upon returning she found the child's head in the bucket. Five minutes later, they arrived at the hospital. After the initial resuscitation he was transported to our pediatric intensive care unit.

On physical examination the patient was lethargic, Glasgow coma score was ten. He has cyanosis, with a heart rate 160/minute, respiratory rate 60/minute, temperature 36 ° C, blood pressure 75/40 mm Hg, delayed capillary refill. Oral mucosa was hyperemic, he has hypersalivation. He was tachypneic, respiratory efforts were irregular, has retractions and rales on auscultation. His heart exam was unremarkable. Abdomen was soft and no tender. Tonus was decreased. Pupils were equal and reactive.

He immediately needed intubation and mechanical ventilation because of severe hypoxemia. Initial fluid resuscitation was done. The seizure was observed and treated with anticonvulsants. The chest x-ray showed small patchy diffuse pulmonary infiltrates. Acute respiratory distress syndrome developed on the first day. PaO2/FiO2 was found 80. Low tidal volume high PEEP was applied as mechanical ventilation strategy. But bilateral pneumothorax developed in the second hospitalization day, chest tube inserted. On the 21th hospital day, tracheotomy operation was done because of the weaning difficulty. On the 30th hospital day the patient weaned from the ventilator.

High-resolution computed tomography (HRCT) examination showed patchy ground-glass opacities, parenchymal fibrosis and traction brochiectasis (Figure 1a and 1b). HSCT obtained 11 months later revealed mostly fibrosis (Figure 2). Cranial magnetic resonance imaging (MRI) showed bilateral basal ganglia infarcts.

Tracheotomy was closed 2.5 months after the admission. The patient discharged from the hospital with severe neurological sequelae.

DISCUSSION:

Drowning is a major cause of pediatric unintentional death worldwide. This is a very lethal injury; 50% of pediatric submersion victims die which is the among the highest percentage oh all ruptured injuries. Drowning rates vary with age in discernable percentage. Drowning rates are highest among 15-19 year-olds. As with all injuries males predominate.

Submersion among infants younger than 1 year of age usually occur in bathtubs, 1 to 4 year olds typically fall into swimming pools. Preschoolers are more likely to fall into lakes and rivers. Buckets may be common risk sites. Our patient was 11-months old, male and was near-drowned in bucket.

Hypoxemia has been described as the single most important consequence of near-drowning. Individuals who survive the initial course near-drowning are at risk for the development secondary drowning: the development of ARDS. In our patient additive risk factor for development of ARDS was, near-drowned in water containing sodium hypo chlorite. Household bleaches that contain sodium hypo chlorite and sodium hydroxide are common domestic agents used all around the world, which are frequently ingested by children. Commercial household bleaches are known to have minor adverse effects, but they cause pneumonitis even though they ingested via gastric way. When they aspirate from the respiratory way acute respiratory failure may occur. In household bleaches aspiration , late death occur especially from progressive lung damage.

CNS dysfunction may be secondary to the initial hypoxic injury and may be caused by progressive CNS injury because of post resuscitation. S tudies have results suggest that pupillary unresponsiveness in the emergency department and initial Glasgow Coma Scale score of less than 5 on arrival to the ICU are associated independently with poor CNS outcome. Intact survival is associated with submersion durations fewer than 5 minutes. In our patient submersion duration

Remarkably, submersion injury has received little attention even though the number of drowning in most countries greater than the total number of drowning in most countries . The key to minimizing morbidity and mortality secondary to submersion accidents is successful prevention.

CONCLUSION:

• Many patients who have nearly drowned and who need ventilatory support may develop ARDS.

• Despite agressive care, neurologic injury with long term sequelae secondary to hypoxic ischemic injury remains a major problem in the management of submersion accidents.

• Prevention important link in the chain of survival for the submersion victim.