foul play?

[venez]

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what do you think about this--a four year old with no past medical history drowing in a bath tub? first to arrive on the seen was police who attached him to AED--shocked him once--resucitated him in ED but died the next day. he had no apparent head trauma from a fall. i never heard the autopsy reports--he was transferred to a peds trauma hospital. also is it common to go into vfib from drowing? and how long could a ped patient maintain vfib before cardiac arrest?

 

[Eme-RG-ency]

Near Drowning, found in Vfib, dies next day... sounds like Rhabdomyolysis and ensuing sequelae.

 

[Apollyon]

My first ped code (way back in 1993) was almost exactly what your case was, except it was a 5 y/o boy, and, although we resuscitated him, we did not record a save - just dwindled into asystole and stayed there.

 

[a_ditchdoc]

I may be missing something because I am not at all sure where the Rhabdomyolysis theory came from. I cannot even begin to reason that out. As for the original questions, it is possible to drown in very little water. Most kids do not go into v-fib immediately following an arrest, or sometimes at all. Like the previous poster said, they usually become bradycardic and later asystolic. With oxygenation they are usually responsive to ACLS but it does little for their brain. Also, being in v-fib means that you are in cardiac arrest. The rythm is incapable of producing a pulse.

 

[Eme-RG-ency]

I am assuming you are a physician ditchdoc and know a hell of a lot more about medicine than I do, but I will explain my rationale nontheless.

There are a few cases of rhabdo in near drowning patients in the literature. Enough that its listed as a cause of rhabdo in some sources. If there was foul play as that OP originally suggested, such as child abuse, then one would have further reasoning to consider rhabdo in a differential. He mentioned no head trauma, but could there possibly have been other trauma? He did say no significant PMH, which makes it less likely I suppose.

My suggestion was: Is it possible that the child went into rhabdomyolysis from the near drowning incident? This would place the child at high risk for hyperkalemic arrythmias in the first few hours following the incident. Peak CPK levels would be at 24-72 hours, with potential acute renal failure or DIC in the days following? The OP said the child dies one day later, which leads me to believe it was not the AED shock, nor the original arrythmia that killed him. It would be interesting to hear the cause of death. A sad story for sure.

With respect to the questions of the OP, I suppose I should have addressed them directly. Below is an interesting article from emedicine about near drowning. They report Asystole (55%), V-tach/fib (29%), Bradycardia (16%) as the causes of cardiopulmonary arrest in a near drowning victim. http://www.emedicine.com/emerg/topic744.htm I could not find any info about how long a typical child would be in Vfib before going to asystole.

 

[a_ditchdoc]

I am assuming you are a physician ditchdoc and know a hell of a lot more about medicine than I do, but I will explain my rationale nontheless.

There are a few cases of rhabdo in near drowning patients in the literature. Enough that its listed as a cause of rhabdo in some sources. If there was foul play as that OP originally suggested, such as child abuse, then one would have further reasoning to consider rhabdo in a differential. He mentioned no head trauma, but could there possibly have been other trauma? He did say no significant PMH, which makes it less likely I suppose.

My suggestion was: Is it possible that the child went into rhabdomyolysis from the near drowning incident? This would place the child at high risk for hyperkalemic arrythmias in the first few hours following the incident. Peak CPK levels would be at 24-72 hours, with potential acute renal failure or DIC in the days following? The OP said the child dies one day later, which leads me to believe it was not the AED shock, nor the original arrythmia that killed him. It would be interesting to hear the cause of death. A sad story for sure.

With respect to the questions of the OP, I suppose I should have addressed them directly. Below is an interesting article from emedicine about near drowning. They report Asystole (55%), V-tach/fib (29%), Bradycardia (16%) as the causes of cardiopulmonary arrest in a near drowning victim. http://www.emedicine.com/emerg/topic744.htm I could not find any info about how long a typical child would be in Vfib before going to asystole.

Thanks for the clarification as I was a bit baffled. I am not a physician but a M3 with 14 years of experience as a paramedic. I understand where your reasoning came from but I think you were looking for a zebra. The near drowning cases you point out with rhabdomyolysis are in all likelyhood secondary muscle damage from the thrashing about that can occur when trying to stay afloat. Probably unlikely in a bathtub. The fact that they defibrillated him indicateds that he was probably in v-fib. As I said before, it is unusual for a child with a healthy heart to go directly into v-fib, usually they have brady-arrythmias deterioratig into v-fib or more often, asystole. This makes me believe that he had been in arrest for more than a few minutes. His heart responded to defibrillation and oxygenation but unfortunately, childrens brains are not as resilient as their hearts. Death due to hypoxic brain injury just screams at me. Perhaps my experience stifles my imagination...

 

[Eme-RG-ency]

Thanks for the clarification as I was a bit baffled. I am not a physician but a M3 with 14 years of experience as a paramedic. Perhaps my experience stifles my imagination...

Love the sarcasm... makes me want to reply with, "perhaps you are just an a$$hole."

I will give you credit though... experience is the best teacher. I dont think anyone would argue with that. Hypoxic brain injury is a much better explanation. Thank you for your contribution to my education.

 

[a_ditchdoc]

Love the sarcasm... makes me want to reply with, "perhaps you are just an a$$hole."

I will give you credit though... experience is the best teacher. I dont think anyone would argue with that. Hypoxic brain injury is a much better explanation. Thank you for your contribution to my education.

Sorry, it was not meant as sarcasm. When you see something enough, and it always happens the same way, it makes you stop looking for other things. You're probably much more likely to diagnose an uncommon illness than myself...