• Remove cold, wet clothing
  
• Supply warm blankets
  
• Warm air system
  
• Heating blanket
  
• Infrared radiant lamp

• Warm intravenous fluids to 39°C to prevent further heat loss
  
• Warm ventilator gases to 42°C to prevent further heat loss
  
• Gastric or bladder lavage with normal (physiological) saline at 42°C
  
• Pleural or pericardial lavage
  
• Endovascular warming
  
• Extracorporeal blood rewarming

The temperature is generally allowed to rise by 0.25–0.5°C per hour to reduce haemodynamic instability. Most hypothermic patients are hypovolaemic. During rewarming vasodilatation occurs, resulting in hypotension requiring large quantities of warmed intravenous fluids, while avoiding overfilling and pulmonary oedema. Continuous haemodynamic monitoring is essential.

Therapeutic hypothermia (32–34°C) for at least 24 hours has been shown to improve neurological outcome in some patients and may be of benefit in children who remain comatose.

19.9 SECONDARY SURVEY AND LOOKING FOR KEY FEATURES IN DROWNING

During the secondary survey, the child should be carefully examined from head to toe. Any injury may have occurred during the incident that preceded immersion, including spinal injuries. Older children may have ingested alcohol and/or drugs.

Investigations

• Blood glucose.
  
• Blood gas analysis (preferably arterial) and blood lactate.
  
• Urea and electrolytes.
  
• Coagulation status
  
• Blood and sputum cultures.
  
• Chest X-ray.
  
• ECG.
  
• Lateral cervical spine X-ray or computed tomography (CT) scan.

19.10 EMERGENCY TREATMENT AND STABILISATION IN DROWNING

The brain is the most vulnerable organ for asphyxia, and cerebral impairment occurs before cardiac problems in submersion. Except for early basic life support and possibly therapeutic hypothermia, there are few effective measures for reducing brain damage in drowning.

It is essential to monitor the vital functions closely, especially during the first couple of hours. An early suggestion of respiratory insufficiency, haemodynamic instability or hypothermia are indications for admission to the intensive care unit.

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