DOI: 10.1542/peds.2010-1177 ; originally published online September ...

Spa-Drain Entrapment Complicated by Suspicions of Nonaccidental Trauma and Epilepsy Onset Matthias Furter, Tanja Germerott and Michael J. Thali Pediatrics 2011;128;e1008; originally published online September 19, 2011; DOI: 10.1542/peds.2010-1177

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.org/content/128/4/e1008.full.html

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Spa-Drain Entrapment Complicated by Suspicions of Nonaccidental Trauma and Epilepsy Onset abstract

AUTHORS: Matthias Furter, MD,a Tanja Germerott, MD,b and Michael J. Thali, MDb

We present here the case of an adolescent female near-drowning victim who was reportedly discovered submerged and unconscious by family members in a whirlpool spa. Physical examination revealed extensive posterior soft tissue bruising, which raised the suspicion of nonaccidental trauma. Detailed forensic evaluation of the injuries and the scene proved that the soft tissue findings represented an unusual manifestation of whirlpool-spa suction-vent injury. Medical evaluation indicated that epilepsy onset might have contributed to the neardrowning, although forensic evaluation of this possibility was less convincing. In this article we review these rare but important injuries, which have the potential to be confused with child abuse, and detail the atypical presentation and clinically presumed etiologic event in our case. Pediatrics 2011;128:e1008–e1012

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University Children’s Hospital Zurich, Zurich, Switzerland; and Institute for Forensic Medicine, University of Bern, Bern, Switzerland b

KEY WORDS nonaccidental trauma, whirlpool, epilepsy, drowning www.pediatrics.org/cgi/doi/10.1542/peds.2010-1177 doi:10.1542/peds.2010-1177 Accepted for publication May 18, 2011 Address correspondence to Matthias Furter, MD, University Children’s Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland. E-mail: [email protected] PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2011 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.


CASE REPORTS

Whirlpool bathtubs, spas, hot tubs, and Jacuzzis (hereafter described as whirlpool spas) have become increasingly popular over recent decades, and there has been a corresponding increase in the number of whirlpoolspa–related injuries to children, some of which were fatal. In California, between 1960 and 1985, 90% of the cases occurred in infants/children between 10 and 41 months of age.1 Only rarely are children between 4 and 11 years of age involved. Three boys between 9 and 10 years of age drowned in whirlpool spas when a body part was sucked against a drain opening. In 1 of the cases, it occurred with such force that a special tool was required to free the corpse. Nonfatal accidents between 1977 and 1981 were also described in California and involved an 8-year-old boy and a 13-year-old girl who were entrapped on their abdomens against the drain on the bottom of a whirlpool spa.2 Afterward, both children exhibited extensive ecchymotic and petechial bruise patterns. Because several children died in these accidents, solutions were suggested by the authors of those 2 reports in which there is an additional drainage opening so that no vacuum can form if 1 of the drains is covered.1,2 Some children also died because their hair was sucked into the drain, an event that could be prevented by including a grate over the opening.1,2 Despite this recommendation, in the year 2000, a 7-year-old girl and two 6-year-old girls drowned in Japan because their hair was sucked into drains with a force of up to 10 kg.3 More-recent use of warning signage and protective covers have prevented similar accidents.3 The risk of entrapment and drowning in whirlpool spas, therefore, represents a known and important risk to infants and children. As in the cases mentioned above, this mechanism has led to childhood fatalities and characPEDIATRICS Volume 128, Number 4, October 2011

teristic skin bruising on the bodies of survivors. The spa involved in our case report is not sold in the United States.

CASE REPORT History A healthy 12-year-old girl went alone into her family’s whirlpool spa. Approximately 9 minutes later, her father found her lying immobile, on her back, underwater. When he extracted her, he noticed a strong suction force. After ⬃30 seconds of untrained resuscitation efforts by the father and brother, she began to cough. When the ambulance arrived the girl was intubated. Her pupils were fixed and dilated, and her eyeballs were turned upward. Jerking of the extremities, which was interpreted as possible convulsions, was noticed, and she was treated with 5 mg of midazolam. During the transport her vital signs were stable, and there were no further convulsions. After arrival at the children’s hospital, a large hematoma was seen that extended from below her shoulder blades to her buttocks. The next evening, the girl was extubated. Her hospital stay was complicated by aspiration pneumonia and sinusitis. No further convulsions occurred. On the day she was released, 12 days after the incident, neurologic examination revealed mild memory and performance disorders as well as reduced resilience. The clinicians presumed that her near-drowning was related to the onset of epilepsy.

lobes bilaterally. Whether these findings were signs of an existing cerebral hyperexcitability or consequences of mild oxygen deprivation could not be determined conclusively. There were no signs of a severe hypoxic encephalopathy. After reexamination on the day she was released, the initial findings had resolved, but there were signs of an elevated disposition for convulsions. Brain MRI performed 5 days after the accident revealed only evidence of sphenoid sinusitis. Cardiology consultation revealed no abnormalities. Forensic Medicine Examinations Forensic evaluation revealed a 12year-old girl who was 160 cm in height and weighed 46 kg. Physical examination performed 1 day after the accident revealed an extensive, violet-red hematoma, 50 ⫻ 27 cm in size, that extended from her left shoulder blade to her right buttock. On the right and the bordering left buttock, as well as over the left shoulder blade, extensive, grid-like, radially formed spaces were definable as gaps in the hematoma (Figs 1 and 2). In the follow-up examination, 5 days after the accident, the girl exhibited a retrograde amnesia for the accident. Evolution of the hematoma was noted, which then appeared yellow-green in color (Fig 3). The grid-like areas in the hematoma at that time were superficial, brown, scab-covered skin abrasions.

Diagnostics

Whirlpool-Bathtub Test Report by an Independent Agency

To help clarify if the child had had a seizure, waking electroencephalography was performed 2 days after the accident and revealed baseline activity consistent with her age, a focus of retardation in the left frontocentrotemporal lobe, and multifocal, partial epileptic potentials in the frontotemporal

An indentation, 45 cm long and 30 cm wide and up to 50 cm below the water surface, was found in the middle of the whirlpool bathtub between the 2 reclined seats (Fig 4). On the floor of this indentation an uncovered drain opening was found, as well as drains on each of the short-side walls that were


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DISCUSSION The mechanism of the accident can be reconstructed as follows. The girl sat directly over the drain opening or just in the front part of the indentation and might have partially covered the front drain. If she then came to partially cover the indentation with her back, suction was created that increased as more and more of the area over the indentation was covered. If she sank far enough down, she covered up the whole indentation with her back and was then vigorously sucked into it. Probably at the time of high, nearmaximal suction forces, the cover of the front drain opening was damaged by her buttocks. Then, with the grate flattened and in pieces, the girl completely sealed the front drain with her buttocks, and the maximum suction in the indentation arose. With great force on the buttocks and the lower part of the back sucked into the indentation, and an estimated water level of 37 cm above the lower part of her left shoulder blade, it was not possible for her to keep her head above the water surface to call for help or breathe (Fig 5).

FIGURE 1 The case patient’s back and buttocks, right side.

FIGURE 2 The case patient’s back and buttocks, left side.

FIGURE 3 The case patient’s back and buttocks in the follow-up examination.

covered with a grate. In the inspection it was determined that 1 of the suction pumps sucks up water via the front drainage opening in the indentation and through the pipe of the separate filter cartridge. If this front drain is blocked, the sucking force is limited by compensatory suction of more water e1010

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moving through the filter cartridge. However, the suction pump for the rear drain is isolated to this single rear drain opening. Obstruction of the rear drain, therefore, allows the pump to suction at full power. Because of the relatively large size of the indentation, the force is considerable.

In the hospital discharge report the cause of this bathing accident was described as most likely being secondary to a first-time convulsion. The authors of 2 investigations with children and youths, almost all of whom had had a previous diagnosis of epilepsy, revealed a 7.5 to 13.9 times elevated submersion risk when compared with healthy children.4,5 The girl presented in our case report had no history of epilepsy. An investigation into injury associated with seizure onset revealed that in the 198 children studied between 1 and 16 years of age, not one suffered a serious injury with the first or subsequent seizure, and no swimming-related injuries occurred.6 Also, in a small investigation, children who were cognitively normal but suffered from epilepsy


CASE REPORTS

mild hypoxia rather than a first-time manifestation of epilepsy. Finally, electroencephalography findings were nonspecific and also could have been related to mild hypoxia, which almost certainly occurred in this case. From a forensic point of view, we feel that the occurrence of epilepsy is much less certain.

CONCLUSIONS

FIGURE 4 Whirlpool bathtub with indentation.

FIGURE 5 Reconstructed diagram of the accident situation (with varying head positions).

exhibited the same rates of injury in general as children who did not suffer from this disease.7 Expected body position during a seizure is not conducive to “fitting” within the indentation that contained the suction vents unless the girl drifted down into the indentation in a semiconscious postictal state, which we consider an unlikely situation.

Two months after the incident, the girl remained seizure free without the use of medication, which reflects the known fact that an accident causing injury will be given more attention and seems to trigger an earlier diagnosis of epilepsy.6,8

Our case of near-drowning illustrates the uncommon but important phenomenon of suction-vent–related entrapment of children in whirlpool spas. Clinicians should keep in mind that specific soft tissue bruising might occur in these cases and look for their typical patterns. In addition, vigilance is required on the part of industry, regulators, and parents to ensure that these devices are constructed with appropriate safety equipment and are used safely. Although epilepsy does increase the risk of submersion accidents, the increased risk applies primarily to patients with known epileptic disease. In this case, the combination of electroencephalography findings, MRI findings, considerations of the whirlpool geometry, and expected body position of ictal patients leads us to conclude that epilepsy is an unlikely etiology.

The convulsions that were reported by the emergency medical services personnel might have been a symptom of

ACKNOWLEDGMENTS We thank the young patient and her family for their cooperation and consent for publication. We are also grateful to M. Bolliger, IFM Bern, for the illustration (Fig 5) and Mrs B. Ritter, the Bernese coroner, and Gary Hatch, MD, for manuscript preparation.

2. Monroe B. Immersion accidents in hot tubs and whirlpool spas. Pediatrics. 1982;69(6): 805– 807

Tokudome S. Fatal drowning of children in whirlpool baths in Japan. Lancet. 2003; 361(9397):2248

3. Hitosugi M, Kawato H, Matsushima K, Nagai T,

4. Kemp AM, Sibert JR. Epilepsy in children and

REFERENCES 1. Shinaberger CS, Anderson CL, Kraus JF. Young children who drown in hot tubs, spas, and whirlpools in California: a 26 year survey. Am J Public Health. 1990;80(5):613– 614

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the risk of drowning. Arch Dis Child. 1993; 68(5):684 – 685 5. Diekema DS, Quan L, Holt VL. Epilepsy as a risk factor for submersion injury in children. Pediatrics. 1993;91(3):612– 616 6. Appleton RE; Mersey Region Paediatric Epi-

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lepsy Interest Group. Seizure-related injuries in children with newly diagnosed and untreated epilepsy. Epilepsia. 2002;43(7): 764 –767 7. Kirsch R, Wirrell E. Do cognitively normal children with epilepsy have a higher rate of in-

jury than their nonepileptic peers? J Child Neurol. 2001;16(2):100 –104 8. Ziegler AL, Reinberg O, Deonna T. Epilepsy and accidents: what is the risk in children [in French]? Arch Pediatr. 1994;1(9): 801– 805


Spa-Drain Entrapment Complicated by Suspicions of Nonaccidental Trauma and Epilepsy Onset Matthias Furter, Tanja Germerott and Michael J. Thali Pediatrics 2011;128;e1008; originally published online September 19, 2011; DOI: 10.1542/peds.2010-1177 Updated Information & Services

including high resolution figures, can be found at: http://pediatrics.aappublications.org/content/128/4/e1008.full. html

References

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2011 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.
