Near-drowning: epidemiology, pathophysiology, and initial treatment

A case of haemoglobinuria in a cat after near-drowning

The aim of this study is to describe a case of haemoglobinuria in a cat after near-drowning. A 6-year-old male neutered domestic short hair cat weighing 6.5 kg with a pre-existing seizure disorder presented to an emergency hospital after near-drowning in a swimming pool during a seizure episode. On presentation, the patient was obtunded, dyspnoeic, bradycardic and hypothermic. Imaging revealed evidence of severe bilateral pulmonary infiltrates. Treatment with intravenous diazepam, amoxicillin, fluid therapy, active warming and oxygen therapy was administered. The cat developed haemoglobinuria approximately 6 h after nearly drowning. Despite improvements in mentation, pulse quality and heart rate, respiratory compromise and poor oxygen saturation persisted, prompting euthanasia approximately 10 h after admission. To the author's knowledge, this is the first reported clinical case of haemoglobinuria following near-drowning in veterinary medicine.

Drowning rule-out with novices (DROWN) in ultrasound

Objectives

Non-fatal drownings confer significant morbidity and mortality in the United States. Chest radiograph (CXR) is typically used as a screening modality for interstitial edema but lacks sensitivity early after submersion. No study has evaluated lung ultrasound in assessing for pulmonary edema after submersion events and we hypothesized that lung point-of-care (POC) ultrasound can identify interstitial edema in patients presenting after non-fatal drownings.

Methods

Patients presenting to the emergency department after a submersion event were eligible if a CXR was obtained as part of their care. Emergency medicine residents performed a lung POC ultrasound and provided a "novice" interpretation of "normal" or "abnormal," which was independently reviewed by a blinded expert sonographer. Patients were contacted 2 weeks after presentation to assess for late sequela.

Results

A prospective convenience sample of 59 patients included 21 adults (36%) and 38 children (64%) enrolled over 17 months with a median age of 6. Twenty-four (41%) patients had abnormalities on CXR. Of these, 20 patients had a positive ultrasound per novice interpretation. Compared to CXR, ultrasound had an overall sensitivity of 83% and a specificity of 66% for detecting pulmonary edema in non-fatal drownings. Notably, out of 35 subjects with a negative CXR, there were 12 (34%) cases with a positive lung ultrasound, 10 of which required hospital admission.

Conclusion

Lung POC ultrasound has a moderate sensitivity and specificity when performed by novice sonographers to detect pulmonary edema presenting to an ED setting after a non-fatal drowning event.

Early application of non-invasive ventilation for children with pulmonary edema after drowning

BACKGROUND

The present study aimed to assess the efficacy of non-invasive ventilation (NIV) on the clinical course, oxygenation, need for invasive mechanical ventilation (IMV), and outcomes for children with pulmonary edema after drowning.

METHODS

We conducted a retrospective chart review. Children who were referred to the pediatric emergency department due to drowning-related pulmonary edema and underwent NIV between May 2014 and October 2020 were included. Demographics, vital signs, clinical findings, and results of laboratory and radiologic investigations were recorded. Patients were divided into six groups using the Szpilman classification system. The need for IMV, the need for pediatric intensive care unit admission, and the length of NIV treatment and stay in the pediatric intensive care unit were recorded for each patient.

RESULTS

Twenty-five patients were enrolled. According to the Szpilman classification, 13 (52.0%) patients were evaluated as grade 3 and 12 (48.0%) as grade 4. All patients were treated with bi-level positive airway pressure in the spontaneous / timed mode. A significant increase in oxygen saturation (SpO₂) and SpO₂/fraction of inspired oxygen ratios was observed from the beginning of NIV treatment and this increase was also observed for the second and fourth hours. There was a decrease in respiratory rate at the fourth hour of NIV treatment. No patient subsequently deteriorated to require IMV.

CONCLUSIONS

We have reported a favorable clinical course of drowning patients who underwent early use of NIV in the pediatric emergency department. Management of drowning patients with pulmonary edema by NIV with close follow-up can be successfully applied in selected cases.

The Pediatric Submersion Score Predicts Children at Low Risk for Injury Following Submersions

OBJECTIVES

Pediatric submersion victims often require admission. We wanted to identify a cohort of children at low risk for submersion-related injury who can be safely discharged from the emergency department (ED) after a period of observation.

METHODS

This was a single-center retrospective derivation/validation cross-sectional study of children (0-18 years) who presented postsubmersion to a tertiary care, children's hospital ED from 2008 to 2015. We reviewed demographics, comorbidities, and prehospital and ED course. Primary outcome was safe discharge at 8 hours postsubmersion: normal mentation and vital signs. To identify potential scoring factors, any p-value of ≤0.25 was included in binary logistic regression; p-values < 0.05 were included in the final score. In the validation data set, we generated a one-point scoring system for each normal ED item. Receiver operating characteristic curves with area under the curve (AUC) were generated to test sensitivity and specificity.

RESULTS

The derivation data set consisted of 356 patients and validation data set of 89 patients. Five factors generated a safe discharge score at 8 hours: normal ED mentation, normal ED respiratory rate, absence of ED dyspnea, absence of need for airway support (bag-valve mask ventilation, intubation, and CPAP), absence of ED systolic hypotension (maximum score = 5; range = 0-5). Only the 80 patients with values for all five factors were included in the sensitivity/specificity analysis. This resulted in an AUC of 0.81 (95% confidence interval [CI] = 0.71-0.91; p < 0.001). Based on the sensitivity/specificity analysis, the discriminative ability peaks at 75% with a score of ≥3.5. A score of 4 or higher in the ED would suggest a safe discharge at 8 hours (sensitivity = 88.2% [95% CI = 72.5%-96.7%]; specificity = 62.9% [95% CI = 44.9%-78.5%]; positive predictive value = 69.8% [95% CI = 53.9%-82.8%]; negative predictive value = 84.6% [95% CI = 65.1%-95.6%]).

CONCLUSIONS

A risk score can identify children at low risk for submersion-related injury who can be safely discharged from the ED after observation.

Diving Into Research of Biomedical Engineering in Scuba Diving

The physiologic response of the human body to different environments is a complex phenomenon to ensure survival. Immersion and compressed gas diving, together, trigger a set of responses. Monitoring those responses in real time may increase our understanding of them and help us to develop safety procedures and equipment. This review outlines diving physiology and diseases and identifies physiological parameters worthy of monitoring. Subsequently, we have investigated technological approaches matched to those in order to evaluated their capability for underwater application. We focused on wearable biomedical monitoring technologies, or those which could be transformed to wearables. We have also reviewed current safety devices, including dive computers and their underlying decompression models and algorithms. The review outlines the necessity for biomedical monitoring in scuba diving and should encourage research and development of new methods to increase diving safety.

A rare type of drowning with a latent period following surviving an episode of immersion

Drowning is a leading cause of accidental death worldwide and its diagnosis is an important part of forensic investigation. It is generally acknowledged that hypoxia due to airway obstruction by fluid is the primary mechanism of death in drowning. Drowned individuals are usually found dead in the water or show severe clinical signs once out of the water. However, sudden death due to drowning after a short period of recovery following immersion/submersion has rarely been reported. A case of a 40-year-old man who died suddenly due to severe pulmonary edema about 40 min after he was recovered from an episode of immersion is reported. We suspected delayed lung injury due to water aspiration as the prime cause of death. This rare type of drowning should be well recognized by a clinician or forensic pathologist.

Effectiveness and safety of in-water resuscitation performed by lifeguards and laypersons: a crossover manikin study

OBJECTIVE

Drowning is associated with a high mortality and morbidity and a common cause of death. In-water resuscitation (IWR) in the case of drowning accidents has been recommended by certain resuscitation guidelines in the last several years. IWR has been discussed controversially in the past, especially with regard to the delay of chest compressions, effectiveness of ventilation, and hazard to the rescuer. The aim of the present study was to assess the effectiveness and safety of IWR.

METHODS

In this crossover manikin study, 21 lifeguards and 21 laypersons performed two rescue procedures in an indoor swimming pool over a 50-meter distance: In random order, one rescue procedure was performed with in-water ventilation and one without. Tidal and minute volumes were recorded using a modified Laerdal Resusci Anne (Laerdal Medical, Stavanger, Norway) and total rescue duration, submersions, water aspiration by the victim, and physical effort were assessed.

RESULTS

IWR resulted in significant increases in rescue duration (lifeguards: 106 vs. 82 seconds; laypersons: 133 vs. 106 seconds) and submersions (lifeguards: 3 vs. 1; laypersons: 5 vs. 0). Furthermore, water aspiration (lifeguards: 112 vs. 29 mL; laypersons: 160 vs. 56 mL) and physical effort (lifeguards: visual analog scale [VAS] score 7 vs. 5; laypersons: VAS score 8 vs. 6) increased significantly when IWR was performed. Lifeguards achieved significantly better ventilation characteristics and performed both rescue procedures faster and with lower side effects. IWR performed by laypersons was insufficient with regard to both tidal and minute volumes.

CONCLUSIONS

In-water resuscitation is associated with a delay of the rescue procedure and a relevant aspiration of water by the victim. IWR appears to be possible when performed over a short distance by well-trained professionals. The training of lifeguards must place particular emphasis on a reduction of submersions and aspiration when IWR is performed. IWR by laypersons is exhausting, time-consuming, and inefficient and should probably not be recommended. Key words: drowning; near-drowning; hypoxia; ventilation, artificial; respiration, artificial; resuscitation, in-water.

Efficacy of ventilation and ventilation adjuncts during in-water-resuscitation--a randomized cross-over trial

INTRODUCTION

Drowning is a common cause of death in young adults. The 2010 guidelines of the European Resuscitation Council call for in-water-resuscitation (IWR). There has been controversy about IWR amongst emergency and diving physicians for decades. The aim of the present study was assessing the efficacy of IWR.

METHODS

In this randomized cross-over trial, nineteen lifeguards performed a rescue manoeuvre over a 100 m distance in open water. All subjects performed the procedure four times in random order: with no ventilation (NV) and transportation only, mouth-to-mouth ventilation (MMV), bag-mask-ventilation (BMV) and laryngeal tube ventilation (LTV). Tidal volumes, ventilation rate and minute-volumes were recorded using a modified Laerdal Resusci Anne manikin. Furthermore, water aspiration and number of submersions of the test mannequin were assessed, as well as the physical effort of the lifeguard rescuers.One lifeguard subject did not complete MMV due to exhaustion and was excluded from analysis.

RESULTS

NV was the fastest rescue manoeuvre (advantage ∼40s). MMV and LTV were evaluated as efficient and relatively easy to perform by the lifeguards. While MMV (mean 199 ml) and BMV (mean 481 ml) were associated with a large amount of aspirated water, aspiration was significantly lower in LTV (mean 118 ml). The efficacy of ventilation was consistently good in LTV (Vt=447 ml), continuously poor in BMV (Vt=197) and declined substantially during MMV (Vt=1,019 ml initially and Vt=786 ml at the end). The physical effort of the lifeguards was remarkably higher when performing IWR: 3.7 in NV, 6.7 in MMV, 6.4 in BMV and 4.8 in LTV as measured on the 0-10 visual analogue scale.

CONCLUSION

IWR in open water is time consuming and physically demanding. The IWR training of lifeguards should put more emphasis on a reduction of aspiration. The use of ventilation adjuncts like the laryngeal tube might ease IWR, reduce aspiration of water and increase the efficacy of ventilation during IWR.

Tako-tsubo syndrome in a 12-year-old girl: exhausted heart, not broken heart

We report the case of a 12-year-old girl with Tako-tsubo cardiomyopathy. She was successfully treated in our Pediatric Intensive Care Unit for acute left ventricular failure, which occurred after a brief submersion in sea water. At 2-month follow-up she showed an almost complete recovery of cardiac function. We consider Tako-tsubo syndrome, which is rarely reported in the pediatric population, to be the most likely diagnosis.

[Retrospective analysis of 44 childhood drowning accidents]

BACKGROUND

Worldwide, drowning is the second leading cause of unintentional death and the leading cause of cardiovascular failure for children [1-3]. The number of near-drownings, where the incident is survived for at least 24 hours, is assumed to be four times as high [5]. In the years 1994 until 2008 there were 44 cases of drowning treated at the children's department of the University of Leipzig. This number shows that even in a medical centre drowning incidents are only occasional incidents. Therefore it is important to know the sequelae and handlings to be able to react in case of an emergency.

PATIENTS

A total of 44 children suffering a drowning accident within the last 48 hours who were treated during the period of 01.01.1994 through 30.06.2008 at the Children's Centre at the University of Leipzig.

METHODS

A retrospective analysis using a structured questionnaire was done. Social demographic data, accident progress, clinical results and progress as well as outcome of the cases were investigated.

RESULTS

During the analysed period in the median three children were treated each year after drowning incidents. Clustering in the summer and winter months and on the weekends was recognizable. The median age was 3.33 years and the group of high risk were children aged 1-3 years, especially boys. Sixty percent of the children came from stable social backgrounds. Half of the children suffered from drowning in created swimming pools or ponds, the rest in natural waters, public pools and sources of water in the household. The median submersion lasted 2 minutes. Correlation of submersions below 1 minute with a good, and submersions above 10 minutes with a negative outcome was shown. A Glasgow Coma Scale (GCS) of 3 points (n = 15) and pupils without light reaction (n = 14) were associated with a lethal outcome or residual neurological deficits. Looking at the laboratory values, correlation between severe acidotic pH-values with a very low base excess, high blood sugar as well as high lactate values and a poor outcome is revealed. Six patients died within the first 24 hours, 6 more over the course suffering organ failure or brain death. Five children retained neurological damages. Twenty-seven children could be released from the clinic healthily.

CONCLUSION

The risk of suffering a drowning incident is highest for boys aged 1-3 years, playing in the yard by themselves. Prognosis is depending on multiple factors and especially the circumstances of the accident. High influence is seen in the time of submersion and the need for cardiopulmonary resuscitation. Clinics and laboratory values at the time of hospital admittance may hint to the outcome. Basic life support at the scene of the accident has the highest impact on the outcome. Training of parents and supervisors in prevention and first aid after drowning incidents can avoid accidents.

Near-drowning syndrome: a possible trigger of tako-tsubo cardiomyopathy

We report a case of transient tako-tsubo cardiomyopathy characterized by an unusual trigger in a woman victim of near-drowning syndrome. After 24 h, electrocardiogram changes and a typical echocardiographic pattern of apical ballooning with a mild increase of serum troponin level induced the suspicion of tako-tsubo cardiomyopathy despite the absence of chest pain. Left ventriculography confirmed the apical ballooning, and coronary angiography revealed normal coronary arteries. Electrocardiogram changes and apical contraction abnormalities were reversed within 1 month. In conclusion, we hypothesize that hypoxemia related to near-drowning syndrome could have induced transient myocardial dysfunction mediated by a sympathetic nerve activation.

[Water rescue. A unique area of emergency medicine with many facets]

Emergencies on or in water are relatively rare in the rescue service. For this reason, water accident treatment and management does not receive much attention in the training of emergency medicine physicians. Consequently doctors working in emergency medicine often have minimal knowledge in this area. On the other hand, the number of fatal accidents on and in water has increased in recent years. In Germany the number of non-swimmers is also increasing, so it can be assumed that the number of water-related accidents will continue to rise. Drowning accidents and near drowning are important in this context and will be discussed in detail in this review as well as hypothermia (a frequent problem), accompanying injuries and diving accidents.

Lethal brain abscess due to the fungusScedosporium apiospermum(teleomorphPseudallescheria boydii) after a near-drowning incident: case report and review of the literature

A 39-year-old healthy man developed a brain abscess weeks after a near-drowning incident. Scedosporium apiospermum, the anamorph of Pseudallescheria boydii, was isolated from the abscess. The patient died 153 days after the accident despite antifungal therapy. We discuss the role of antifungals and review the literature for comparable cases.

Systematic review of definitions for drowning incidents

OBJECTIVES

In preparation for the World Congress on Drowning uniform reporting consensus document of drowning incidents we reviewed systematically the medical literature for the terms and definitions used to describe drowning incidents to assess the uniformity of these terms in the medical literature.

METHODS

The search strategy included a literature search of PubMed, MEDLINE and the Cochrane Database from 1966 to April 2002, as well as a review of reference lists of identified studies and a hand search of relevant textbooks and reference works. Search terms used included drowning, near-drowning, submersion, immersion, suffocation, asphyxiation, water injuries, and aspiration. Any article with drowning as a primary focus and containing a definition of drowning was included. Study designs included experimental studies, observational studies, case control studies, reviews, letters, and editorials.

RESULTS

The search identified approximately 6000 articles. Of these 650 were reviewed and 43 articles addressing the definition of drowning were identified. We found a total of 33 different definitions to describe drowning incidents, 20 for drowning and 13 for near-drowning; along with another 13 related terms. There were at least 20 different outcome measures for drowning incidents reported.

CONCLUSIONS

A review of existing drowning literature demonstrates a lack of a standard definition of drowning and a lack of agreement on measures of outcome. This variability in definitions and outcomes makes it very difficult to assess and analyze studies both individually and as a whole and draw conclusions that will influence practice. These objective findings support the need for the drowning Utstein focus on one definition of drowning and validated measures of functional and neurological outcome.

Environmental insults: smoke inhalation, submersion, diving, and high altitude

In the expanding search for recreation, we spend more and more of our time in various environments. Whether the air is thin or compressed or smoke-filled or there is no air at all, emergency physicians continue to meet and treat the various pulmonary emergencies that the environment may create. The authors present the background, diagnosis, and management of a few of the more common pulmonary emergencies that the environment may produce.

Near drowning: thin-section CT findings in six patients

PURPOSE

The purpose of this study was to assess the thin-section CT findings of near drowning in six patients.

METHOD

Thin-section (1 mm collimation) CT scans of six patients who experienced near drowning were retrospectively analyzed. The CT scans were performed 0-5 days (median 1 day) after near drowning.

RESULTS

Thin-section CT findings included bilateral patchy or diffuse areas of ground-glass attenuation (n = 6) with geographic pattern (n = 3) and fine intralobular reticular opacities ("crazy-paving" appearance) (n = 3), ill-defined centrilobular nodules (n = 4), and air-space consolidation (n = 1). Distribution of ground-glass attenuation was predominantly central (n = 4) or diffuse (n = 2). Interstitial pulmonary emphysema and pneumomediastinum were present in two patients.

CONCLUSION

The thin-section CT findings of near drowning consist of ground-glass opacities with or without associated reticular opacities and centrilobular nodules.

Predicting discharge in uncomplicated near-drowning

To determine if routine, noninvasive parameters could be measured which predict early (4-6 hour) discharge from the emergency department (ED) in mildly symptomatic and asymptomatic victims of childhood near-drowning, a retrospective cohort study was undertaken. Patients with fresh water near-drowning were studied over a 3-year period who presented with Glascow Come Scale (GCS) > or =13 and required no advanced life support prior to or < or =4 hours after ED presentation. Three groups of patients were found: 39 patients (81%) had normal pulmonary examination (PEx) and normal room air oxygen saturation (RASaO2) by 4 to 6 hours and did not deteriorate during the hospital admission (<24 hours); 5 patients (10%) had normal PEx by 4 to 6 hours and RASaO2 by 8 to 12 hours and did not deteriorate during hospitalization (<24 hours). Four patients (8%) were hospitalized for more than 24 hours. No patient with normal RASaO2 at 6 hours deteriorated while in the hospital (CI 92.3-100%). Children who present to the ED with GCS > or =13 and have normal PEx/respiratory effort and RA-SaO2 more than 95% at 4 to 6 hours after ED presentation can be safely discharged home.

Near drowning

Submersion accidents continue to be a significant cause of morbidity and mortality in children and adults. The key to successful management is prevention of these accidents. Proactive efforts to minimize submersion accidents in the community should be made by medical and legislative groups. Anticipatory guidance by primary care physicians, particularly for families and individuals at increased risk, should be performed. Outcomes of individuals who have become victims of submersion accidents can be optimized by the development of a rapid response system, because successful initial resuscitation efforts clearly improve outcomes. For individuals who have nearly drowned and who have arrived in the emergency department, a systematic and aggressive approach needs to be followed with particular emphasis on cardiorespiratory support to optimize neurologic outcome. Despite many studies aimed at developing predictors of outcomes, there is limited information that can be used in a prospective manner to guide the emergency-room physician in limiting the level of interventions. Thus, all aggressive supportive care and resuscitation should be performed at this stage, except in clearly futile situations. Once patients arrive in the ICU, meticulous care, including monitoring of cardiorespiratory and neurologic status and attention to electrolytes and acid-base status, needs to be continued. Besides providing basic supportive measures, the ICU physician should investigate for other associated trauma and medical conditions that may need to be addressed once the patient is stabilized. Patients who have nearly drowned are likely to have long ICU stays, predisposing them to nosocomial infections. Despite efforts at minimizing barotrauma and volutrauma, many patients who have nearly drowned and who need ventilatory support may develop ARDS. The management of these patients is similar to other patients who have ARDS. However, strategies like permissive hypercapnia that are used commonly in patients who have ARDS may not be suitable in patients who have CNS injury. Despite aggressive care, neurologic injury with long-term sequelae secondary to hypoxic ischemic injury remains a major problem in the management of victims of submersion accidents. It is important for the clinician to keep the pathophysiologic and cellular mechanisms of CNS injury in mind, because future interventions are likely to be based on these pathways. Besides providing care for the patient, it is important for the ICU physician to be sensitive to the needs of the family and to support them through this catastrophe that is likely to place a tremendous financial and emotional burden on most of them.

Near-drowning: life-saving steps

Cervical-spine injury, trauma, and hypothermia should be considered in all sports-related near-drownings. The focus of resuscitation should be on prompt restoration of respiration, CPR, and advanced cardiac life support with cervical-spine precautions. A subset of near-drowning victims can be discharged after only 4 to 6 hours of observation. Although total drowning deaths have decreased 45% in the past 15 years, a greater emphasis on public education to prevent drowning remains in order.