Systematic review of definitions for drowning incidents

Does adjunctive hemoadsorption provide benefit in the management of ischemia-reperfusion syndrome following near-drowning? A case report

Drowning remains a significant global health concern, claiming over 300,000 lives annually, with a disproportionate impact on young individuals in low-and middle-income countries. Conventional mechanical ventilation, while common, falls short in addressing the hypoxemia and hypercapnia often observed in severe near-drowning cases. Veno-venous extracorporeal membrane oxygenation (vvECMO) emerges as a critical intervention for cardiopulmonary failure post-drowning. This case report delves into the pivotal role of ischemia-reperfusion injury (IRI) in a near-drowning-related pathology. Following the initial insult, reoxygenation exacerbates the inflammatory cascade, resulting in a surge of pro-inflammatory mediators. In this context, CytoSorb®, a hemoadsorption cartridge, demonstrates promise by effectively removing these mediators from circulation. This report outlines its application in a critically ill adolescent patient who experienced near-drowning, presenting a compelling case for CytoSorb as an adjunctive therapy in managing IRI-induced hyperinflammation.

Feasibility study of the Utstein Style For Drowning to aid data collection on the resuscitation of drowning victims

Aim

The revised Utstein Style For Drowning (USFD) was published in 2015. Core data were considered feasible to be reported in most health systems worldwide. We aimed to determine the suitability of the USFD as a template for reporting data from drowning research.

Method

Clinical records of 437 consecutive drowning presentations to the Sunshine Coast Hospital and Health Service Emergency Departments (ED) between 1/1/2015 and 31/12/2021 were examined for data availability to complete the USFD. The proportions of patients with each variable documented is reported. Time taken to record core and supplementary variables was recorded for 120 consecutive patients with severity of drowning Grade 1 or higher.

Results

There were 437 patients, including 227 (51.9%) aged less than 16 years. There were 253 (57.9%) males and 184 (42.1%) females. Sixty-one patients (13.9%) received cardiopulmonary resuscitation (CPR). There were nine (2.1%) deaths after presentation to the ED. Median time for data entry was 17 minutes for core variables and 6 min for supplementary. This increased to 29 + 6 minutes for patients in cardiac arrest. Sixteen (32.7%) of 49 core variables and four (13.3%) of 30 supplementary variables were documented 100% of the time. One (2.0%) core and seven (23.3%) supplementary variables were never documented. Duration of submersion was documented in 100 (22.9%) patients.

Conclusion

USFD is time consuming to complete. Data availability to enable completion of the USFD varies widely, even in a resource rich health system. These results should be considered in future revisions of the USFD.

Danish Drowning Formula for identification of out-of-hospital cardiac arrest from drowning

BACKGROUND

Accurate, reliable, and sufficient data is required to reduce the burden of drowning by targeting preventive measures and improving treatment. Today's drowning statistics are informed by various methods sometimes based on data sources with questionable reliability. These methods are likely responsible for a systematic and significant underreporting of drowning. This study's aim was to assess the 30-day survival of patients with out-of-hospital cardiac arrest (OHCA) identified in the Danish Cardiac Arrest Registry (DCAR) after applying the Danish Drowning Formula.

METHODS

This nationwide, cohort, registry-based study with 30-day follow-up used the Danish Drowning Formula to identify drowning-related OHCA with a resuscitation attempt from the DCAR from January 1st, 2016, through December 31st, 2021. The Danish Drowning Formula is a text-search algorithm constructed for this study based on trigger-words identified from the prehospital medical records of validated drowning cases. The primary outcome was 30-day survival from OHCA. Data were analyzed using multiple logistic regression.

RESULTS

Drowning-related OHCA occurred in 374 (1%) patients registered in the DCAR compared to 29,882 patients with OHCA from other causes. Drowning-related OHCA more frequently occurred at a public location (87% vs 25%, p < 0.001) and were more frequently witnessed by bystanders (80% vs 55%, p < 0.001). Both 30-day and 1-year survival for patients with drowning-related OHCA were significantly higher compared to OHCA from other causes (33% vs 14% and 32% vs 13%, respectively, p < 0.001). The adjusted odds ratio for 30-day survival for drowning-related OHCA and other causes of OHCA was 2.3 [1.7-3.2], p < 0.001. Increased 30-day survival was observed for drowning-related OHCA occurring at swimming pools compared to public location OHCA from other causes with an OR of 11.6 [6.0-22.6], p < 0.001.

CONCLUSIONS

This study found higher 30-day survival among drowning-related OHCA compared to OHCA from other causes. This study proposed that a text-search algorithm (Danish Drowning Formula) could explore unstructured text fields to identify drowning persons. This method may present a low-resource solution to inform the drowning statistics in the future.

REGISTRATION

This study was registered at ClinicalTrials.gov before analyses (NCT05323097).

Evaluation and Management of Watercraft-Related Injuries for Acute Care Surgeons: Towards Improving Care and Implementing Effective Public Health Prevention Policies

Boating has exposed humans to elemental hazards for centuries. What was once a lifelong craft and time-honored skillset is now, with modern technology, a popular recreational activity. Boating safety has inherent limitations and has been historically challenging to enforce. These circumstances have given way to a rising number of watercraft-associated injuries and fatalities. This review aims to investigate the diagnosis, work-up, and management of watercraft-related injuries, including blunt mechanisms, propeller wounds, water-force trauma, associated marine infections, and submersion injuries, as well as outline gaps in current public health policy on watercraft injuries, potential interventions, and available solutions. Motorboats and personal watercraft differ in size, power modality, and differential risk for injury. Accidents aboard watercraft often share commonalities with motor vehicles and motorcycles, namely: rapid deceleration, ejection, and collision with humans. The complexity of care is added by the austere environment in which many watercraft accidents occur, as well as the added morbidity of drowning and hypothermia. Wounds can also become infected by marine organisms, which require wound care and antimicrobial therapy specific to the aquatic environment in which the injury occurred. The treatment of these patients can be further exacerbated by the prolonged transportation times due to complicated water rescue. There are many measures that can prevent or abate watercraft injuries, but inconsistent regulations and enforcement may impair the success of these interventions. Further research is needed to identify possible solutions to common causes of watercraft injuries, such as inconsistent lifejacket use and bow riding.

Childhood Drowning: Review of Patients Presenting to the Emergency Departments of 2 Large Tertiary Care Pediatric Hospitals Near and Distant From the Sea Coast

OBJECTIVE

Drowning is a leading cause of death among infants and toddlers. Unique physiological and behavioral factors contribute to high mortality rates. Drowning incidents predominantly occur during warmer months and holidays. The aim of this study was to describe the characteristics of pediatric drowning victims who attended 2 different emergency departments (EDs), 1 near and 1 distant from the sea coast, to recognize risk factors, complications, causes of death, and the educational needs of families and caregivers.

METHODS

Retrospective cohort analysis of incident history, clinical presentation, treatments, and outcomes of drowning victims was performed. Data were analyzed both by age group and proximity of institution to the sea coast.

RESULTS

From 2005 to 2015, 70 drowning patients presented to the 2 institutions; there was no difference in incident history or outcomes based on proximity to the sea coast. Fifty-six percent of patients were younger than 6 years, the majority drowning in pools. More of the older children drowned in the sea (48% vs 23%). Half of all patients were treated and followed in the ED or ward, and the other half were treated in the pediatric intensive care unit; 12 suffered severe complications, including 5 diagnosed with brain death. Cardiopulmonary resuscitation was performed in 80% of the fatal group and 23% of the nonfatal group (P = 0.006). Seven children who experienced a cardiac arrest with hypothermia were treated before arrival in the ED, and 5 had ongoing cardiac arrest upon arrival in the ED (these were the 5 suffering brain death).

DISCUSSION

Most of patients younger than 6 years drowned in swimming pools, suggesting that parents are perhaps less vigilant in these circumstances, even though they may remain in close proximity. Active adult supervision entails attention, proximity, and continuity. Educational efforts should be aimed at reminding parents of this, especially in the summer months.

Trauma on the high seas: an overview of recreational water use injuries

Recreational water use (RWU) injuries span from superficial lacerations to even death. Given the global popularity of RWU, radiologists should be aware of the common mechanisms and key imaging findings related to injuries in this setting. The goal of this article is to depict common RWU injuries and their emergent radiographic findings, which may have both important surgical and management implications. We present a broad review with case illustrations of these injuries seen at our level 1 trauma center showing the breadth of injury that can occur, general mechanisms and sample imaging findings.

Is drowning a mere matter of resuscitation?

International data severely underestimates actual drowning numbers. Almost all victims are able to help themselves or are rescued in time. This study aims to report the occurrence of Drowning Chain of Survival actions and resuscitations needed in a fully operational lifeguard service.

METHODOLOGY

Data was collected from Dec-2009 to Mar-2015 by lifeguards at a 6km-long beach in Brazil. The Drowning Chain of Survival links were summarized into 3 main action-response sections: Prevention; rescue; and provide care. Rescues were classified by severity.

RESULTS

Lifeguards reported 1,565,699 actions during the study period. Preventative actions comprised 1,563,300(99.8%) and 2044 (0.1%) involved recognizing a person in stress/distress and rescuing them. Of those requiring rescue, 355(0.02%) needed medical assistance due to respiratory symptoms, isolated respiratory arrest, or cardiopulmonary arrest. Those cases were classified by severity as: Grade 1 = 234(65.9%), grade 2 = 78(22%), grade 3 = 22(6.2%), grade 4 = 7(2%), grade 5 = 4(1.1%), and Grade 6 = 10(2.8%). From all 2044 rescues, 14(0.7%) were grade 5 and 6 and needed respiratory or cardiorespiratory resuscitation. An estimative incident rate for each day at a lifeguarded beach revealed: 1 rescue for every 4.227 beach attendances, 1 drowning for every 24,338 beach attendances, and 1 instance of CPR being performed for every 617,142 beach attendances. The prevalent misconception that majority of drowning require resuscitation is perpetuated by the media and publishers. We are only just seeing the tip of the iceberg and urgently need to look at the problem in its entirety. Considering all the intervention undertaken by lifeguards in a fully operational system, the incidence of resuscitation being performed is only one in every 112,000 lifeguarding actions (0.0009%).

Review of 14 drowning publications based on the Utstein style for drowning

BACKGROUND

The Utstein style for drowning (USFD) was published in 2003 with the aim of improving drowning research. To support a revision of the USFD, the current study aimed to generate an inventory of the use of the USFD parameters and compare the findings of the publications that have used the USFD.

METHODS

A search in Pubmed, Embase, the Cochrane Library, Web of Science and Scopus was performed to identify studies that used the USFD and were published between 01-10-2003 and 22-03-2015. We also searched in Pubmed, Embase, the Cochrane Library, Web of Science, and Scopus for all publications that cited the two publications containing the original ILCOR advisory statement introducing and recommending the USFD. In total we identified 14 publications by groups that explicitly used elements of the USFD for collecting and reporting their data.

RESULTS

Of the 22 core and 19 supplemental USFD parameters, 6-19 core (27-86%) and 1-12 (5-63%) supplemental parameters were used; two parameters (5%) have not been used in any publication. Associations with outcome were reported for nine core (41%) and five supplemental (26%) USFD parameters. The USFD publications also identified non-USFD parameters related to outcome: initial cardiac rhythm, time points and intervals during resuscitation, intubation at the drowning scene, first hospital core temperature, serum glucose and potassium, the use of inotropic/vasoactive agents and the Paediatric Index of Mortality 2-score.

CONCLUSIONS

Fourteen USFD based drowning publications have been identified. These publications provide valuable information about the process and quality of drowning resuscitation and confirm that the USFD is helpful for a structured comparison of the outcome of drowning resuscitation.

2015 revised Utstein-style recommended guidelines for uniform reporting of data from drowning-related resuscitation: An ILCOR advisory statement

BACKGROUND

Utstein-style guidelines use an established consensus process, endorsed by the international resuscitation community, to facilitate and structure resuscitation research and publication. The first "Guidelines for Uniform Reporting of Data From Drowning" were published over a decade ago. During the intervening years, resuscitation science has advanced considerably, thus making revision of the guidelines timely. In particular, measurement of cardiopulmonary resuscitation elements and neurological outcomes reporting have advanced substantially. The purpose of this report is to provide updated guidelines for reporting data from studies of resuscitation from drowning.

METHODS

An international group with scientific expertise in the fields of drowning research, resuscitation research, emergency medical services, public health, and development of guidelines met in Potsdam, Germany, to determine the data that should be reported in scientific articles on the subject of resuscitation from drowning. At the Utstein-style meeting, participants discussed data elements in detail, defined the data, determined data priority, and decided how data should be reported, including scoring methods and category details.

RESULTS

The template for reporting data from drowning research was revised extensively, with new emphasis on measurement of quality of resuscitation, neurological outcomes, and deletion of data that have proved to be less relevant or difficult to capture.

CONCLUSIONS

The report describes the consensus process, rationale for selecting data elements to be reported, definitions and priority of data, and scoring methods. These guidelines are intended to improve the clarity of scientific communication and the comparability of scientific investigations.

The use of non-uniform drowning terminology: a follow-up study

BACKGROUND

In 2002, the World Congress on Drowning developed a uniform definition for drowning. The aim of this study is to determine the prevalence of "non-uniform drowning terminology" (NUDT) and "non-uniform drowning definitions" (NUDD) in peer-reviewed scientific literature from 2010 to 2016, and compare these findings with those from our unpublished study performing a similar analysis on literature from 2003 to 2010.

METHODS

A systematic review was performed using drowning-specific search terms in Pubmed and Web of Science. Titles and abstracts published between July 2010 and January 2016 were screened for relevance to the study focus. Articles meeting screening criteria were reviewed for exclusion criteria to produce the final group of studies. These articles were reviewed by four reviewers for NUDT and NUDD. The Fisher exact test was used to determine any statistically significant changes.

RESULTS

The final group of studies included 167 articles. A total of 53 articles (32%) utilized NUDT, with 100% of these including the term "near drowning". The proportion of articles utilizing NUDT was significantly less than reported by our previous study (p < 0.05). In addition, 32% of the articles included a definition for drowning (uniform or non-uniform), with 15% of these utilizing NUDD.

DISCUSSION

Our study reveals a statistically significant improvement over the past thirteen years in the use of uniform drowning terminology in peer-reviewed scientific literature, although year-to-year variability over the current study period does not yield an obvious trend.

CONCLUSIONS

Of the articles reviewed during the 2010-2016 study period, 32% included outdated and non-uniform drowning terminology and definitions. While this reveals an absolute decrease of 11% as compared with the previous study period (2003-2010), there is still significant room for improvement.

2015 Revised Utstein-Style Recommended Guidelines for Uniform Reporting of Data From Drowning-Related Resuscitation: An ILCOR Advisory Statement

BACKGROUND

Utstein-style guidelines use an established consensus process, endorsed by the international resuscitation community, to facilitate and structure resuscitation research and publication. The first "Guidelines for Uniform Reporting of Data From Drowning" were published over a decade ago. During the intervening years, resuscitation science has advanced considerably, thus making revision of the guidelines timely. In particular, measurement of cardiopulmonary resuscitation elements and neurological outcomes reporting have advanced substantially. The purpose of this report is to provide updated guidelines for reporting data from studies of resuscitation from drowning.

METHODS

An international group with scientific expertise in the fields of drowning research, resuscitation research, emergency medical services, public health, and development of guidelines met in Potsdam, Germany, to determine the data that should be reported in scientific articles on the subject of resuscitation from drowning. At the Utstein-style meeting, participants discussed data elements in detail, defined the data, determined data priority, and decided how data should be reported, including scoring methods and category details.

RESULTS

The template for reporting data from drowning research was revised extensively, with new emphasis on measurement of quality of resuscitation, neurological outcomes, and deletion of data that have proved to be less relevant or difficult to capture.

CONCLUSIONS

The report describes the consensus process, rationale for selecting data elements to be reported, definitions and priority of data, and scoring methods. These guidelines are intended to improve the clarity of scientific communication and the comparability of scientific investigations.

Drowning: an overlooked cause of out-of-hospital cardiac arrest in Canada

INTRODUCTION

Drowning is a major public health concern, yet little is known about the characteristics of drowning patients. The objectives of this study were to describe the demographic and clinical characteristics of out-of-hospital cardiac arrest (OHCA) attributed to drowning in Ontario and to compare the characteristics of OHCA attributed to drowning to those of presumed cardiac etiology.

METHODS

A retrospective, observational study was carried out of consecutive OHCA patients of drowning etiology in Ontario between August 2006 and July 2011. Bivariate analysis was used to evaluate differences between drowning and presumed cardiac etiologies.

RESULTS

A total of 31,763 OHCA patients were identified, and 132 (0.42%) were attributed to drowning. Emergency medical services treated 98 patients, whereas the remaining 34 met the criteria for legislative death. Overall, 5.1% of drowning patients survived to hospital discharge. When compared to patients of presumed cardiac etiology, drowning patients were younger and their arrest was more likely to be unwitnessed, present with a nonshockable initial rhythm, occur in a public location, and receive bystander cardiopulmonary resuscitation (CPR). A nonsignificant trend was noted for drowning cases to more frequently have a public access AED applied. There were no significant differences in the gender ratio or paramedic response times. Drowning patients were more likely to be transported to hospital but had a trend to be less likely to arrive with a return of spontaneous circulation. They were also more likely to be admitted to hospital but had no difference in survival to hospital discharge.

CONCLUSIONS

Significant differences exist between OHCA of drowning and presumed cardiac etiologies. Most drownings are unwitnessed, occur in public locations, and present with nonshockable initial rhythms, suggesting that treatment should focus on bystander CPR. Future initiatives should focus on strategies to improve supervision in targeted locations and greater emphasis on bystander-initiated CPR, both of which may reduce drowning mortality.

The Use of the Developmental Rate of the Aquatic Midge Chironomus riparius (Diptera, Chironomidae) in the Assessment of the Postsubmersion Interval

Nonbiting midges (Diptera, Chironomidae) are the most abundant members of the fauna associated with submerged carcasses, but their use in the medicolegal context is very restricted because of their complex ontogeny. In this case, the corpse of a woman was recovered in late spring from a river in Granada (Iberian Peninsula). It showed obvious signs of long permanence in the aquatic environment and, along with pulmonary and microscopical analyses, led to the conclusion that the cause of death was drowning. Several larvae-like specimens were sampled from the scalp and later identified by morphological external features as IV instar larvae of Chironomus riparius Meigen, 1804 (Diptera, Chironomidae). Sequencing of cytochrome oxidase subunit I was performed to confirm the identification. The knowledge of the biology of C. riparius at low temperatures was critical to assess a postsubmersion interval of 16-17 days.

Brain resuscitation in the drowning victim

Drowning is a leading cause of accidental death. Survivors may sustain severe neurologic morbidity. There is negligible research specific to brain injury in drowning making current clinical management non-specific to this disorder. This review represents an evidence-based consensus effort to provide recommendations for management and investigation of the drowning victim. Epidemiology, brain-oriented prehospital and intensive care, therapeutic hypothermia, neuroimaging/monitoring, biomarkers, and neuroresuscitative pharmacology are addressed. When cardiac arrest is present, chest compressions with rescue breathing are recommended due to the asphyxial insult. In the comatose patient with restoration of spontaneous circulation, hypoxemia and hyperoxemia should be avoided, hyperthermia treated, and induced hypothermia (32-34 °C) considered. Arterial hypotension/hypertension should be recognized and treated. Prevent hypoglycemia and treat hyperglycemia. Treat clinical seizures and consider treating non-convulsive status epilepticus. Serial neurologic examinations should be provided. Brain imaging and serial biomarker measurement may aid prognostication. Continuous electroencephalography and N20 somatosensory evoked potential monitoring may be considered. Serial biomarker measurement (e.g., neuron specific enolase) may aid prognostication. There is insufficient evidence to recommend use of any specific brain-oriented neuroresuscitative pharmacologic therapy other than that required to restore and maintain normal physiology. Following initial stabilization, victims should be transferred to centers with expertise in age-specific post-resuscitation neurocritical care. Care should be documented, reviewed, and quality improvement assessment performed. Preclinical research should focus on models of asphyxial cardiac arrest. Clinical research should focus on improved cardiopulmonary resuscitation, re-oxygenation/reperfusion strategies, therapeutic hypothermia, neuroprotection, neurorehabilitation, and consideration of drowning in advances made in treatment of other central nervous system disorders.

Prevention of drowning by community-based intervention: implications for low- and middle- income countries

Background

Drowning is a serious but neglected health problem in low-and middle-income countries.

Objectives

To describe the effectiveness of drowning prevention program on the reduction of drowning mortality rates in rural settings at the north of Iran, and guide its replication elsewhere.

Patients and Methods

This interventional design included pre- and post-intervention observations in the rural area of the Caspian Sea coastline without a comparison community. Cross-sectional data were collected at pre- and post-intervention phases. Outcome evaluation was based on a four-year period (March 2005-March 2009) utilizing drowning registry data for the north of Iran.

Results

The implementation program increased the rate of membership in an organization responsible for promoting safety in high risk areas near the Caspian Sea. Compared to a WHO standardized population, drowning incidence in rural areas of the study demonstrated a continuous decrease in age-specific drowning rate among the oldest victims with a gradual decline during the implementation. In the study area, the epidemiological aspects of the study population were exposed and contributing factors were highlighted.

Conclusions

This study showed that the promotion of passive interventions had a greater effect on drowning rate than that of active interventions.

Neurologic long term outcome after drowning in children

Drowning is a major source of mortality and morbidity in children worldwide. Neurocognitive outcome of children after drowning incidents cannot be accurately predicted in the early course of treatment. Therefore, aggressive out-of-hospital and in-hospital treatment is emphasized. There are "miracle" cases after long submersion times that have been reported in the medical literature, which mostly concern small children. However, many of the survivors will remain severely neurologically compromised after remarkably shorter submersion times and will consequently be a great burden to their family and society for the rest of their lives. The duration of submersion, the need of advanced life support at the site of the accident, the duration of cardiopulmonary resuscitation, whether spontaneous breathing and circulation are present on arrival at the emergency room are important factors related to survival with mild neurological deficits or intact function in drowned children. Data on long-term outcome are scarce. The used outcome measurement methods and the duration of follow-up have not been optimal in most of the existing studies. Proper neurological and neurophysiological examinations for drowned children are superior to outcome scales based chart reviews. There is evidence that gross neurological examination at the time of discharge from the hospital in young children does not reveal all the possible sequelae related to hypoxic brain injury and thus long-term follow-up of drowned resuscitated children is strongly recommended.

Drowning--a scientometric analysis and data acquisition of a constant global problem employing density equalizing mapping and scientometric benchmarking procedures

Background

Drowning is a constant global problem which claims approximately half a million victims worldwide each year, whereas the number of near-drowning victims is considerably higher. Public health strategies to reduce the burden of death are still limited. While research activities in the subject drowning grow constantly, yet there is no scientometric evaluation of the existing literature at the present time.

Methods

The current study uses classical bibliometric tools and visualizing techniques such as density equalizing mapping to analyse and evaluate the scientific research in the field of drowning. The interpretation of the achieved results is also implemented in the context of the data collection of the WHO.

Results

All studies related to drowning and listed in the ISI-Web of Science database since 1900 were identified using the search term "drowning". Implementing bibliometric methods, a constant increase in quantitative markers such as number of publications per state, publication language or collaborations as well as qualitative markers such as citations were observed for research in the field of drowning. The combination with density equalizing mapping exposed different global patterns for research productivity and the total number of drowning deaths and drowning rates respectively. Chart techniques were used to illustrate bi- and multilateral research cooperation.

Conclusions

The present study provides the first scientometric approach that visualizes research activity on the subject of drowning. It can be assumed that the scientific approach to this topic will achieve even greater dimensions because of its continuing actuality.

How is recovery from low back pain measured? A systematic review of the literature

Recovery is commonly used as an outcome measure in low back pain (LBP) research. There is, however, no accepted definition of what recovery involves or guidance as to how it should be measured. The objective of the study was designed to appraise the LBP literature from the last 10 years to review the methods used to measure recovery. The research design includes electronic searches of Medline, EMBASE, CINAHL, Cochrane database of clinical trials and PEDro from the beginning of 1999 to December 2008. All prospective studies of subjects with non-specific LBP that measured recovery as an outcome were included. The way in which recovery was measured was extracted and categorised according to the domain used to assess recovery. Eighty-two included studies used 66 different measures of recovery. Fifty-nine of the measures did not appear in more than one study. Seventeen measures used pain as a proxy for recovery, seven used disability or function and seventeen were based on a combination of two or more constructs. There were nine single-item recovery rating scales. Eleven studies used a global change scale that included an anchor of 'completely recovered'. Three measures used return to work as the recovery criterion, two used time to insurance claim closure and six used physical performance. In conclusion, almost every study that measured recovery from LBP in the last 10 years did so differently. This lack of consistency makes interpretation and comparison of the LBP literature problematic. It is likely that the failure to use a standardised measure of recovery is due to the absence of an established definition, and highlights the need for such a definition in back pain research.

Prognostic factors and outcome after drowning in an adult population

BACKGROUND

Drowning remains an actual problem. Although medical assistance has improved, it still has high rates of morbidity and mortality. We set out to explore the clinical characteristics and outcome of drowning patients admitted to the intensive care unit (ICU) of tertiary-care university hospital.

METHODS

We designed a retrospective observational study to analyse all drowning patients admitted to our ICU after successful cardiopulmonary resuscitation. The study was conducted during 1 January 1992-31 December 2005. There was no exclusion. We used a univariate analysis to evaluate the effect on patient and management characteristics on survival.

RESULTS

There were 43 patients (five children and 38 adults), with male predominance. Fifteen patients, all adults (34.9%), died. Submersion time, age, Glasgow Coma Score (GCS), pupillary reactivity and acute physiology and chronic health evaluation (APACHE II) at ICU admission were related to mortality. Non-survivors presented a higher glycaemia level at ICU admission than survivors (P=0.005).

CONCLUSIONS

The outcome is closely related to the patient's clinical status on arrival to the hospital. We have found that submersion time, age, GCS, pupillary reactivity and APACHE II at ICU admission were related to mortality. Further research in prospective studies is needed.

Out-of-hospital cardiac arrest due to drowning: An Utstein Style report of 10 years of experience from St. Mary's Hospital

BACKGROUND

Drowning is a unique form of cardiac arrest and is often preventable. "Utstein Style for Drowning" was published in 2003 by the International Liaison Committee on Resuscitation (ILCOR) to improve the knowledge-base, to provide epidemiological stratification, to recommend appropriate treatments and to ultimately save lives. We report on the largest single-center study of the Utstein Style resuscitation for drowning.

METHODS

All patients with out-of-hospital cardiac arrest (OHCA) due to drowning admitted to St. Mary's Hospital between 1998 and 2007 were included. Utstein Style variables and other time intervals not included in the Utstein Style guidelines were evaluated for their ability to predict survival. The primary end point of this study was survival to discharge.

RESULTS

We enrolled 131 patients with OHCA due to drowning; 21 patients (16.03%) had survival to discharge and 9 patients (6.87%) were discharged with a good neurologic outcome, i.e., cerebral performance categories (CPC) of 1 or 2. For the Utstein Style variables witnessed, the duration of submersion and the time of first emergency medical systems (EMS) resuscitation attempt influenced survival. For other time intervals, the transportation time (i.e., time interval from witnessing of the drowning to EMS arrival at the hospital, or if events were not witnessed, the time interval from calling the EMS to EMS arrival at the hospital), the duration of advanced cardiovascular life support (ACLS) and the duration of total arrest time were associated with survival.

CONCLUSIONS

Our report is the largest single-center study of OHCA due to drowning reported according to the guidelines of the Utstein Style. Being witnessed, having a short duration of submersion, having early resuscitation by EMS, and rapid transportation are important for survival after drowning.

Indoor versus outdoor childhood submersion injury in a densely populated city

AIM

To review the outcome of childhood submersion injury (SI).

METHODS

We reviewed discharge data of all children with SI who were hospitalized in a university teaching hospital between January 2002 and January 2008.

RESULTS

There were 15 admissions (8 males and 7 females). Outdoor SI (n = 10) were more common than indoor SI (n = 5) and 7 cases occurred in public swimming pools with life guard service. There were significant differences between the two types of SI. Indoor SI more likely occurred in the Chinese mainland. The victims were generally younger, more likely to have low Glasgow Coma Scale (GCS), asystole and intubation at the emergency department (ED). They were more likely to require intensive care, ventilatory support, neurological imaging and had worse neurological sequlae of death or hypoxic-ischaemic encephalopathy (HIE).

CONCLUSION

Indoor SI was associated with worse prognosis. All patients with GCS of 3 at ED and required intensive care support were either dead or incapacitated. Low GCS, pulselessness and intubation at the ED and seizures are also associated with adverse outcomes. Describing the mode of paediatric SI in a city where SI rarely occurs serves to heighten public awareness especially of home safety in the prevention of SI.

[Advanced life support under special circumstances: part 1]

Based on the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science with Treatment Recommendations of the International Liaison Committee on Resuscitation (ILCOR), guidelines were published for managing basic and advanced life-saving procedures in the event of cardiac arrest. The fact that special circumstances sometimes must be considered in patient treatment resulted in a separate chapter. This first part of a two-part article reviews essential information as well as necessary modifications of the standard advanced life support algorithm in cases of life-threatening drowning, asthma, anaphylaxis, and poisoning. The second part will deal with electrolyte disorders, hypothermia, electrical emergencies, trauma, cardiac arrest during pregnancy, and cardiac surgery.

Myocardial infarction after near drowning

During summer, near drowning is a common accident in Taiwan. It may lead to multiple organ damages in cases where severe hypothermia and hypoxemia occur. We present a case of myocardial infarction after near drowning. The patient was sent to our ED by the emergency medical services called by the witness. On arrival to our ED, hypothermia and hypoxemia overcame him. Endotracheal intubation and warm intravenous fluid were applied at once owing to drowsy consciousness, respiratory distress, and hypothermia. Electrocardiogram showed diffuse ST-segment elevation over the precordial leads V2-V6. The initial level of cardiac enzymes was within normal limit but elevated in troponin I on the second day after hospitalization. We presumed that the possibility of myocardial infarction resulted from near drowning-related hypoxemia. To our knowledge, this is the first case describing myocardial injury with electrocardiogram changes after near drowning.

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.