Near Drowning

Angiotensin II for Near Drowning: A Case Series

Objective:

This case series describes the effect of angiotensin II administration on hemodynamics in patients with parenchymal lung injury due to submersion injury.

Case Summary:

A 33-year-old female and a 72-year-old female were both brought to the emergency department after incidents of near drowning. Upon arrival to the emergency department, both patients were hemodynamically unstable and were eventually intubated for airway protection. Imaging done by conventional chest radiograph for both patients revealed bilateral pulmonary edema. Due to their hemodynamic status, vasopressors were initiated for both patients and were quickly titrated, leading to the initiation of angiotensin II. In one patient, angiotensin II was initiated early in shock and resulted in rapid improvement of hemodynamics. In the other patient, angiotensin II was initiated later and a more muted response was observed.

Conclusions:

In patients with near drowning, angiotensin II appeared to improve hemodynamic status rapidly. This is the first case series to report the use of this new vasoactive agent in this population and poses noteworthy mechanistic considerations.

Morphological and biochemical changes in the pancreas associated with acute systemic hypoxia

This study aimed to investigate the changes associated with acute systemic hypoxia in the endocrine system, particularly in pancreatic tissues. The investigation was based on macroscopic, pathohistological, biochemical, and molecular biological findings in cell lines and human cadavers. The results showed that cases of death due to asphyxia more frequently showed severe subcapsular/interstitial hemorrhage versus the other causes of death. Histological examination showed that asphyxia cases were associated with severe morphological changes. Although measured insulin levels in the asphyxia were higher compared to other causes of death, no differences were noted for the glucagon and amylase levels with regard to the cause of death. Increased blood insulin levels were not associated with macro- and micromorphological changes, and did not show any association with glucose or cortisol levels. The experiment conducted under hypoxic conditions in cultured cells demonstrated that insulin mRNA expression and insulin protein levels peaked at 10 min after hypoxia exposure. However, there were no changes in either the amylase mRNA or protein levels. Corticosterone level peaked at 120 min after exposure to hypoxic conditions. Overall, acute systemic hypoxic conditions can directly affect the mechanisms involved in pancreatic insulin secretion.

Drowning in Children: Retrospective Analysis of Incident Characteristics, Predicting Parameters, and Long-Term Outcome

BACKGROUND

Drowning is the second leading cause of unnatural death in childhood worldwide. More than half of the drowned children, who were in need of cardiopulmonary resuscitation (CPR) at the scene suffered from lifelong neurological sequelae. There are few data about prognostic predictors in the pediatric population of drowning victims. The objective of the study was to assess incident characteristics, prognostic parameters, and long-term outcome of children recovering from a drowning incident.

METHODS

We carried out a retrospective analysis of data of the cohort of pediatric cases (age 0-18) of drowning victims admitted in the years 2000-2015 to the emergency room/intensive care unit/pediatric ward at the University Children's Hospital of Zurich, Switzerland. Outcome was classified by the Pediatric Cerebral Performance Category Scale (PCPCS). New subcategories of severity for known prognostic parameters have been defined. A correlation analysis was performed between the subcategories of the prognostic parameters and the PCPCS.

RESULTS

A total of 80 patients were included in the analysis. Of these, 64% were male, most of the patients were at the age of 0-5 years. More than 80% of the patients were unattended at a public or private pool when the drowning incident happened. In all, 61% (n = 49) needed cardiopulmonary resuscitation (CPR). Of the resuscitated children, 63% showed good to mildly impaired long-term outcome (PCPCS 1-3). Furthermore, 15% (n = 12) were transferred to rehabilitation. Seven children died during the hospital stay and another four died due to complications in the ten years following the incident. The newly defined subcategories of the parameter submersion time, Glasgow Coma Scale (GCS) at time of admission, body temperature at time of admission, blood pH, blood glucose, and blood lactate level correlated significantly with the PCPCS.

CONCLUSIONS

Supervision of children, especially boys of the age 0-5 years, next to public or private pools is most important for prevention of drowning incidents in Switzerland. Cardiopulmonary resuscitation done by trained staff leads to a better long-term outcome. Medical decision making in severe cases of drowning should consider submersion time, GCS at time of admission, body temperature at time of admission, blood pH, blood glucose, and blood lactate levels, as these parameters correlate with long-term outcome.

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.

Predictors for hospital admission of asymptomatic to moderately symptomatic children after drowning

Drowning is a leading cause of injury-related death worldwide, but there are limited data on the management and disposition of asymptomatic and mildly symptomatic adults and children following a drowning event. Some authors have recommended admission for all drowning victims due to the possibility of respiratory and clinical deterioration in a seemingly well patient. In order to identify predictors for admission and to establish a unified approach for management, we retrospectively collected all children ≤ 16 years old presented following a drowning event to the pediatric ED over a period of 12 years. The children were divided into two groups, those who were discharged home from the ED and those who were admitted. Seventy-one surviving and non-intubated children were asymptomatic to moderately symptomatic, and they comprised the study group. Crepitations on lung auscultation, oxygen desaturation, and respiratory distress were significantly higher in the admitted group (n = 26) compared with the discharged group (n = 45) (P < 0.05). Respiratory distress and lung crepitations were independent predictors for admission. Eventually, 30% of the hospitalized patients required oxygen therapy, but there were no cases that deteriorated and required invasive ventilation. No readmissions occurred in the group of children who were discharged from the ED.Conclusion: Children who after six hours show no respiratory distress and have normal oxygen saturation and normal auscultation can be safely discharged home. Respiratory distress and lung crepitations should both warrant the physician to consider admission of asymptomatic to moderately symptomatic children following a drowning event. An algorithm to assist patient management is proposed. What is Known: •There are few data in the literature regarding the management and disposition of asymptomatic to moderately symptomatic children after drowning. What is New: •We found that respiratory distress and lung crepitations are independent predictors for admission. An algorithm to assist patient management is proposed.

Incidence and Consequences of Near-Drowning-Related Pneumonia-A Descriptive Series from Martinique, French West Indies

Drowning represents one major cause of accidental death. Near-drowning patients are exposed to aspiration that may result in pneumonia with life-threatening consequences. We designed this descriptive study to investigate the frequency, nature, and consequences of post-drowning pneumonia. One hundred and forty-four near-drowning patients (33 children and 111 adults) admitted during four years to the University Hospital of Martinique, French Indies, were included. Patients presented pre-hospital cardiac arrest (41%) and exhibited acute respiratory failure (54%), cardiovascular failure (27%), and lactic acidosis (75%) on admission. Empirical antibiotics, as decided by the physicians in charge, were administered in 85 patients (59%). Post-drowning early onset bacterial pneumonia was diagnosed as “possible” in 13 patients (9%) and “confirmed” in 22 patients (15%). Tracheal aspiration revealed the presence of polymorphous pharyngeal flora (59%) or one predominant bacteria species (41%) including Enterobacter aerogenes, Enterobacter cloacae, Staphylococcus aureus, Pseudomonas aeruginosa, Aeromonas hydrophilia, and Morganella morgani. Despite adequate supportive care, drowning resulted in 45 fatalities (31%). Early onset bacterial aspiration pneumonia (either possible or confirmed) did not significantly influence the risk of death. In conclusion, near-drowning–related bacterial aspiration pneumonia seems rare and does not influence the mortality rate. There is still a need for practice standardization to improve diagnosis of post-drowning pneumonia and near-drowning patient management.

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.

Drowning--post-mortem imaging findings by computed tomography

The aim of this study was to identify the classic autopsy signs of drowning in post-mortem multislice computed tomography (MSCT). Therefore, the post-mortem pre-autopsy MSCT- findings of ten drowning cases were correlated with autopsy and statistically compared with the post-mortem MSCT of 20 non-drowning cases. Fluid in the airways was present in all drowning cases. Central aspiration in either the trachea or the main bronchi was usually observed. Consecutive bronchospasm caused emphysema aquosum. Sixty percent of drowning cases showed a mosaic pattern of the lung parenchyma due to regions of hypo- and hyperperfused lung areas of aspiration. The resorption of fresh water in the lung resulted in hypodensity of the blood representing haemodilution and possible heart failure. Swallowed water distended the stomach and duodenum; and inflow of water filled the paranasal sinuses (100%). All the typical findings of drowning, except Paltau's spots, were detected using post-mortem MSCT, and a good correlation of MSCT and autopsy was found. The advantage of MSCT was the direct detection of bronchospasm, haemodilution and water in the paranasal sinus, which is rather complicated or impossible at the classical autopsy.

Use of the histopathology in the differential diagnosis of drowning in fresh and salty water: an experimental model establishment in rats

PURPOSE: To develop a method of differential diagnosis to drowning, due to analysis of the alveolar macrophages quantitative, in rats submitted to induced drowning in fresh water and salty water. METHODS: Were used 15 male adult rats Wistar EPM-1, weight 360g (SD=21,3), randomized in three groups: G1- Control; G2- Fresh water; G3- Salty water, each one with n=5. The animals have been anesthetized and tracheostomized to insert a cannula inside the trachea, for drowning induction. The lungs have been removed, weighed, prepared for histology and colored by immunohistochemistry. The macrophages have been counted in both lungs (right and left) of each animal. The statistical test used was ANOVA (SPSS.10) with p<0,05. RESULTS: The amount of macrophages was G3>G2>G1 with p=0,0001 in each comparison. The weight of lungs of G3 and G2 was higher than G1, with p>0,0001, however G3 and G2 do not possess difference statistics in the weight of lungs. CONCLUSION: The developed diagnostic method was efficient in rats. The results, if expanded, will be able to assist the Forensic Pathology for technique of low cost and high trustworthiness.

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.

Drowning: a review of epidemiology, pathophysiology, treatment and prevention

Although often preventable, drowning remains a leading cause of accidental death, especially in children. New definitions classify drowning as the process of experiencing respiratory impairment from submersion or immersion in a liquid. The key pathophysiological feature in drowning is hypoxia. Accurate neurological prognosis cannot be predicted from the initial clinical presentation, laboratory, radiological, or electrophysiological examinations. Prompt and aggressive resuscitation attempts are crucial for optimal survival. This article reviews the epidemiology, pathophysiology, treatment, and prevention of drowning.

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.

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.

Helicopter transport of patients to tertiary care centers after cardiac arrest

Air transport is commonly used to transfer survivors of cardiac arrest from rural hospitals to large tertiary-care centers, presumably to improve outcome. To examine this issue, a retrospective review of patients stabilized after a cardiac arrest was conducted; 157 transports were reviewed. The mean age of patients was 37.9 +/- 27.8 yrs, with a male to female ratio of 2.2:1. Survivors were significantly older than nonsurvivors. Thirty-one of 69 patients (45%) with primary cardiac disease were discharged alive from the hospital, 75% without neurological sequelae. Only a minority of patients with noncardiac medical illness (7%), electrical injury (33%), suffocation (15%), near-drowning (15%), and inhalation (0%) were discharged alive from the hospital. Outcomes for cardiac arrest in adult patients older than 65 years (32.3% survival) were similar to those for adult patients younger than 65 years (36.2% survival) (P = .887). These results show that survivors of a primary cardiac event have a favorable outcome when transferred by air to tertiary centers when compared with historical controls that were transported by ground. On the other hand, cardiac arrests from noncardiac medical illness, suffocation, near-drowning, and inhalation have a grim prognosis. Prospective studies should clarify the role of air transport in these patients.

Pneumonia associated with near-drowning

Drowning and near-drowning can abruptly devastate the lives of both the affected victims and their families. In addition to the complications directly caused by the submersion, several indirect causes of morbidity exist. Infection is one of the complications associated with near-drowning, and pneumonia is the most severe of these infectious complications. The risk factors, microbiological causes, diagnostic approach, and appropriate therapy for pneumonia associated with near-drowning are not well described in the literature. Herein, we review the epidemiology and pathophysiology associated with near-drowning, discuss the potential mechanisms of infection, and describe the likely risk factors for pneumonia related to near-drowning. We also detail the microbiological causes of this entity and provide important clinical and epidemiological information associated with specific pathogens. Finally, we summarize an appropriate diagnostic and therapeutic approach to pneumonia associated with near-drowning.

Near-drowning-associated Aeromonas pneumonia

Aeromonas is increasingly recognized as a human pathogen that causes a variety of different infections. Aeromonas has rarely been reported as a cause of respiratory infection, and it has been described in near-drowning-associated pneumonia. This article reviews a case of Aeromonas sobria pneumonia associated with a near drowning and considers the clinical and epidemiological characteristics of 10 previously reported cases. Nearly all of the cases involved young healthy men, a rapid development of pneumonia and sepsis after a brief stable period postimmersion, and bilateral infiltrates on chest radiography. A very high rate of positive blood cultures and mortality was also noted. The epidemiological and clinical data in this review may be helpful to the clinician caring for near-drowning victims. Although prophylactic antibiotics are not recommended for near-drowning victims, broad-spectrum antibiotics should be rapidly instituted with any evidence of infection.

Near-drowning: epidemiology, pathophysiology, and initial treatment

Drowning is a major cause of accidental deaths, especially in children. The most serious pathophysiologic consequence of near-drowning is hypoxemia, which usually is due to aspiration-induced noncardiogenic edema. Therefore, initial resuscitative efforts need to be directed at establishing adequate oxygenation and ventilation, followed by rewarming and fluid administration. Although completely asymptomatic patients with normal vital signs, oxygenation and chest radiographs require only 4 to 6 hours of observation, many near-drowning victims will require at least 24 hours of observation. Despite these measures, approximately 25% of victims presenting to the Emergency Department will die and another 6% will develop neurological sequelae. Therefore, it is vital that better efforts be made by the community in promoting and instituting water safety programs.

Advanced Cardiac Life Support

In brief Changes in the advanced car-brief diac life support guidelines in-elude a new classification system for interventions, training in the use of automated defibrillators, and required early defibrillation for ventricular fibrillation. The algorithms for treating ventricular fibrillation and pulseless ventricular tachycardia, pulseless electrical activity, and asystole are reviewed. Cardiac arrest caused by special circumstances-hypothermia, near drowning, trauma, and electrical injuries-presents additional treatment considerations.