Submersion injuries in children and adults

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).

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.

Childhood drowning in Manitoba: A 10-year review of provincial Paediatric Death Review Committee data

BACKGROUND

Drowning is the second leading cause of unintentional injury death for Canadian children up to 19 years of age. Specific regional drowning prevention strategies require a detailed understanding of patterns of injury, including risk factors. Paediatric death review committees have the opportunity to identify these risk factors, and to identify and advocate prevention strategies.

OBJECTIVES

The purpose of the present study was to analyze Manitoba Paediatric Death Review Committee (PDRC) drowning data to identify drowning risk factors and potential prevention strategies.

METHODS

A 10-year (1988-1997) review of the College of Physicians and Surgeons of Manitoba PDRC database was performed. Drowning deaths were summarized in terms of demographic variables and lack of supervision at the time of the drowning events.

RESULTS

Seventy-three drowning deaths were reviewed by the PDRC during the study period. These children ranged from 29 days to 14 years of age. They included 50 boys and 30 First Nations children. The highest mortality rates were found in First Nations children (12.4/100,000 First Nations children compared with 1.9/100,000 non-First Nations children), boys (3.9/100,000 boys compared with 1.9/100,000 girls) and toddlers aged one to four years (5.9/100,000 children).

CONCLUSIONS

Priority populations for drowning prevention in Manitoba include First Nations children, boys and toddlers. Death review committees can contribute to childhood injury prevention by reviewing injury deaths, analyzing and reporting injury mortality data, and identifying and advocating prevention strategies.

Drowning for love: the aquatic victim-instead-of-rescuer syndrome: drowning fatalities involving those attempting to rescue a child

INTRODUCTION

Non-intentional child drowning remains a leading cause of child mortality. A related and secondary syndrome is composed of those who drown in impulsive, altruistic attempts to go to the aid of a drowning child. Such 'rescuers' who attempt to save a drowning child may themselves drown, a tragic event we term the AVIR syndrome or aquatic victim-instead-of-rescuer.

METHODS

This study is composed of a five-year (1 July 2002 to 30 June 2007) total population Australian survey, using the National Coroners Information System to identify cases and an analysis of every immersion rescuer-victim dyad where the primary 'victim' was a child and where the 'rescuer' drowned.

RESULTS

In Australia (2002-2007), 17 rescuers drowned in 15 incidents in which the primary victim was a drowning child. In 93% of the incidents, the primary 'child-victim' survived, 82% of the victims were unfamiliar with the aquatic location (i.e. were a visitor) and 76% of the victims were a male parent, partner of first-degree relative. Alcohol was not generally involved.

CONCLUSION

We define the AVIR syndrome as one that typically involves the following: a male, parent, partner or relative; an unfamiliar water hazard; a 'rescuer' who is a tourist; alcohol is not usually involved; and the primary victim usually survives. We posit that an increased awareness of such risks, the promotion of rudimentary rescue skills (e.g. being able to throw a lifeline) and increased advocacy for parents to learn the simple and basic life-saving skills of non-contact rescue will help reduce these drowning tragedies.

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.

Childhood drowning in low- and middle-income countries: Urgent need for intervention trials

Data available for low- and middle-income countries (LMICs) indicate that the burden of drowning in children is significant and becoming a leading public health problem. At the same time, interventions for drowning are not well documented in LMICs. The overall purpose of this paper is to make the case for research investments in conducting intervention trials to prevent child drowning in LMICs. In high-income countries (HICs), existing drowning prevention interventions include among others: pool fencing, supervision, lifeguards and water safety training at a young age. However, these measures may not be the most relevant in curtailing the number of drowning deaths in LMICs. There are differences with regard to geographical, social, cultural and behavioural factors associated with drowning between HICs and LMICs, often making it inappropriate to apply existing interventions directly in LMIC settings. This paper focuses on drowning from LMICs and reveals a dearth of data on incidence rates and risk factors; absence of public health interventions; lack of research on intervention effectiveness and cost-effectiveness; and paucity of national drowning prevention programs. Based on this evidence, this paper calls for immediate attention to drowning prevention by increasing research investments. This paper specifically discusses Bangladesh as a case study and proposes a drowning intervention study focusing on children less than 5 years in LMICs as an example of appropriate research investment.

Strontium levels in different causes of death: diagnostic efficacy in drowning

Trace element determination can be applied in forensic medicine to diagnose the cause of death. Drowning is the second leading cause of death from unintentional injury. Despite the many diagnostic methods used, the post-mortem diagnosis of drowning continues to be one of the most difficult in forensic pathology. Strontium is a highly sensitive marker of water aspiration in a liquid medium rich in this metal. The aims of this study were to confirm the diagnostic value of strontium in cases of drowning compared with other causes of death, to analyse factors that could affect its concentration and to ascertain the sensitivity and specificity of strontium in right and left ventricles and peripheral serum for the post-mortem diagnosis of drowning. We studied 120 cadavers selected from medico-legal autopsies with different causes of death. Strontium (Sr) levels were measured in the serum (left and right ventricles and peripheral vein) of all cadavers and, in the case of drowning, in the water medium itself, by using Zeeman AAS. Our results confirm the usefulness of blood Sr levels for diagnosing seawater and freshwater drowning, although great care should be exercised in the latter case.

Cardiac troponin I as a predictor of mortality for pediatric submersion injuries requiring out-of-hospital cardiopulmonary resuscitation

BACKGROUND

It is difficult to predict ultimate survivors to hospital discharge in children who are successfully resuscitated after a cardiorespiratory arrest associated with a submersion injury. Serum measurements of organ injury or dysfunction may serve as a surrogate marker of the degree of hypoxic injury. We designed a prospective study whose purpose was to assess the predictive value for outcome of serum cardiac troponin I measurements after submersion injury and cardiorespiratory arrest.

METHODS

This is a prospective, observational study of children admitted to a postintensive care unit after experiencing an out-of-hospital cardiorespiratory arrest associated with a submersion event. Cardiac troponin I measurements were examined upon admission to the postoperative intensive care unit after successful emergency department resuscitation.

RESULTS

Nine patients were admitted, and 2 patients (22%) survived to hospital discharge. The area under the receiver operating characteristic curve is 0.786 (95% confidence interval, 0.481-1.0). This suggests that cardiac troponin I has a moderate degree of discriminatory power in selecting children who did not survive to hospital discharge.

Recommendations for water safety and drowning prevention for travelers

Drowning is a serious worldwide, mostly preventable injury problem, particularly among international travelers. In 2000, approximately 449,000 people have drowned worldwide, and the exact number of travelers is not precisely known. Although comprehensive infectious disease information has been available to international travelers for many years, advice on injury risk and prevention, more specifically on drowning prevention, has received little attention. The goals of this review were to develop research-based drowning prevention and water-safety recommendations for travelers and to identify research needs for future recommendations. A group of injury-prevention and travel-medicine experts conducted several rounds of voting and ranking of the strength and evidence of drowning-prevention recommendations. Each of the thirty-two recommendations created have also been categorized using the Committee to Advise on Tropical Medicine and Travel scale and have been framed in the context of preevent, event, and postevent categories commonly used in injury-control theory and Haddon's Matrix. These recommendations were developed for use by travel-medicine professionals or others who prepare individuals for travel. Several of the identified interventions to prevent drownings lack conclusive scientific evidence of their effectiveness and warrant further studies to better understand their true effectiveness. Furthermore, funding for the studies of intervention effectiveness and the implications of these interventions for international travelers are essential, yet insufficient.

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.

Ahogamientos y casi ahogamientos en niños

OBJECTIVE

Immersion accidents are still an important cause of morbidity and mortality in children. We performed a retrospective study to identify the prognostic factors associated with outcome in children who experience near-drowning, which could serve to guide decision-making. Our data were compared with other published data.

PATIENTS AND METHODS

The medical records of children treated for near-drowning in our hospital from January 1995 to April 2003 were reviewed. The data analyzed referred to the patient, the accident, the patient's clinical status in the emergency unit, the unit to which the patient was admitted, and outcome.

RESULTS

Sixty-two patients were included. Of these, outcome was bad in 12 (death in seven and irreversible sequelae in five). Statistically significant predictors of bad prognosis were age > or = 4 years, female sex, immersion time > or = 5 min, cyanosis in the emergency room, cardiac arrest, apnea or severe distress, hypothermia (core temperature < 35 degrees C), metabolic acidosis (pH < or = 7.10) and neurologic damage (Glasgow coma Scale score 3; Conn C; nonreactive and mydriatic pupils) on arrival at the hospital.

CONCLUSIONS

Outcome is closely related to the patient's clinical status on arrival at the hospital. Although data that can serve as a guide to the final outcome of the nearly-drowned patient are available, early models to predict the final clinical results of each case, which could be used to guide initial resuscitation and subsequent treatment, are lacking.

Submersion

Many thousands of individuals are submersion victims each year in the United States. The majority of victims are young, previously healthy people. There have been no recent breakthroughs in medical technology or treatment modalities that have improved survival rates for submersion victims. The key to their successful outcome and return to productive, full lives is aggressive resuscitation by emergency physicians and prehospital care providers. Most submersion incidents should never take place. Emergency physicians can take the lead in public education and prevention.

Characteristic features of suicidal drownings: a 20-year study

A retrospective study of cases of drowning suicide was undertaken at the Forensic Science Centre in Adelaide, South Australia for the period April 1980 to March 2000. A total of 123 cases were found, with 76 males (age, 16-88 years; average, 50.5 years; standard deviation [SD], 20.1 years) and 47 females (age, 34-88 years; average, 60.6 years; SD, 13.9 years). There were 66 fresh water drownings and 57 saltwater drownings. Female victims were significantly older than male victims for both fresh water and saltwater drownings (P < .05 and P < .01, respectively). Deaths in young women were rare. No temporal trend in drowning suicides could be shown, with annual numbers varying from 0 to 12 cases (average, 6.15; median, 7). Women preferentially chose the ocean or bath to drown themselves in, whereas males chose rivers, ditches, and lakes. Swimming pools were rarely used for suicide in this population; alcohol use was not usual; and there was often a significant history of mental illness.

Drowning. Rescue, resuscitation, and reanimation

Several myths about drowning have developed over the years. This article has attempted to dispel some of these myths, as follows: 1. Drowning victims are unable to call or wave for help. 2. "Dry drownings" probably do not exist; if there is no water in the lungs at autopsy, the victim probably was not alive when he or she entered the water. 3. Do not use furosemide to treat the pulmonary edema of drowning; victims may need volume. 4. Seawater drowning does not cause hypovolemia, and freshwater drowning does not cause hypervolemia, hemolysis, or hyperkalemia. 5. Drowning victims swallow much more water than they inhale, resulting in a high risk for vomiting spontaneously or on resuscitation. No discussion of drowning would be complete without mentioning the importance of prevention. Proper pool fencing and water safety training at a young age are instrumental in reducing the risk for drowning. Not leaving an infant or young child unattended in or near water can prevent many of these deaths, especially bathtub drownings. Also crucial is the use of personal flotation devices whenever boating. Proper training in water safety is crucial for participation in water recreation and sporting activities, including SCUBA diving. The incidence of pediatric drowning deaths in the United States has decreased steadily over the past decade, perhaps as a result of increased awareness and attention to drowning-prevention measures (Box 1).

Predicting outcome in hypoxic-ischemic brain injury

Predicting the neurologic outcome of children after a hypoxic-ischemic event continues to be a challenge for intensivists and pediatric neurologists. Nevertheless, with accurate history taking, serial neurologic examination, and some ancillary studies, the clinician can predict accurately whether a child will die or have profound neurologic damage. Aggressive resuscitation should be offered to all children when found in CPA. A simple ingestion might have led to this clinical scenario, and complete neurologic recovery may be possible if effective resuscitation is implemented. In cases of drowning, several factors, if present, are consistent with profound neurologic sequelae or death. These include prolonged submersions with asystole, delayed onset of CPR, no spontaneous respirations on arrival to the emergency department, and low initial pH value. The options of withdrawal of life support or a DNR status should be offered to families of children who have survived a devastating hypoxic-ischemic event but who are in a PVS. If brain-death criteria have been fulfilled, the patient must then be disconnected from life support after organ donation has been discussed with the family.

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.