Prognostic implications of hyperglycemia and reduced cerebral blood flow in childhood near-drowning

We retrospectively examined the clinical courses of 20 children with severe near-drowning and divided their outcomes into 3 groups: normal (4), persistent vegetative state (9), and dead (7). We reviewed serial blood glucose levels and cerebral blood flow measured by stable xenon computed tomography within the 1st 48 hours of admission to determine whether they were predictive of outcome. Total, frontal gray, frontal white, and temporal and parietal gray matter cerebral blood flows were significantly decreased in children who died compared with those who completely recovered. Only 1/2 the children surviving in a vegetative state had decreased flows compared with those who recovered. An elevated initial blood glucose was highly predictive of those patients who died (mean, 511 +/- 110 mg%) or those with vegetative survival (465 +/- 104 mg%) compared with those who recovered completely (238 +/- 170 mg%). The predictive value of initial blood glucose alone (68%) or CBF alone (50%) was similar to that of clinical rating scales or immersion/resuscitation times. The combination of blood glucose with CBF improved predictability to 79%. Our results suggest that CBF measurements are predictive of eventual death but cannot differentiate normal from vegetative survival. Combining multiple laboratory studies may be of value in predetermining the eventual outcome in near-drowning.

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.

The etiology of pulmonary edema in fresh water near-drowning

Drowning is a significant cause of death in children and young adults. It is thought to result from the inhalation of either fresh or sea water resulting in lung damage and ventilation-perfusion mismatching. The clinical course, chest roentgenographs, serum electrolytes, alveolar-arterial oxygen gradient, and complete blood count of 10 fresh water drowning victims with pulmonary edema were recorded. Six responded dramatically clinically and radiographically within 24 hours, and most did not have significant alterations of their serum electrolyte levels, especially serum chloride. On the basis of the rapid clearing of the pulmonary edema and the lack of evidence of significant fluid aspiration, neurogenic pulmonary edema is postulated to have played a role in the development of the pulmonary edema in these patients.

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.

Near-drowning in the Dead Sea: a retrospective observational analysis of 69 patients

BACKGROUND

The Dead Sea in Israel has a very high mineral content. Near-drowning in the Dead Sea is expected to result in severe electrolyte abnormalities and respiratory failure. Previous limited studies reported a high mortality rate.

OBJECTIVE

To evaluate the clinical and biochemical manifestations and disease outcome of near-drowning in the Dead Sea.

METHODS

Data were abstracted from the archives of Soroka University Medical Center. The cohort comprised 69 patients who nearly drowned in the Dead Sea.

RESULTS

The median age of the patients was 68 years (range 21-84). There were two major manifestations of near-drowning in the Dead Sea: electrolyte imbalance and acute lung injury. Serum calcium, magnesium and phosphorus (but not sodium, potassium and chloride) were abnormal in most patients. Median serum electrolyte levels (and range) on admission were 10.9 mg/dl (9-24) for calcium, 4.3 mg/dl (1-30) for magnesium, and 4.1 mg/dl (2-9) for phosphorus. These levels quickly normalized with forced diuresis within 24 hours. Acute lung injury--namely, hypoxic bilateral pneumonitis--occurred in 29 patients. Mechanical ventilation was required in 11 patients. Sixty-five patients recovered fully, while the remaining 4 had minor sequelae.

CONCLUSIONS

Near-drowning in the Dead Sea is a syndrome of severe electrolyte abnormalities and lung injury. Early treatment with forced diuresis and supportive care results in prompt recovery.

Extracorporeal membrane oxygenation and CO2 removal in an adult after near drowning

Near drowning is a common event among otherwise healthy young people. The development of ARDS in the setting may significantly increase mortality. The traditional means of ventilation may lead to barotrauma. Extracorporeal membrane oxygenation (ECMO) is an effective means to improve oxygenation and remove carbon dioxide, while allowing the lungs to recover from the acute insult. It may be especially successful in those victims with single organ injury. We report the use of ECMO in a young adult with ARDS and pneumonia after near drowning.

Drowning and near-drowning: current concepts and neutrophil function studies

A near-drowning by a young man in an indoor pool is reported, and the current concepts of therapy are discussed. Laboratory studies of the patient's neutrophil function and chemotactic response were performed on the day of admission and on hospital days 2 and 4. Neutrophil function and chemotaxis were equal to control values, indicating no effect of near-drowning on these aspects of the host immune system. Hospital admission and supportive therapy including intubation, positive end-expiratory pressure, steroids, and antibiotics are recommended, if necessary, in management of the nearly drowned patient.