Pulmonary oedema, pneumonia and mortality in submersion victims; a retrospective study in 125 patients

Factors Associated with Pediatric Drowning-Associated Lung Injury

OBJECTIVE

To identify risk factors for clinically-important drowning-associated lung injury (ciDALI) in children.

STUDY DESIGN

This was a cross-sectional study of children (0 through 18 years) who presented to 32 pediatric emergency departments (EDs) from 2010 through 2017. We reviewed demographics, comorbidities, prehospital data, chest radiographs reports, and ED course from emergency medical services, medical, and fatality records. We defined ciDALI as presence of any of the following: (1) drowning deaths without cerebral/cervical spine injuries; (2) supplemental oxygen >8 hours postdrowning; (3) invasive/noninvasive ventilatory support in first 24 hours; or (4) abnormal chest radiographic findings in the first 24 hours without resolution within 8 hours postdrowning. We used mixed-methods logistic regression with site as random effect to identify risk factors and bootstrapping to reduce overfitting.

RESULTS

We enrolled 4213 patients (no ciDALI = 3045 [72%]; ciDALI = 1168 [28%]). The median age was 3 years (IQR: 1, 5). The risk factors for patients with ciDALI were age >5 years old (aOR: 2.4 [95% CI: 2.0-3.0]); submersion >5 minutes (aOR: 6.0 [95% CI: 3.5-10.2]); any scene resuscitation (aOR: 3.3 [95% CI: 2.5-4.5]) and at presentation to the ED abnormal mentation (aOR: 6.4 [95% CI: 4.1-10.0]), abnormal heart rate (aOR: 1.8 [95% CI: 1.6-2.1]), abnormal respiratory rate (aOR: 1.8 [95% CI: 1.4-2.3]), hypotension (aOR: 2.8 [95% CI: 1.0-7.4]), and abnormal lung auscultation (OR: 3.9 [95% CI: 2.9-5.4]).

CONCLUSIONS

Pediatric ciDALI risk factors include older age, scene resuscitation, prolonged submersion, and abnormal pulmonary, hemodynamic, and neurological findings at ED presentation. Prospective research to stratify risks based on submersion-related lung injury is needed to help determine short-term outcome and optimize patient disposition.

Impact of lifeguard oxygen therapy on the resuscitation of drowning victims: Results from an Utstein Style for Drowning Study

INTRODUCTION

No published evidence was identified regarding the use of oxygen in the treatment of drowning in two recent systematic reviews. The aim of our study was to investigate the impact of on scene, pre-Emergency Medical Services (EMS) oxygen therapy by lifeguards in the resuscitation of drowning victims.

METHOD

We conducted a retrospective case match analysis of drowning patients presenting to the EDs of Sunshine Coast Hospital and Health Service. Patients were matched for age, sex and severity of drowning injury. The primary outcome was in-hospital mortality. Secondary outcomes included positive pressure ventilation (PPV) by EMS and the ED, as well as admission to the Intensive Care Unit.

RESULTS

There were 108 patients in each group. Median (IQR) age was 22 (15-43) in the oxygen group and 23 (15-44) years in the non-oxygen group. There were 45 females in the oxygen group and 41 females in the non-oxygen group. Sixteen patients had suffered cardiac arrest and three patients respiratory arrest in each group. There were five deaths in each group. Initial oxygen saturation on arrival of EMS was identical in both groups 89.2% (±19.9) in the oxygen group versus 89.3% (±21.1) (P = 0.294) in the non-oxygen group. The oxygen group required PPV more frequently with EMS (19 vs 11, P < 0.01) and in the ED (19 vs 15, P < 0.01).

CONCLUSION

On scene treatment with oxygen by lifeguards did not improve oxygenation or outcomes in drowning patients.

Microbiological features of drowning-associated pneumonia: a systematic review and meta-analysis

BACKGROUND

Drowning-associated pneumonia (DAP) is frequent in drowned patients, and possibly increases mortality. A better understanding of the microorganisms causing DAP could improve the adequacy of empirical antimicrobial therapy. We aimed to describe the pooled prevalence of DAP, the microorganisms involved, and the impact of DAP on drowned patients.

METHODS

Systematic review and meta-analysis of studies published between 01/2000 and 07/2023 reporting on DAP occurrence and microorganisms involved.

RESULTS

Of 309 unique articles screened, 6 were included, involving 688 patients. All were retrospective cohort studies, with a number of patients ranging from 37 to 270. Studies were conducted in Europe (France N = 3 and Netherland N = 1), United States of America (N = 1) and French West Indies (N = 1). Mortality ranged between 18 to 81%. The pooled prevalence of DAP was 39% (95%CI 29-48), similarly following freshwater (pooled prevalence 44%, 95%CI 36-52) or seawater drowning (pooled prevalence 42%, 95%CI 32-53). DAP did not significantly impact mortality (pooled odds ratio 1.43, 95%CI 0.56-3.67) but this estimation was based on two studies only. Respiratory samplings isolated 171 microorganisms, mostly Gram negative (98/171, 57%) and mainly Aeromonas sp. (20/171, 12%). Gram positive microorganisms represented 38/171 (22%) isolates, mainly Staphylococcus aureus (21/171, 12%). Water salinity levels had a limited impact on the distribution of microorganisms, except for Aeromonas sp. who were exclusively found following freshwater drowning (19/106, 18%) and never following seawater drowning (0%) (p = 0.001). No studies reported multidrug-resistant organisms but nearly 30% of the isolated microorganisms were resistant to amoxicillin-clavulanate, the drug that was the most commonly prescribed empirically for DAP.

CONCLUSIONS

DAP are commonly caused by Gram-negative bacteria, especially Aeromonas sp. which is exclusively isolated following freshwater drowning. Empirical antimicrobial therapy should consider covering them, noting than amoxicillin-clavulanate may be inadequate in about one-third of the cases. The impact of DAP on patients' outcome is still unclear.

Wilderness Medical Society Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2024 Update

The Wilderness Medical Society convened a panel to review available evidence supporting practices for acute management of drowning in out-of-hospital and emergency care settings. Literature about definitions and terminology, epidemiology, rescue, resuscitation, acute clinical management, disposition, and drowning prevention was reviewed. The panel graded available evidence supporting practices according to the American College of Chest Physicians criteria and then made recommendations based on that evidence. Recommendations were based on the panel's collective clinical experience and judgment when published evidence was lacking. This is the second update to the original practice guidelines published in 2016 and updated in 2019.

Drowning in Children and Predictive Parameters: A 15-Year Multicenter Retrospective Analysis

BACKGROUND

Drowning is a serious and underestimated public health problem, with the highest morbidity and mortality reported among children. Data regarding pediatric outcomes of drowning are often inadequate, and data collection is poorly standardized among centers. This study aims to provide an overview of a drowning pediatric population in pediatric emergency department, focusing on its main characteristics and management and evaluating prognostic factors.

METHODS

This is a retrospective multicenter study involving eight Italian Pediatric Emergency Departments. Data about patients between 0 to 16 years of age who drowned between 2006 and 2021 were collected and analyzed according to the Utstein-style guidelines for drowning.

RESULTS

One hundred thirty-five patients (60.9% males, median age at the event 5; interquartile range, 3-10) were recruited and only those with known outcome were retained for the analysis (133). Nearly 10% had a preexisting medical conditions with epilepsy being the most common comorbidity. One third were hospitalized in the intensive care unit (ICU) and younger males had a higher rate of ICU admission than female peers. Thirty-five patients (26.3%) were hospitalized in a medical ward while 19 (14.3%) were discharged from the emergency department and 11 (8.3%) were discharged after a brief medical observation less than 24 hours. Six patients died (4.5%). Medium stay in the ED was approximately 40 hours. No difference in terms of ICU admission was found between cardiopulmonary resuscitation performed by bystanders or trained medical personnel ( P = 0.388 vs 0.390).

CONCLUSIONS

This study offers several perspectives on ED victims who drowned. One of the major finding is that no difference in outcomes was seen in patients who received cardiopulmonary resuscitation performed by bystanders or medical services, highlighting the importance of a prompt intervention.

Noncardiogenic pulmonary edema in small animals

OBJECTIVE

To review various types of noncardiogenic pulmonary edema (NCPE) in cats and dogs.

ETIOLOGY

NCPE is an abnormal fluid accumulation in the lung interstitium or alveoli that is not caused by cardiogenic causes or fluid overload. It can be due to changes in vascular permeability, hydrostatic pressure in the pulmonary vasculature, or a combination thereof. Possible causes include inflammatory states within the lung or in remote tissues (acute respiratory distress syndrome [ARDS]), airway obstruction (post-obstructive pulmonary edema), neurologic disease such as head trauma or seizures (neurogenic pulmonary edema), electrocution, after re-expansion of a collapsed lung or after drowning.

DIAGNOSIS

Diagnosis of NCPE is generally based on history, physical examination, and diagnostic imaging. Radiographic findings suggestive of NCPE are interstitial to alveolar pulmonary opacities in the absence of signs of left-sided congestive heart failure or fluid overload such as cardiomegaly or congested pulmonary veins. Computed tomography and edema fluid analysis may aid in the diagnosis, while some forms of NCPE require additional findings to reach a diagnosis.

THERAPY

The goal of therapy for all types of NCPE is to preserve tissue oxygenation and reduce the work of breathing. This may be achieved by removing the inciting cause (eg, airway obstruction) and cage rest in mild cases and supplemental oxygen in moderate cases and may require mechanical ventilation in severe cases.

PROGNOSIS

Prognosis is generally good for most causes of veterinary NCPE except for ARDS, although data are scarce for some etiologies of NCPE.

Addressing gaps in our understanding of the drowning patient: a protocol for the retrospective development of an Utstein style database and multicentre collaboration

INTRODUCTION

This retrospective observational study aims to create a comprehensive database of the circumstances of drowning (including care provided and outcomes of care) to report against the Utstein style for drowning (USFD) for patients presenting to the emergency department (ED). Four areas will be examined: a feasibility study of the USFD; a comparison of classification and prognostication systems; examination of indications and efficacy of different ventilation strategies; and differences in the circumstances, severity, treatment and outcomes of drowning by sex and gender.

METHODS AND ANALYSIS

This protocol outlines retrospective data collection for all patients presenting to EDs of the Sunshine Coast Hospital and Health Service in Queensland, Australia with the presenting problem or discharge diagnosis of drowning or immersion between 2015 and 2022. Patients computerised health records (emergency medical service record, pathology, radiology results, medical and nursing notes for ED, inpatient units and intensive care units) will be used to extract data for entry into an USFD database. Descriptive (eg, median, IQR) and inferential statistical analyses (eg, analysis of variance) will be used to answer the separate research questions. Development of an International Drowning Registry using the USFD dataset and the Research Electronic Data Capture (REDCap) web application is discussed.

ETHICS AND DISSEMINATION

This study has been approved by Metro North Human Research and Ethics Committee (Project No: 49754) and James Cook University Human Research Ethics Committee (H8014). It has been endorsed by national drowning prevention organisations Royal Life Saving Society Australia (RLSSA) and Surf Life Saving Australia (SLSA). Study findings will provide data to better inform clinical management of drowning patients and provide an evidence base on sex and gender differences in drowning. Results will be disseminated through peer review publications, conference presentations and media releases. Results will also be disseminated through RLSSA and SLSA membership of the Australian and New Zealand Resuscitation Council and the Australian Water Safety Council.

Clinical and microbiological features of drowning-associated pneumonia: a retrospective multicentre cohort study

OBJECTIVE

Pneumonia is the most frequent infectious complication in patients who have experienced drowning that requires intensive care unit (ICU) admission. We aimed to describe clinical, microbiological, and therapeutic data as well as predictors and impacts of such pneumonia on patients' outcomes.

METHODS

We conducted a retrospective, multicentre study (2013-2020) of 270 consecutive patients admitted for drowning to 14 ICUs in Western France. Their baseline characteristics and outcomes were compared according to the occurrence of drowning-associated pneumonia (DAP), defined as pneumonia diagnosed within 48 hours of ICU admission. A Cox regression model was used to compare survival on day 28, and logistic regression was used to identify risk factors for DAP. Microbiological characteristics and empirical antibacterial treatment were also analysed.

RESULTS

Among the 270 patients admitted to the ICU for drowning, 101 (37.4%) and 33 (12.2%) experienced pneumonia and microbiologically proven DAP, respectively. The occurrence of pneumonia was associated with higher severity scores at ICU admission (median Simplified Acute Physiology Score II, 34 [interquartile range {IQR}, 25-55] vs. 45 [IQR, 28-67]; p 0.006) and longer ICU length of stay (2 days [IQR, 1-3] vs. 4 days [IQR, 2-7]; p < 0.001). The 28-day mortality rate was higher among these patients (29/101 [28.7%] vs. 26/169 [15.4%]; p 0.013). Microbiologically proven DAP remained associated with higher 28-day mortality after adjustments for cardiac arrest and water salinity (adjusted hazard ratio, 1.86 [95% CI, 1.06-3.28]; p 0.03). A microbiological analysis of respiratory samples showed a high proportion of gram-negative bacilli (23/56; 41.1%), with a high prevalence of amoxicillin-clavulanate resistance (12/33; 36.4%).

CONCLUSIONS

Pneumonia is a common complication in patients admitted in the ICU for drowning and is associated with increased mortality.

[Clinical and microbiological characteristics of children with drowning-associated aspiration pneumonia]

OBJECTIVES

To study the clinical and microbiological characteristics of children with drowning-associated aspiration pneumonia, so as to provide a reference for empirical selection of antibacterial agents.

METHODS

A retrospective analysis was performed on the medical data of 185 children with drowning-associated aspiration pneumonia who were admitted to Children's Hospital of Chongqing Medical University from January 2010 to October 2020. According to the drowning environment, these children were divided into four groups: fecal group (n=44), freshwater group (n=69), swimming pool group (n=41), and contaminant water group (n=31). The clinical characteristics and pathogen detection results were reviewed and compared among the four groups.

RESULTS

The 185 children had an age of 4 months to 17 years (median 34 months). Sputum cultures were performed on 157 children, and 103 were tested positive (65.6%), with 87 strains of Gram-negative bacteria (68.5%), 37 strains of Gram-positive bacteria (29.1%), and 3 strains of fungi (2.4%). Gram-negative bacteria were the main pathogen in the fecal group and the contaminant water group, accounting for 88.2% (30/34) and 78.3% (18/23), respectively. The freshwater group had a significantly higher detection rate of Gram-positive bacteria than the fecal group (P<0.008), and the swimming pool group had an equal detection rate of Gram-negative bacteria and Gram-positive bacteria.

CONCLUSIONS

For pulmonary bacterial infection in children with drowning in feces or contaminant water, antibiotics against Gram-negative bacteria may be applied empirically, while for children with drowning in a swimming pool or freshwater, broad-spectrum antibiotics may be used as initial treatment, and subsequently the application of antibiotics may be adjusted according to the results of the drug sensitivity test.

Neurological outcomes in adult drowning patients in China

BACKGROUND

Drowning is the third leading cause of unintentional death worldwide. The epidemiological characteristics of adult drownings are rarely reported.

OBJECTIVE

Investigate factors associated with neurological prognosis in adult drowning inpatients.

DESIGN

Multicenter medical record review.

SETTING

Tertiary health care institutions.

PATIENTS AND METHODS

We collected demographic and clinical data on patients who drowned but survived between September 2006 and January 2020. Neurological prognosis was compared in patients with and without cardiac arrest.

MAIN OUTCOME MEASURES

Neurological outcomes.

SAMPLE SIZE AND CHARACTERISTICS

142 patients with mean age of 50.6 (19.8) years, male/female ratio of 1.54:1.

RESULT

Forty-five patients (31.7%) received CPR, 90 patients (63.4%) experienced unconsciousness, and 59 patients (41.5%) received endotracheal intubation and mechanical ventilation. Multivariate logistic regression analysis showed that the initial blood lactic acid level (OR: 7.67, 95%CI: 1.23-47.82, P=.029) was associated with a poor neurological prognosis in patients without cardiac arrest. The incidence of ICU admission (OR: 16.604, 95%CI: 1.15-239.49, P=.039) was associated with a poor neurologic prognosis in patients with cardiac arrest.

CONCLUSIONS

For the drowning patients with cardiac arrest, ICU admission was associated with neurological function prognosis in these patients. Among the patients without cardiac arrest, the initial lactate value was associated with neurological function prognosis of these patients.

LIMITATIONS

Retrospective.

CONFLICT OF INTEREST

None.

Treatment of the lung injury of drowning: a systematic review

Background

Drowning is a cause of significant global mortality. The mechanism of injury involves inhalation of water, lung injury and hypoxia. This systematic review addressed the following question: In drowning patients with lung injury, what is the evidence from primary studies regarding treatment strategies and subsequent patient outcomes?

Methods

The search strategy utilised PRISMA guidelines. Databases searched were MEDLINE, EMBASE, CINAHL, Web of Science and SCOPUS. There were no restrictions on publication date or age of participants. Quality of evidence was evaluated using GRADE methodology.

Results

Forty-one papers were included. The quality of evidence was very low. Seventeen papers addressed the lung injury of drowning in their research question and 24 had less specific research questions, however included relevant outcome data. There were 21 studies regarding extra-corporeal life support, 14 papers covering the theme of ventilation strategies, 14 addressed antibiotic use, seven papers addressed steroid use and five studies investigating diuretic use. There were no clinical trials. One retrospective comparison of therapeutic strategies was found. There was insufficient evidence to make recommendations as to best practice when supplemental oxygen alone is insufficient. Mechanical ventilation is associated with barotrauma in drowning patients, but the evidence predates the practice of lung protective ventilation. There was insufficient evidence to make recommendations regarding adjuvant therapies.

Conclusions

Treating the lung injury of drowning has a limited evidentiary basis. There is an urgent need for comparative studies of therapeutic strategies in drowning.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13054-021-03687-2.

Evaluation of Antimicrobial Utilization in the Pediatric Drowning Population

BACKGROUND

Management of pediatric drowning often includes evaluation and treatment of infectious disease. There are few data describing the infections associated with pediatric drowning.

METHODS

A descriptive retrospective study was designed, and patients aged < 19 years admitted for > 24 hours to our institution after a drowning were included from January 2011 through June 30, 2017. Data collection included patient demographics, submersion injury details, resuscitation details, patient admission details, chest radiograph on admission, use of intubation and mechanical ventilation, hospital length of stay, culture data, antimicrobial use, and mortality. Descriptive statistical methods (mean and standard deviation, median and range, percentage) were used to characterize the patient population, and Fisher exact test was used to evaluate the association between antimicrobial use in the first 72 hours of admission and mortality.

RESULTS

A total of 114 patients met study criteria (male, 59.7%; median age, 3.7 years [range, 0.15-17.79 years]). Median hospital length of stay was 2 days (range, 1-60 days). Intensive care unit admission occurred in 80.7%, intubation occurred in 46.5%, and mortality was 18.4%. The most common submersion location was a pool (76.3% [n = 87]) with water primarily characterized as freshwater (82.5% [n = 94]). Reported submersion time for the majority of patients was < 5 minutes (54.4%) with cardiopulmonary resuscitation in 78.1%. In the first 72 hours after admission, culture were obtained in 40 patients (35.1%), and 27.5% of these cultures were positive. The primary organisms identified were consistent oropharyngeal flora. Antimicrobials were initiated in 50% of the patient population with clindamycin as most common. There was not a significant association between antimicrobial use in the first 72 hours after admission and mortality (17.2% vs 19.6%, P = .81).

CONCLUSIONS

Infectious disease associated with pediatric drowning in pools is uncommon. Empiric use of antimicrobials does not appear to affect outcomes.

Drowning injuries in the United States: Patient characteristics, mortality risk, and associated primary diagnoses

OBJECTIVES

To determine patient demographics, associated primary diagnoses, mortality risk, and inpatient mortality of admitted drowning patients in the U.S.

METHODS

Retrospective cross-sectional study using 2016 National Inpatient Sample Healthcare Cost and Utilization Project Agency for Healthcare Research and Quality dataset. External cause codes were used to identify drowning records, excluding self-inflicted/suicides. ICD-10 diagnosis and procedure codes, patient demographics, and admission-related data were collected.

RESULTS

Of the 4,355 admissions in 2016, 68.3% were male (95% CI 65.3-71.3%) and 70.3% were white (95% CI 66.9-73.6%) with mean length of stay of 5.5 days (95% CI 4.9-6.2) and mean total charge of $81,624 (95% CI $70926-$92321). 8.2% of admissions resulted in inpatient death. Those that died were significantly younger than those that did not die (χ²=5.9, p=0.02). There was a statistically significant association between primary payer and inpatient mortality (χ²=10.5, p=0.02).

CONCLUSION

Younger, male, and white patients accounted for the majority of drowning admissions and deaths. A significantly larger proportion of Medicaid patients died compared to inpatient mortality of those with other insurance. Recognizing those most impacted by drowning could help better tailor prevention efforts.

Management for the Drowning Patient

Drowning is "the process of experiencing respiratory impairment from submersion or immersion in liquid." According to the World Health Organization, drowning claims the lives of > 40 people every hour of every day. Drowning involves some physiological principles and medical interventions that are unique. It occurs in a deceptively hostile environment that involves an underestimation of the dangers or an overestimation of water competency. It has been estimated that > 90% of drownings are preventable. When water is aspirated into the airways, coughing is the initial reflex response. The acute lung injury alters the exchange of oxygen in different proportions. The combined effects of fluid in the lungs, loss of surfactant, and increased capillary-alveolar permeability result in decreased lung compliance, increased right-to-left shunting in the lungs, atelectasis, and alveolitis, a noncardiogenic pulmonary edema. Salt and fresh water aspirations cause similar pathology. If the person is not rescued, aspiration continues, and hypoxemia leads to loss of consciousness and apnea in seconds to minutes. As a consequence, hypoxic cardiac arrest occurs. The decision to admit to an ICU should consider the patient's drowning severity and comorbid or premorbid conditions. Ventilation therapy should achieve an intrapulmonary shunt ≤ 20% or Pao₂:Fio₂ ≥ 250. Premature ventilatory weaning may cause the return of pulmonary edema with the need for re-intubation and an anticipation of prolonged hospital stays and further morbidity. This review includes all the essential steps from the first call to action until the best practice at the prehospital, ED, and hospitalization.

Wilderness Medical Society Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2019 Update

The Wilderness Medical Society convened a panel to review available evidence supporting practices for acute management and treatment of drowning in out-of-hospital and emergency medical care settings. Literature about definitions and terminology, epidemiology, rescue, resuscitation, acute clinical management, disposition, and drowning prevention was reviewed. The panel graded available evidence supporting practices according to the American College of Chest Physicians criteria and then made recommendations based on that evidence. Recommendations were based on the panel's collective clinical experience and judgment when published evidence was lacking. This is the first update to the original practice guidelines published in 2016.

Acute respiratory failure after drowning: a retrospective multicenter survey

OBJECTIVES

Despite the extensive literature on drowning, clinical data are still lacking on the best medical strategy to use. Acute respiratory failure (ARF) is the main component of drowning pathophysiology. The objectives of this multicenter study were to analyze the clinical course of drowning-related ARF patients and to describe the efficacy of the ventilatory strategies used.

METHODS

Medical records of drowned adult patients admitted in seven ICUs after prehospital emergency medical care during three consecutive summer periods were retrospectively analyzed.

RESULTS

Among the 126 patients (58±21 years) admitted, 38 patients with cardiac arrest at the scene were not analyzed, 26 received mechanical ventilation (MV), and 48 patients received noninvasive ventilation (NIV). Compared with patients placed under MV, the NIV patients presented a better initial neurological (Glasgow Coma Scale of 7±4 vs. 12±3, P<0.05) and hemodynamic status from the prehospital stage (mean arterial pressure of 77±18 vs. 96±18, P<0.001). With comparable ARF-related hypoxemia to MV, the NIV was maintained with success in 92% (44/48). Both MV and NIV were associated with rapid improvement of oxygenation and short ICU length of stay [3 (1-14) and 2 (1-7), respectively].

CONCLUSION

Despite the absence of recommendation for NIV use in case of drowning-related ARF, this technique was often used with safety and efficacy. The decision for NIV use was mainly based on the preserved or improved neurological status.

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.

Sports related to drowning

Aquatic sports are included in the top list of risky practices as the environment per se carries a possibility of death by drowning if not rescued in time. Not only are aquatic sports related to a high risk of death, but also all sports practiced on the water, over the water and on ice. Whatever the reason a person is in the water, drowning carries a higher possibility of death if the individual is unable to cope with the water situation, which may simply be caused by an inability to stay afloat and get out of the water or by an injury or disease that may lead to physical inability or unconsciousness. The competitive nature of sports is a common pathway that leads the sports person to exceed their ability to cope with the environment or simply misjudge their physical capability. Drowning involves some principles and medical interventions that are rarely found in other medical situations as it occurs in a deceptively hostile environment that may not seem dangerous. Therefore, it is essential that health professionals are aware of the complete sequence of action in drowning. This article focuses on the pulmonary injury in sports and recreational activities where drowning plays the major role.

Physiology Of Drowning: A Review

Drowning physiology relates to two different events: immersion (upper airway above water) and submersion (upper airway under water). Immersion involves integrated cardiorespiratory responses to skin and deep body temperature, including cold shock, physical incapacitation, and hypovolemia, as precursors of collapse and submersion. The physiology of submersion includes fear of drowning, diving response, autonomic conflict, upper airway reflexes, water aspiration and swallowing, emesis, and electrolyte disorders. Submersion outcome is determined by cardiac, pulmonary, and neurological injury. Knowledge of drowning physiology is scarce. Better understanding may identify methods to improve survival, particularly related to hot-water immersion, cold shock, cold-induced physical incapacitation, and fear of drowning.

Near-drowning-associated pneumonia with bacteremia caused by coinfection with methicillin-susceptible Staphylococcus aureus and Edwardsiella tarda in a healthy white man: a case report

BACKGROUND

Edwardsiella tarda is an Enterobacteriaceae found in aquatic environments. Extraintestinal infections caused by Edwardsiella tarda in humans are rare and occur in the presence of some risk factors. As far as we know, this is the first case of near-drowning-associated pneumonia with bacteremia caused by coinfection with methicillin-susceptible Staphylococcus aureus and Edwardsiella tarda in a healthy patient.

CASE PRESENTATION

A 27-year-old previously healthy white man had an episode of fresh water drowning after acute alcohol consumption. Edwardsiella tarda and methicillin-sensitive Staphylococcus aureus were isolated in both tracheal aspirate cultures and blood cultures.

CONCLUSION

This case shows that Edwardsiella tarda is an important pathogen in near drowning even in healthy individuals, and not only in the presence of risk factors, as previously known.

Leucocyte depletion in a drowning victim during rewarming with extracorporeal circulation may limit pulmonary oedema

Introduction: We report two drowning victims with hypothermic circulatory arrest who were resuscitated with the use of extracorporeal circulation (ECC). The first patient developed severe post–bypass pulmonary oedema and inspired us to use a leucocyte–depletion filter in the second patient to attenuate leucocyte–mediated pulmonary reperfusion injury. Methods: In the first patient, a standard extracorporeal circuit was used. In the second patient, systemic leucocyte depletion was applied using leucocyte–depletion filters (Pall RS 1, Pall, Portsmouth, UK), in the venous side of the extracorporeal circuit. Circulating leucocyte counts were measured and arterial blood gas analysis and chest X–rays were performed. Results: Both patients showed a decrease of the circulating leucocyte counts during rewarming and had nearly similar leucocyte counts on arrival at the intensive care unit (ICU). The first patient developed severe pulmonary oedema, with poor arterial blood gases, whereas the second patient, who had leucocyte–depletion by filtration, did not develop severe pulmonary oedema, and had good arterial blood gases. Conclusion: Profound leucocyte–depletion by means of filtration may have contributed to limit leucocyte–mediated pulmonary reperfusion injury.

Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning

The Wilderness Medical Society convened a panel to review available evidence supporting practices for the prevention and acute management of drowning in out-of-hospital and emergency medical care settings. Literature about definition and terminology, epidemiology, rescue, resuscitation, acute clinical management, disposition, and drowning prevention was reviewed. The panel graded evidence supporting practices according to the American College of Chest Physicians criteria, then made recommendations based on that evidence. Recommendations were based on the panel's collective clinical experience and judgment when published evidence was lacking.

Chromobacterium haemolyticum Pneumonia Possibly Due to the Aspiration of Runoff Water

Here, we report a case of pneumonia possibly caused by the aspiration of runoff water containing Chromobacterium haemolyticum. A 69-year-old man became intoxicated with alcohol, fell into a ditch, and lost consciousness after suffering a blow to the head. The lower half of his body was completely paralyzed because of damage to his spinal cord, and he aspirated runoff water from the ditch. Chest computed tomography scans revealed consolidation in the right upper lobe and bilateral lower lobes. A sputum culture detected gram-negative bacteria that was identified as C. haemolyticum. Antibacterial chemotherapy was initiated, and the clinical course was favorable. To the best of our knowledge, this is the first report of C. haemolyticum pneumonia in the literature.

Journey of a survivor of near drowning, polymicrobial pneumonia, and acute respiratory distress syndrome

This article discusses a woman who collapsed and landed in a puddle of water in a park near a horse trail. Her rescue and resuscitation started an extraordinary effort by her body to heal from multiple insults. This case study highlights the diagnosis and support of polymicrobial pneumonia secondary to near drowning and the multisystem complications throughout the 3-month hospitalization. It highlights the evidence for treatment of the polymicrobial nature of submersion injury, acute lung injury, and benefits of progressive mobility. Social media as a tool for the family's communication and coping are also discussed.

Drowning associated pneumonia: a descriptive cohort

PURPOSE

Pneumonia is the most common infectious complication of drowning. Pneumonia is potentially life threatening and should be treated by effective antibiotic therapy. However the risk factors, microbiological causes, diagnostic approach and appropriate therapy for pneumonia associated with drowning are not well described. The microbiological ecology of the body of water where immersion occurred could be of import. The aim of this study was to report on microorganisms involved in pneumonia associated with drowning and out of hospital cardiac arrest after successful cardiopulmonary resuscitation. Additionally, we retrieved and undertook microbiological analysis on samples of water from our local river.

METHODS

This retrospective study included all patients having suffered an out of hospital cardiac arrest due to drowning and admitted to our tertiary care academic hospital between 2002 and 2010. Data concerning bacteriological lung samples (tracheal aspirate or bronchoalveolar lavage) at admission were reported and compared to bacteriological samples obtained from our local river (the river Seine).

RESULTS

A total of thirty-seven patients were included in the study. Lung samples were obtained for twenty-one of these patients. Lung samples were positive in nineteen cases, with a high frequency of multi-drug resistant bacteria. Samples from the Seine River found microorganisms similar to those found in drowning associated pneumonia.

CONCLUSIONS

Drowning associated pneumonia can be due to multi drug resistant bacteria. When treating drowning associated pneumonia, antibiotics should be effective against bacteria similar to those found in the body of water where immersion occurred.

Combat-associated drowning

BACKGROUND

The purpose of this article is to describe the clinical course and outcome of drowning cases related to current US military combat operations.

METHODS

This retrospective case series spans December 2002 to January 2009 of survivors transferred to an echelon IV military trauma center in Europe serving as the primary evacuation hub for ongoing combat operations. Patient demographics and the situational and clinical findings at the initial drowning scene were reviewed. A comprehensive analysis of care as each patient transitioned through the combat theater to the echelon IV trauma center in Europe was performed.

RESULTS

Overall, mortality was 37.5% mortality rate (3 of 8 patients). Advanced modes of respiratory support such as high-frequency ventilation, airway pressure release ventilation, and extracorporeal membrane oxygenation were required in a majority of the cohort (6 of 8 patients). Limited-duration vasopressor infusions (7 of 8 patients) were also required to ensure adequate end-organ perfusion. Glasgow Coma Scale (GCS) scores and the need for cardiopulmonary resuscitation (CPR) at the scene of injury were associated with eventual patient mortality (100% mortality for an initial GCS score of 3 and 75% mortality for on-scene CPR). Survivor long-term morbidity was often related to the sequelae of acute respiratory distress syndrome and hypoxic encephalopathy.

CONCLUSION

Drowning associated with combat operations was associated with severe acute respiratory distress syndrome and cardiovascular shock. GCS score and the need for CPR at the scene of injury were associated with eventual mortality because of anoxic brain injury in all cases.

The role of bystanders during rescue and resuscitation of drowning victims

BACKGROUND

Bystanders make a critical difference in the survival of drowning victims. Little information on their role before arrival of the Emergency Medical Services (EMS) is available in the scientific literature. In a descriptive study, this role is investigated.

METHODS AND RESULTS

We studied 289 rescue reports (1999-2004) available from the Dutch Maatschappij tot Redding van Drenkelingen (Society to Rescue People from Drowning), an organisation that, since 1767, acknowledges awards to bystanders who have contributed to the survival of a drowning victim. There were 138 variables retrieved from these reports. The Utstein Style for Drowning (USFD) was used as a guideline. Of the 26 USFD parameters on victim and scene information, 21 were available for analysis. Eight non-USFD parameters, defined by the authors of this research, were available in >60% of the cases. There were 343 victims, rescued by 503 rescuers. 109 victims were resuscitated by bystanders. Of the 18 victims who first received resuscitation from bystanders and then consequently from pre-hospital professionals, 14 survived. Rescues often occurred in dangerous circumstances: multiple victims (n=90/343), cold or ice-cold water (n=295/341), deep water (n=316/334), swimming to the victims (n=262/376), young age of rescuers (the youngest rescuer was 5 years of age).

CONCLUSIONS

Bystander rescue and resuscitation of drowning victims seems to contribute to a positive outcome. Bystanders are prepared to take responsibility to rescue a drowning victim in spite of significant dangers. The USFD is helpful in understanding the role of bystanders in drowning situations, but may need modification to become more instrumental.

Near-drowning: clinical course of lung injury in adults

BACKGROUND AND OBJECTIVES

Although anoxic encephalopathy is the most dreaded consequence of submersion accidents, respiratory involvement is also very common in these patients. Nevertheless, few data are available about the clinical course and resolution of lung injury in adult victims of near-drowning. Our goal was to study the clinical manifestations of near-drowning and the course of respiratory involvement in a retrospective cohort of adult, mostly elderly patients.

PATIENTS

Our study included adult patients who were hospitalized after near-drowning in seawater over an 8-year period. Forty-three patients (26 female, 17 male), with an age range of 18-88 years old, were studied. Most (79%) of the patients were elderly (>60 years).

RESULTS

In the Emergency Department two patients were comatose and required intubation. Another patient was intubated within the first 24 h because of ARDS. At presentation, all patients but two had a PaO(2)/FiO(2) < 300, while ARDS was present in 17 and acute lung injury in 15 cases. The nine remaining hypoxemic patients had either focal infiltrates or a negative chest X-ray. Superimposed pneumonia was observed in four patients and resulted in a protracted hospital stay. Improvement of lung injury was rapid in most cases: by day 4 resolution of hypoxemia was observed in 33/43 (76.7%) of the cases and resolution of radiographic findings in 66.6%. Duration of hospitalization varied from 2 to 14 days (mean = 5.2 +/- 0.5 days). One patient with coma died due to ventilator-associated pneumonia (mortality = 2.3%).

CONCLUSION

Respiratory manifestations of near-drowning in adult immersion victims are often severe. Nevertheless, in noncomatose patients at least, intubation can often be avoided and quick improvement is the rule while a good outcome is usually expected even in elderly patients.

Oropharyngeal dysphagia in long-term care: misperceptions of treatment efficacy

The assessment and management of patients in long-term care who have oropharyngeal dysphagia has developed into an apparently complex and distinct field of practice. It is unfortunate that it lacks an evidence base, the efficacy of treatment is not established, and many clinicians are unfamiliar with appropriate and effective interventions because of a lack of training. Some commonly used interventions are not only ineffective but potentially hazardous. Physicians must become more familiar with the assessment process and appropriate management.

Radiologic findings in tsunami trauma: experience with 225 patients injured in the 2004 tsunami

The objective of this study was to determine the spectrum of radiographic findings, frequency, and type of injuries in tsunami victims. From December 2004 to May 2005, all tsunami victims admitted to our hospital were retrospectively identified by a search of medical records. Patients who received radiologic examinations were reviewed for their radiographic findings. The authors identified 225 tsunami victims. One hundred eight victims received radiologic evaluations on admission that included 350 plain radiographs, 19 ultrasound exams, 18 computed tomography (CT) scans and 3 magnetic resonance imaging (MRI) scans. Overall positivity rate was 48% (187/390). Most common trauma involved musculoskeleton (102/187, 54.5%). Retained foreign bodies in soft tissues, pneumonia/aspiration, and tsunami sinusitis were found in 22, 28, and 31 patients (9.8, 12.4, and 13.8%), respectively. These were unique findings in tsunami trauma. Imaging played an important role in detection of these abnormalities.

Drowning

PURPOSE OF REVIEW

To summarize current knowledge on pathophysiology and treatment of drowning accidents. Studies and case reports were searched using the keywords drowning, near-drowning, asphyxia, hypoxia and hypothermia in conjunction with organ systems and specific treatment options.

RECENT FINDINGS

Drowning is defined as death by suffocation in a liquid. In contrast, near-drowning is defined as survival beyond 24 h after a drowning accident. Drowning is a frequent preventable accident with a significant morbidity and mortality in a mostly healthy population. In the majority of patients the primary injury is pulmonary, resulting in severe arterial hypoxemia and secondary damage to other organs. Damage to the central nervous system is most critical in terms of patient survival and subsequent quality of life. Therefore, prompt resuscitation and aggressive respiratory and cardiovascular treatment are crucial for optimal survival. Immediate interruption of hypoxia, aggressive treatment of hypothermia and cardiovascular failure are the cornerstones of correct medical treatment. Unfortunately, accurate neurologic prognosis cannot be predicted from initial clinical presentation, laboratory, radiological or electrophysiological examinations.

SUMMARY

Several case studies have convincingly demonstrated that drowning victims may survive neurologically intact even after prolonged submersion times, in particular in cold water. Therefore, aggressive initial therapeutic efforts are indicated in most near-drowning victims.

Melioidosis in 6 tsunami survivors in southern Thailand

BACKGROUND

Six cases of melioidosis were identified in survivors of the 26 December 2004 tsunami who were admitted to Takuapa General Hospital in Phangnga, a region in southern Thailand where melioidosis is not endemic. All 6 cases were associated with aspiration, and 4 were also associated with laceration.

METHODS

We compared the clinical, laboratory, and radiographic findings and the outcomes for these 6 patients with those for 22 patients with aspiration-related melioidosis acquired during 1987-2003 in a melioidosis-endemic region in northeast Thailand. Results of tests for detection of Burkholderia pseudomallei in soil specimens from Phangnga and from northeast Thailand were compared.

RESULTS

The 6 patients (age range, 25-65 years) presented with signs and symptoms of pneumonia 3-38 days (median duration, 6.5 days) after the tsunami. Chest radiograph findings at the onset of pneumonia were abnormal in all cases; 1 patient developed a lung abscess. B. pseudomallei was grown in blood cultures in 3 cases and in cultures of respiratory secretions in 4 cases. Two patients required ventilation and inotropes; 1 patient died. Compared with tsunami survivors, patients with aspiration-related melioidosis in northeast Thailand had a shorter interval (median duration, 1 day) between aspiration and onset of pneumonia; were more likely to exhibit shock, respiratory failure, renal failure, and/or altered consciousness (P=.03); and had a higher in-hospital mortality (64% [14 of 22 patients]; P=.07). These differences may be related to the severity of the near-drowning episode, the inhalation of sea water versus fresh water, the size of bacterial inoculum, and the possible acquisition (among tsunami survivors) of B. pseudomallei via laceration. Only 3 (0.8%) of 360 soil samples from Phangnga were positive for B. pseudomallei, compared with 26 (20%) of 133 samples from northeast Thailand (P<.0001).

CONCLUSIONS

Tsunami survivors are at increased risk of melioidosis if they are injured in an environment containing B. pseudomallei.

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.

Drowning and near-drowning

Water immersion is a frequent cause of accidental death and hospital admission. This article outlines the pathogenesis and principles of treatment. Drowning is defined as death by asphyxia due to submersion in a liquid medium. Near-drowning is defined as immediate survival after asphyxia due to submersion.

Drowning

Recent epidemiologic data have shown that the burden of drowning is much greater than expected. Prevention and timely rescue are the most effective means of reducing the number of persons at risk. Early bystander cardiopulmonary resuscitation is the most important factor for survival after submersion. Cerebral damage is a serious threat when the hypoxic period is too long. In most situations, low body temperature is an indication of the severity of the drowning incident. Sometimes hypothermia that occurs during the submersion period can be brain protective. There is also new evidence to support the strategy of inducing mild hypothermia for a period of 12 to 24 hours in comatose drowning victims. In immersed patients, hypothermia should be treated. The most appropriate technique will depend on the available means in the hospital and the condition of the patient. Treatment of pulmonary complications depends on the lung injury that occurred during aspiration and the bacteria involved in aspiration. Understanding the pathophysiology of drowning may help us to understand lung injuries and ischemic brain injuries.