Drowning. Rescue, resuscitation, and reanimation

Drowning and Nonfatal Drowning in Children and Adolescents: A Subsequent Retrospective Data Analysis

Fatal and nonfatal drowning are among the leading causes of death and lifelong severe neurological impairment among children and adolescents. This study aimed to complement research from Leipzig 1994-2008 to seek trends within risk factors, treatments, and outcomes throughout the last decade. We retrospectively investigated data of 47 inpatients aged 0-18 admitted to Leipzig University Department of Pediatrics who matched ICD-10 code T75.1 from 2008 to 2020 and compared them to a preceding study at the same institution. We also examined the prognostic value of parameters regarding the patients' outcomes. There were three median incidents per annum. The median age was 2.75 years; 76% of incidents happened in males. An accumulation was seen during the summer months and weekends. Most drowning incidents occurred in private ponds or pools (48.9%). Thirty-nine children were discharged without resulting morbidity, four showed neurological impairment, and three died. Risk factors concerning age, sex, and incident characteristics were confirmed. Special supervision needs still apply to 1-3-year-old male children or children with pre-existing health conditions around private pools and ponds. Hospitalization duration shortened, and morbidity and lethality decreased since the previous study. There was structural improvement in primary care and medical documentation. Parameters suggesting good outcomes include a submersion time < 5 min, GCS > 3 points, spontaneous movement upon admission, remaining pupillary light response, the absence of cardiovascular arrest, body temperature ≥ 32 °C, pH > 7, blood glucose < 15 mmol/L, lactate < 14 mmol/L, base excess ≥ -15 mmol/L, and the absence of ARDS. Clear legislation can contribute to improved private home water safety. Further studies should include a broad in- and outpatient spectrum and standardized incident documentation presupposing Utstein-style reporting. Regular reinvestigation of consistent geographical regions facilitates process evaluations of drowning epidemiology and therapy evolution.

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.

Laryngopharyngeal Mucosal Injury Due to Nasogastric Tube Insertion during Cardiopulmonary Resuscitation: A Retrospective Cohort Study

BACKGROUND

Patients under cardiopulmonary resuscitation (CPR) are at high risk of aspirating gastric contents. Nasogastric tube insertion (NGTI) after tracheal intubation is usually performed blindly. This sometimes causes laryngopharyngeal mucosal injury (LPMI), leading to severe bleeding. This study clarified the incidence of LPMI due to blind NGTI during CPR.

METHODS

We retrospectively analyzed 84 patients presenting with cardiopulmonary arrest on arrival, categorized them into a Smooth group (Smooth; blind NGTI was possible within 2 min), and Difficult group (blind NGTI was not possible), and consequently performed video laryngoscope-assisted NGTI. The laryngopharyngeal mucosal condition was recorded using video laryngoscope. Success rates and insertion time for the Smooth group were calculated. Insertion number and LPMI scores were compared between the groups. Each regression line of outcome measurements was obtained using simple regression analysis. We also analyzed the causes of the Difficult group, using recorded video laryngoscope-assisted videos.

RESULTS

The success rate was 78.6% (66/84). NGTI time was 48.8 ± 4.0 s in the Smooth group. Insertion number and injury scores in the Smooth group were significantly lower than those in the Difficult group. The severity of LPMI increased with NGT insertion time and insertion number.

CONCLUSIONS

Whenever blind NGTI is difficult, switching to other methods is essential to prevent unnecessary persistence.

Epidemiology, clinical aspects, and management of pediatric drowning

Drowning is the third leading cause of injury death in the pediatric population worldwide, with incidence peaking among those aged 1-4 years and again in adolescence.The purpose of this commentary is to review the basic pathophysiology of drowninginjury and factors that affect the outcome, such as submersion and hypothermia. We also discuss principles of prehospital and in-hospital management, comprising resuscitation and stabilization, administration of oxygen and intravenous liquids, and central reheating.Even though the mortality rate has decreased in recent years, further investments and safety measures are needed to prevent child drowning deaths.

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.

Dying to help: Fatal bystander rescues in Australian coastal environments

Bystanders who drown during a rescue attempt in aquatic waterways are becoming an increasingly important issue within drowning prevention. In the Australian context, the majority of these incidents occur in coastal water ways. This study documents and characterizes bystander rescuer fatalities within Australian coastal waterways that occurred between 1 July 2004 and 30 June 2019 in order to provide suggestions for future public safety interventions involving bystander rescuers. Data was sourced through Surf Life Saving Australia's (SLSA) Coastal Fatality Database, which collates information from multiple sources. Sixty-seven bystander rescuer fatalities in coastal waterways were reported during the 15-year period, an average of 4.5 per year, which is a significant proportion of the five fatalities previously reported across all Australian waterways. The majority of coastal bystander rescuer fatality incidents occurred in the state of New South Wales (49%), at beaches (64%), in regional or remote areas (71%), more than 1 km from the nearest lifesaving service (78%), during summer (45%), in the afternoon (72%), in the presence of rip currents (73%), and did not involve the use of flotation devices to assist rescue (97%). The majority of coastal bystander rescuer victims were Australian residents (88%) born in Australia/Oceania (68%), males (81%), aged between 30-44 years old (36%), visitors to the location (55%), either family (69%) or friends (15%) of the rescuee(s), and were attempting to rescue someone younger than 18 years old (64%). Our results suggest future safety intervention approaches should target males, parents and carers visiting beach locations in regional locations during holiday times and should focus on the importance of flotation devices when enacting a rescue and further educating visitors about the rip current hazard. Future research should examine the psychology of bystander rescue situations and evaluate the effectiveness of different safety intervention approaches.

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

OBJECTIVE

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

METHODS

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

RESULTS

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

DISCUSSION

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

Who rescues who? Understanding aquatic rescues in Australia using coronial data and a survey

OBJECTIVE

To examine fatal drowning associated with aquatic rescues and prior self-reported experience of undertaking an aquatic rescue in Australia.

METHODS

Previous aquatic rescue experience was sourced through the 2013 Queensland Computer Assisted Telephone Instrument Survey and compared to data on rescue-related fatal unintentional drowning between 1 January 2006 and 31 December 2015.

RESULTS

Twenty-three per cent (n=294/1291) of survey respondents had previously performed an aquatic rescue. Males (X² =35.2; p<0.001) were more likely to have performed a rescue; commonly at a beach/ocean/harbour location (X² =13.5; p<0.001). Females were more likely to have rescued a child (0-4 years of age) (X² =29.2; p<0.001) from a swimming pool (X² =34.3; p<0.001). Fifty-one people drowned while performing an aquatic rescue (Males=82.4%; 25-44 years of age=53.0%; beaches=54.9%).

CONCLUSIONS

Drownings are prevented by bystanders; this is not without risk to the rescuer. Most people perform only one rescue in their life, often at a younger age, on an altruistic basis, of family members or young children. Community-wide rescue skills, taught at a young age, with consideration for coastal, inland and swimming pool environments, may prevent drowning. Implications for public health: There is a need to train people early in their life on how to undertake a safe rescue and provide resuscitation, including promoting regular updates, in particular if supervising children.

Investigation of Drowning Deaths: A Practical Review

Drowning, which typically involves a watery environment, remains a serious public health concern claiming an estimated 362 000 lives per year worldwide across all socioeconomic classifications and has remained under close observation by the World Health Organization and its signatories. A significant number of water-related deaths are attributed to accidental drowning, while a smaller but still significant number represent suicidal or homicidal drowning. Others involve a combination of drowning precipitated by injury, intoxication, or environmental extremes. Still others involve victims that die from injury, intoxication, or a natural disease entity of such significance as to preclude the drowning process, while near or in water. While there may be an initial presumption that all water-related deaths are accidental drownings, other possibilities must be considered in the investigation of these types of deaths, as drowning as a cause of death is a diagnosis based on the exclusion of other potential causes. The coordinated investigative efforts of multiple agencies and disciplines are required not only for the designation as drowning as the cause of death but also for death certification. The ongoing analysis and dissemination of data generated from all levels of investigation augment our understanding of the impact on public health and safety, guiding allocation of monetary and educational resources in an effort to prevent further mortality and disability.

Drowning in swimming pools: clinical features and safety recommendations based on a study of descriptive records by emergency medical services attending to 995 calls

INTRODUCTION

This study was a descriptive analysis of national ambulance case records and aimed to make practical safety recommendations in order to reduce the incidence of drowning in swimming pools.

METHODS

A search was performed of a national database of descriptive summaries by first-responder paramedics of all 995 calls made to the Singapore Civil Defence Force between 1 January 2012 and 31 December 2014. We included all cases of submersion in both public and private pools for which emergency medical services were activated.

RESULTS

The highest proportion of drowning cases occurred in the age group of 0-9 years. Males accounted for 57.0% (61/107) of cases. Bystander cardiopulmonary resuscitation (CPR) was performed in 91.3% (21/23) and 68.6% (48/70) of cases of cardiac/respiratory arrest from drowning in public and private pools, respectively; the rate of bystander CPR was higher when a lifeguard was present (88.5%, 23/26 vs. 68.7%, 46/67). The majority (72.0%, 77/107) of drowning incidents occurred in private pools, most of which had no lifeguards present.

CONCLUSION

To our knowledge, this study was the first in Singapore to examine data from emergency medical services. Since the majority of incidents occurred in private pools without lifeguards, it is recommended that a lifeguard be present at every pool. For pools that are too small to justify mandatory lifeguard presence, safety measures, such as guidelines for pool design and pool fencing with latched gates, may be considered. As strict enforcement may not be possible, public education and parental vigilance remain vital.

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.

Post-mortem CT: Hounsfield unit profiles obtained in the lungs with respect to the cause of death assessment

Segmentation of the lungs using post-mortem computed tomography (PMCT) data was so far not feasible due to post-mortem changes such as internal livores. Recently, an Osirix plug-in has been developed allowing automatically segmenting lungs also in PMCT data. The aim of this study was to investigate if the Hounsfield unit (HU) profiles obtained in PMCT data of the segmented lung tissue present with specific behaviour in relation to the cause of death. In 105 PMCT data sets of forensic cases, the entire lung volumes were segmented using the Mia Lite plug-in on Osirix. HU profiles of the lungs were generated and correlated to cause of death groups as assessed after forensic autopsy (cardiac death, fatal haemorrhage, craniocerebral injury, intoxication, drowning, hypothermia, hanging and suffocation). Especially cardiac death cases, intoxication cases, fatal haemorrhage cases and hypothermia cases showed very specific HU profiles. In drowning, the profiles showed two different behaviours representing wet and dry drowning. HU profiles rather varied in craniocerebral injury cases, hanging cases as well as in suffocation cases. HU profiles of the lungs segmented from PMCT data may support the cause of death diagnosis as they represent specific morphological changes in the lungs such as oedema, congestion or blood loss. Especially in cardiac death, intoxication, fatal haemorrhage, hypothermia and drowning cases, HU profiles may be very supportive for the forensic pathologist.

Veterinary Forensic Pathology

Determining the cause of death in animals recovered from bodies of water, swimming pools, or other water-containing vessels is challenging. Animals recovered from water may or may not have drowned. The diagnosis of drowning is usually one of exclusion, requiring information from the crime scene, recovery scene, the medical history or reliable witness accounts. While there are characteristic macroscopic and microscopic lesions of drowning, none are specific and are dependent on the volume and tonicity of the drowning medium. Beyond interpreting the postmortem findings, the court may ask pathologists to comment on the behavioral and welfare implications of drowning. This requires an understanding of the drowning process, which is a complex series of sequential, concurrent, and overlapping cardiorespiratory reflexes, electrolyte and blood gas abnormalities, aspiration, physical exhaustion, and breathlessness eventually culminating in death. This review addresses the mechanisms, lesions, and diagnostic issues associated with drowning in nonaquatic companion animals.

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.

Pattern of presenting complaints recorded as near-drowning events in emergency departments: a national surveillance study from Pakistan

Background

Drowning is a heavy burden on the health systems of many countries, including Pakistan. To date, no effective large-scale surveillance has been in place to estimate rates of drowning and near-drowning in Pakistan. The Pakistan National Emergency Department Surveillance (Pak-NEDS) study aimed to fill this gap.

Methods

Patients who presented with a complaint of "near-drowning" were analyzed to explore patterns of true near-drowning (unintentional) and intentional injuries that led to the "near-drowning" complaint. Bivariate analysis was done to establish patterns among patients treated in emergency departments, including socio-demographic information, injury-related information, accompanying injuries, and emergency department resource utilization.

Results

A total of 133 patients (0.2% of all injury patients) with "near-drowning" as presenting complaints were recorded by the Pak-NEDS system. True near-drowning (50.0%) and intentional injuries that led to "near-drowning" complaints (50.0%) differed in nature of injuries. The highest proportion of true near-drowning incidents occurred among patients aged between 25-44 years (47.5%), and among males (77.5%). True near-drowning patients usually had other accompanying complaints, such as lower limb injury (40.0%). Very few patients were transported by ambulance (5.0%), and triage was done for 15% of patients. Eleven (27.5%) true near-drowning patients received cardiopulmonary resuscitation.

Conclusion

There was major under-reporting of drowning and near-drowning cases in the surveillance study. The etiology of near-drowning cases should be further studied. Patients who experienced non-fatal drownings were more commonly sent for medical care due to other accompanying conditions, rather than near-drowning event itself. There is also need for recognizing true near-drowning incidents. The results of this study provide information on data source selection, site location, emergency care standardization, and multi-sector collaboration for future drowning prevention studies.

Vomiting is not associated with poor outcomes in pediatric victims of unintentional submersions

INTRODUCTION

The outcome of submersion victims depends on submersion duration and the availability of timely and effective resuscitation. The prognostic implication of vomiting during resuscitation of submersion victims is unclear. The study sought to determine whether vomiting during resuscitation in children treated for unintentional submersion injuries adversely impacts outcome.

METHODS

This was a retrospective study of unintentional submersion victims under age 18 treated at an urban tertiary-care children's hospital from 2003-2009. Submersion and victim details were obtained from hospital, EMS, and fatality records. Outcomes studied were survival at 24 hours and condition (Favorable: good/mild impairment or Poor: death/severe disability) at hospital discharge. Descriptive comparisons between emesis groups (yes/no) and categorical covariates were analyzed.

RESULTS

There were 281 victims. The median age was 3 years; 66% were males. Most incidents occurred at swimming pools (77%) and bathtubs (16%). Most were hospitalized (83%). The presence or absence of emesis was documented in 246 (88%). Victims with emesis were significantly less likely to have apnea or be intubated in the ED, have a low ED GCS or die. No patient who had emesis died at 24 hours or had a poor outcome at hospital discharge. Victims who had emesis post-resuscitation were significantly more likely to have received CPR or chest compressions than rescue breaths.

CONCLUSIONS

Emesis in pediatric submersion victims is inversely associated with death at 24 hours or poor outcome at hospital discharge. The relationship between emesis and the adequacy of resuscitation of pediatric submersion victims needs to be further studied.

The Forensic Pathology of Drowning and Pulmonary Overexpansion Injury

Drowning deaths are commonly seen in most forensic pathology practices. Experienced forensic pathologists perform autopsies and assign a cause and manner of death in such cases as a matter of routine. Deaths due to pulmonary overexpansion injury and subsequent air embolism are far less common and typically involve individuals who have been breathing compressed gas at depth, generally SCUBA (self-contained underwater breathing apparatus) divers. This review outlines the pathophysiological basis of these two forensic pulmonary issues and recommends an approach to performing and interpreting the results of a forensic autopsy when faced with such cases.

Drowning related out-of-hospital cardiac arrests: characteristics and outcomes

AIM

There are few studies on drowning-related out-of-hospital cardiac arrest (OHCA) in which patients are followed from the scene through to hospital discharge. This study aims to describe this population and their outcomes in the state of Victoria (Australia).

METHODS

The Victorian Ambulance Cardiac Arrest Registry was searched for all cases of OHCA with a precipitating event of drowning attended by emergency medical services (EMS) between October 1999 and December 2011.

RESULTS

EMS attended 336 drowning-related OHCA during the study period. Cases frequently occurred in summer (45%) and the majority of patients were male (70%) and adult (77%). EMS resuscitation was attempted on 154 (46%) patients. Of these patients, 41 (27%) survived to hospital arrival and 12 (8%) survived to hospital discharge (5 adults [6%] and 7 [12%] children). Few patients were found in a shockable rhythm (6%), with the majority presenting in asystole (79%) or pulse-less electrical activity (13%). An initial shockable rhythm was found to positively predict survival (AOR 48.70, 95% CI: 3.80-624.86) while increased EMS response time (AOR 0.73, 95% CI: 0.54-0.98) and salt water drowning (AOR 0.69, 95% CI: 0.01-0.84) were found to negatively predict survival.

CONCLUSIONS

Rates of survival in OHCA caused by drowning are comparable to other OHCA causes. Patients were more likely to survive if they did not drown in salt water, had a quick EMS response and they were found in a shockable rhythm. Prevention efforts and reducing EMS response time are likely to improve survival of drowning patients.

Neurologic long term outcome after drowning in children

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

Diagnosis and management of environmental thoracic emergencies

Physiologic sequelae from increasing ambient pressure in underwater activities, decreasing ambient pressure while at altitude, or the consequences of drowning present a unique set of challenges to emergency physicians. In addition, several environmental toxins cause significant respiratory morbidity, whether they be pulmonary irritants, simple asphyxiants, or systemic toxins. It is important for emergency physicians to understand the pathophysiology of these illnesses as well as to apply this knowledge to the clinical arena either in the prehospital setting or in the emergency department. Current treatment paradigms and controversies within these regimens are discussed.

[Out-of-hospital treatment in case of drowning]

INTRODUCTION

Drowning is a leading preventable cause of unintentional morbidity and mortality. The dominant pathophysiological mechanism of drowning includes the development of acute hypoxia.

FIRST AID

The rescue procedure of a drowning person includes careful pulling the victim out of the water, examination, maintenance of the airways passable and urgent transfer to hospital.

BASIC LIFE SUPPORT

The first and most important treatment option of a drowning victim is the provision of ventilation which increases the chances of survival. As soon as the unresponsive victim is removed from the water, the lay rescuer should immediately begin chest compressions and provide cycles of ventilations and compressions. Some recent investigations have revealed that exterior compression of the chest is a necessary measure even in a situation when bystanders cannot provide airway. It is recommended to train bystanders to provide basic life support and apply automated external defibrillator in a drowning person whenever indicated and as early as possible.

ADVANCED LIFE SUPPORT

In drowning, the victim with cardiac arrest requires advanced life support, including an early intubation. Extended medical measures, which are primarily provided by medical professionals, include cervical spine immobilization in case a spinal injury is suspected, or, establishment of the ventilation with oxygen, emergency transport, application of reanimation and advanced vital support measures.

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.

Comparison of the characteristics and outcome among patients suffering from out-of-hospital primary cardiac arrest and drowning victims in cardiac arrest

Background

In 2003, the International Liaison Committee on Resuscitation (ILCOR) published the Recommended Guidelines for Uniform Reporting of Data from Drowning: the “Utstein style” (“Utstein Style for Drowning,” USFD) to improve the understanding of epidemiology, treatment, and outcome prediction after drowning.

Aims

The aim of this study was to compare the characteristics and outcome between patients suffering from out-of-hospital primary cardiac arrest (OHPCA) and drowning victims in cardiac arrest (DCA) by analysis of variables based on the USFD.

Methods

All cases of OHPCA and DCA from February 1998 to February 2007 were included in the research and analysis. Data on OHPCA and DCA patients were collected using the Utstein method. Data on DCA patients were then compared with data of OHPCA patients.

Results

During the study period 788 cardiac arrests with resuscitation attempts were identified: 528 of them were OHPCA (67%) and 32 (4%) were DCA. The differences between DCA and OHPCA patients were: the DCA patients were younger (46.5 ± 21.4 vs 62.5 ± 15.8; p = 0.01), suffered a witnessed cardiac arrest less frequently (9/32 vs 343/528; p = 0.03), were more often found in a nonshockable rhythm (29/32 vs 297/528; p < 0.0001), had a prolonged ambulance response time (11 vs 6 min; p = 0.001), had a relatively better (but not statistically significant) return of spontaneous circulation (ROSC) in the field [22/32 (65%) vs 301/528 (57%); p = 0.33], more of them were admitted to hospital [19/32 (60%) vs 253/528 (48%); p = 0.27], and also had a significantly higher survival rate (discharge from hospital) [14/32 (44%) vs 116/528 (22%); p = 0.01]. DCA patients had higher values of initial PETCO₂ (53.2 ± 16.8 vs 15.8 ± 8.3 mmHg; p < 0.0001) and average PETCO₂ (43.5 ± 13.8 vs 23.5 ± 8.2; p = 0.002). These values of PETCO₂ suggest an asphyxial mechanism of cardiac arrest. The analysis showed that DCA patients who survived were younger, had more bystander cardiopulmonary resuscitation (CPR), shorter call-arrival interval, higher values of PETCO₂ after 1 min of CPR, higher average and final values of PETCO₂, lower value of initial serum K+, and more of them received vasopressin (p < 0.05) in comparison with DCA patients who did not survive.

Conclusion

DCA patients had a better survival rate (discharge from hospital), higher initial and average PETCO₂ values, and more of them had nonshockable initial rhythm. Survival (discharge from hospital) in DCA patients is associated with the PETCO₂ values, initial serum K+ values, administration of vasopressin, and ambulance response time.

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.

Forensic Lung Pathology

Sudden and unexpected natural deaths and nonnatural deaths may result from various pulmonary conditions. Additionally, several nonpulmonary conditions of forensic significance may be complicated by the development of respiratory lesions. Certain situations with pulmonary pathology are particularly likely to be critically scrutinized and may form the basis of allegations of medical negligence, other personal injury liability, or wrongful death.1

Hemolysis due to inadvertent hemodialysis against distilled water: Perils of bedside dialysate preparation

OBJECTIVE

To describe the physiologic consequences of dialysis against distilled water and to provide recommendations by which other institutions may avoid similar errors in dialysate preparation.

DATA SOURCE

Four cases of dialysis against distilled water are described, occurring at three teaching hospitals within a 2-yr period. In addition, an in vitro experiment of banked whole blood exposure to distilled water dialysate was performed.

DATA EXTRACTION

Because all four cases occurred within a critical care setting, intensive monitoring of clinical, biochemical, and hematologic abnormalities was possible.

DATA SYNTHESIS

Serum sodium decreased by an average of 22 mmol/L, followed by a decrease in hemoglobin averaging 32 g/L. Additional investigations and the in vitro experiment provided evidence that hemolysis occurred primarily via clearance of damaged erythrocytes within the patient's reticuloendothelial system. Physiologic derangements secondary to dialysis against distilled water likely contributed to a stroke suffered by one patient and the death of at least one other patient.

CONCLUSIONS

Accidental dialysis against distilled water is a potentially serious but preventable complication of bedside dialysate preparation.

Factors affecting strontium absorption in drownings

This study examines the effects of age, gender, a cold water medium versus warm water medium, and salinity on strontium levels determined in left ventricular blood in drownings. Significant differences in the amount of strontium absorbed into the bloodstream (p<0.001) were detected between individuals who drowned in fresh water versus those drowning in seawater, and between those drowning in cold water versus warm water (p=0.030). However, no significant differences were noted in the strontium concentrations of left ventricular blood according to gender or age.

Drowning, haemodilution, haemolysis and staining of the intima of the aortic root – preliminary observations

In order to demonstrate that hyponatraemia due to haemodilution occurs within the left ventricle following freshwater drowning, and to determine whether lysed blood resulting from left ventricular haemodilution may cause staining of the aortic intima, the following studies were undertaken. Measurements of left ventricular sodium levels were performed in 74 consecutive coronial cases where death was attributed to drowning, consisting of 44 and 30 deceased who were believed to be victims of freshwater and saltwater drowning, respectively. Left ventricular sodium levels differed significantly between the two groups (p<0.001), with a range of 93-147 mmol/L in freshwater drowning (mean=117+/-14.2 mmol/L) and 123-183 in saltwater drowning (mean=153+/-14.4 mmol/L). In addition, the mean sodium level of 117 mmol/L in freshwater drowning was significantly lower than the standard range of 137-145 mmol/L. In a second study, portions of aorta and pulmonary trunk from a euthanised pig were soaked in lysed blood resulting in marked haemolytic staining of the intima of both vessels after 20 min. Water and a mixture of blood and water were then injected into the left ventricles in two further pig carcasses, respectively, resulting in haemolytic staining of the intima of the aortic roots, with no staining of the pulmonary trunks. These studies have confirmed that significant hyponatraemia secondary to haemodilution may occur within the left ventricle in freshwater drowning, and that haemolysed blood is capable of causing staining of the aortic root in an animal model. These results provide further data to support haemolytic staining of the aortic root intima as a possible manifestation of freshwater drowning.

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.

What Is the Incidence and Significance of “Dry-Lungs” in Bodies Found in Water?

BACKGROUND

Drowning without aspiration of liquid, generally attributed to death from asphyxia while submerged and in laryngospasm, has been reported to occur in approximately 10% to 15% of drowning victims.

OBJECTIVES

The occurrence of "dry-drowning" recently has been questioned and the hypothesis developed that "dry-lungs" in bodies found dead in the water could conceal more natural deaths than previously recognized.

METHODS

Based on 578 selected adult victims who presumably drowned, we analyzed the correlation between the cases with a low combined lung/pleura liquid weight (< 1000 g and < 750 g) and a wide set of individual, circumstantial, and postmortem (PM) variables, using multivariate logistic regression analysis. Victims with lung weight < 1000 g were screened for long-QT syndrome (LQTS) founder mutations in KCNQ1 and KCNH2 genes.

RESULTS

Of the 578 victims, 120 (20.7%) had a lung weight of < 1000 g, and 22 of these (3.8%) of < 750 g. Multivariate analysis showed a significant correlation for women (P < 0.001), for women aged 65 years or older (P < 0.001), and for men with prolonged PM submersion time (P < 0.001). "Normal" lungs were found in only 8 (1.4%) victims. Low-weight (< 1000 g), overdistended lungs with no sign of liquid penetration were seen in 11 (1.9%). No LQTS founder mutations were detected.

CONCLUSIONS

The actual incidence of death of persons found in water who have normal lungs or do not have penetration of liquid into their airways, based on our study, is much lower (below 2%) than currently assumed.