Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study

An 18-year, single centre, retrospective study of long-term neurological outcomes in paediatric submersion-related cardiac arrests

Aim

Investigate long-term outcome in paediatric submersion-related cardiac arrests (CA).

Methods

Children (age one day-17 years) were included if admitted to the Erasmus MC Sophia Children's Hospital, after drowning with CA, between 2002 and 2019. Primary outcome was survival with favourable neurological outcome, defined as a Paediatric Cerebral Performance Category (PCPC) score of 1-3 at longest available follow-up. Secondary outcome were age-appropriate neuropsychological assessments at longest available follow-up.

Results

Upon hospital admission, 99 children were included (median age at time of CA 3.2 years [IQR 2.0-5.9] and 65% males). Forty children died in-hospital (no return of circulation (45%) or withdrawal of life sustaining therapies (55%)) and 4 children deceased after hospital discharge due to complications following the drowning-incident. Among survivors, with a median follow-up of 2.3 years [IQR 0.2-5.5], 47 children had favourable neurological outcome (i.e. PCPC 1-3) and 8 children unfavourable (unfavourable outcome group total n = 52, i.e. PCPC 4-5 or deceased). Twenty-six (47%) children participated in a neuropsychological assessment (median follow-up 4.0 years [IQR 2.3-8.7]). Compared with normative test data, participants obtained worse general (p = 0.008) and performance (p = 0.003) intelligence scores, processing speed (p = 0.002) and visual motor integration scores (p = 0.0012).

Conclusions

Although overall outcome in survivors was favourable at longest available follow-up, significant deficits in neuropsychological assessments were found. This study underlines the need for a standardized long term follow-up program as standard of care in paediatric drowning with CA.

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.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

A quest for an integrated management system of children following a drowning incident: A review of the literature

PURPOSE

Management of children following a drowning incident is based on specific interventions which are used in the prehospital environment, the emergency department (ED) and the Paediatric Intensive Care Unit (PICU). This paper presents a review of the literature to map and describe the management and interventions used by healthcare professionals when managing a child following a drowning incident. Of specific interest was to map, synthesise and describe the management and interventions according to the different clinical domains or practice areas of healthcare professionals.

DESIGN AND METHODS

A traditional review of the literature was performed to appraise, map and describe information from 32 relevant articles. Four electronic databases were searched using search strings and the Boolean operators AND as well as OR. The included articles were all published in English between 2010 and 2022, as it comprised a timeline including current guidelines and practices necessary to describe management and interventions.

RESULTS

Concepts and phrases from the literature were used as headings to form a picture or overview of the interventions used for managing a child following a drowning incident. Information extracted from the literature was mapped under management and interventions for prehospital, the ED and the PICU and a figure was constructed to display the findings. It was evident from the literature that management and interventions are well researched, evidence-informed and discussed, but no clear arguments or examples could be found to link the interventions for integrated management from the scene of drowning through to the PICU. Cooling and/or rewarming techniques and approaches and termination of resuscitation were found to be discussed as interventions, but no evidence of integration from prehospital to the ED and beyond was found. The review also highlighted the absence of parental involvement in the management of children following a drowning incident.

PRACTICE IMPLICATIONS

Mapping the literature enables visualisation of management and interventions used for children following a drowning incident. Integration of these interventions can collaboratively be done by involving the healthcare practitioners to form a link or chain for integrated management from the scene of drowning through to the PICU.

A century of exercise physiology: concepts that ignited the study of human thermoregulation. Part 3: Heat and cold tolerance during exercise

In this third installment of our four-part historical series, we evaluate contributions that shaped our understanding of heat and cold stress during occupational and athletic pursuits. Our first topic concerns how we tolerate, and sometimes fail to tolerate, exercise-heat stress. By 1900, physical activity with clothing- and climate-induced evaporative impediments led to an extraordinarily high incidence of heat stroke within the military. Fortunately, deep-body temperatures > 40 °C were not always fatal. Thirty years later, water immersion and patient treatments mimicking sweat evaporation were found to be effective, with the adage of cool first, transport later being adopted. We gradually acquired an understanding of thermoeffector function during heat storage, and learned about challenges to other regulatory mechanisms. In our second topic, we explore cold tolerance and intolerance. By the 1930s, hypothermia was known to reduce cutaneous circulation, particularly at the extremities, conserving body heat. Cold-induced vasodilatation hindered heat conservation, but it was protective. Increased metabolic heat production followed, driven by shivering and non-shivering thermogenesis, even during exercise and work. Physical endurance and shivering could both be compromised by hypoglycaemia. Later, treatments for hypothermia and cold injuries were refined, and the thermal after-drop was explained. In our final topic, we critique the numerous indices developed in attempts to numerically rate hot and cold stresses. The criteria for an effective thermal stress index were established by the 1930s. However, few indices satisfied those requirements, either then or now, and the surviving indices, including the unvalidated Wet-Bulb Globe-Thermometer index, do not fully predict thermal strain.

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces

The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Termination of Cardiopulmonary Resuscitation in Mountain Rescue: A Scoping Review and ICAR MedCom 2023 Recommendations

Lugnet, Viktor, Miles McDonough, Les Gordon, Mercedes Galindez, Nicolas Mena Reyes, Alison Sheets, Ken Zafren, and Peter Paal. Termination of cardiopulmonary resuscitation in mountain rescue: a scoping review and ICAR MedCom 2023 recommendations. High Alt Med Biol. 24:274-286, 2023. Background: In 2012, the International Commission for Mountain Emergency Medicine (ICAR MedCom) published recommendations for termination of cardiopulmonary resuscitation (CPR) in mountain rescue. New developments have necessitated an update. This is the 2023 update for termination of CPR in mountain rescue. Methods: For this scoping review, we searched the PubMed and Cochrane libraries, updated the recommendations, and obtained consensus approval within the writing group and the ICAR MedCom. Results: We screened a total of 9,102 articles, of which 120 articles met the inclusion criteria. We developed 17 recommendations graded according to the strength of recommendation and level of evidence. Conclusions: Most of the recommendations from 2012 are still valid. We made minor changes regarding the safety of rescuers and responses to primary or traumatic cardiac arrest. The criteria for termination of CPR remain unchanged. The principal changes include updated recommendations for mechanical chest compression, point of care ultrasound (POCUS), extracorporeal life support (ECLS) for hypothermia, the effects of water temperature in drowning, and the use of burial times in avalanche rescue.

Rewarming Young Children After Drowning-Associated Hypothermia and Out-of-Hospital Cardiac Arrest: Analysis Using the CAse REport Guideline

OBJECTIVES

Extracorporeal membrane oxygenation (ECMO) is recommended in adults with drowning-associated hypothermia and out-of-hospital cardiac arrest (OHCA). Our experience of managing a drowned 2-year-old girl with hypothermia (23°C) and cardiac arrest (58 min) prompted this summary using the CAse REport (CARE) guideline to address the question of optimal rewarming procedure in such patients.

DESIGN/PATIENTS

Following the CARE guideline, we identified 24 reports in the "PubMed database" describing children less than or equal to 6 years old with a temperature less than or equal to 28°C who had been rewarmed using conventional intensive care ± ECMO. Adding our patient, we were able to analyze a total of 57 cases.

MAIN RESULTS

The two groups (ECMO vs non-ECMO) differed with respect to submersion time, pH and potassium but not age, temperature or duration of cardiac arrest. However, 44 of 44 in the ECMO group were pulseless on arrival versus eight of 13 in the non-ECMO group. Regarding survival, 12 of 13 children (92%) undergoing conventional rewarming survived compared with 18 of 44 children (41%) undergoing ECMO. Among survivors, 11 of 12 children (91%) in the conventional group and 14 of 18 (77%) in the ECMO group had favorable outcome. We failed to identify any correlation between "rewarming rate" and "outcome."

CONCLUSIONS

In this summary analysis, we conclude that conventional therapy should be initiated for drowned children with OHCA. However, if this therapy does not result in return of spontaneous circulation, a discussion of withdrawal of intensive care might be prudent when core temperature has reached 34°C. We suggest further work is needed using an international registry.

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.

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.

A systematic review of interventions for resuscitation following drowning

Objectives

The International Liaison Committee on Resuscitation, in collaboration with drowning researchers from around the world, aimed to review the evidence addressing seven key resuscitation interventions: 1) immediate versus delayed resuscitation; (2) compression first versus ventilation first strategy; (3) compression-only CPR versus standard CPR (compressions and ventilations); (4) ventilation with and without equipment; (5) oxygen administration prior to hospital arrival; (6) automated external defibrillation first versus cardiopulmonary resuscitation first strategy; (7) public access defibrillation programmes.

Methods

The review included studies relating to adults and children who had sustained a cardiac arrest following drowning with control groups and reported patient outcomes. Searches were run from database inception through to April 2023. The following databases were searched Ovid MEDLINE, Pre-Medline, Embase, Cochrane Central Register of Controlled Trials. Risk of bias was assessed using the ROBINS-I tool and the certainty of evidence was assessed using Grading of Recommendations Assessment, Development and Evaluation. The findings are reported as a narrative synthesis.

Results

Three studies were included for two of the seven interventions (2,451 patients). No randomised controlled trials were identified. A retrospective observational study reported in-water resuscitation with rescue breaths improved patient outcomes compared to delayed resuscitation on land (n = 46 patients, very low certainty of evidence). The two observational studies (n = 2,405 patients), comparing compression-only with standard resuscitation, reported no difference for most outcomes. A statistically higher rate of survival to hospital discharge was reported for the standard resuscitation group in one of these studies (29.7% versus 18.1%, adjusted odds ratio 1.54 (95% confidence interval 1.01-2.36) (very low certainty of evidence).

Conclusion

The key finding of this systematic review is the paucity of evidence, with control groups, to inform treatment guidelines for resuscitation in drowning.

Hypothermia and cold injuries in children and young people

Although hypothermia and cold injuries are rare in children and young people in the UK, the risk is persistent and requires urgent medical management when it does occur. This article outlines some considerations for professionals who may be caring for hypothermic patients or those at risk of becoming hypothermic.

Resuscitation of Drowned Persons During the COVID-19 Pandemic: A Consensus Statement

IMPORTANCE

Resuscitation is a niche example of how the COVID-19 pandemic has affected society in the long term. Those trained in cardiopulmonary resuscitation (CPR) face the dilemma that attempting to save a life may result in their own harm. This is most of all a problem for drowning, where hypoxia is the cause of cardiac arrest and ventilation is the essential first step in reversing the situation.

OBJECTIVE

To develop recommendations for water rescue organizations in providing their rescuers with safe drowning resuscitation procedures during the COVID-19 pandemic.

EVIDENCE REVIEW

Two consecutive modified Delphi procedures involving 56 participants from 17 countries with expertise in drowning prevention research, resuscitation, and programming were performed from March 28, 2020, to March 29, 2021. In parallel, PubMed and Google Scholar were searched to identify new emerging evidence relevant to each core element, acknowledge previous studies relevant in the new context, and identify knowledge gaps.

FINDINGS

Seven core elements, each with their own specific recommendations, were identified in the initial consensus procedure and were grouped into 4 categories: (1) prevention and mitigation of the risks of becoming infected, (2) resuscitation of drowned persons during the COVID-19 pandemic, (3) organizational responsibilities, and (4) organizations unable to meet the recommended guidelines. The common measures of infection risk mitigation, personal protective equipment, and vaccination are the base of the recommendations. Measures to increase drowning prevention efforts reduce the root cause of the dilemma. Additional infection risk mitigation measures include screening all people entering aquatic facilities, defining criteria for futile resuscitation, and avoiding contact with drowned persons by rescuers with a high-risk profile. Ventilation techniques must balance required skill level, oxygen delivery, infection risk, and costs of equipment and training. Bag-mask ventilation with a high-efficiency particulate air filter by 2 trained rescuers is advised. Major implications for the methods, facilities, and environment of CPR training have been identified, including nonpractical skills to avoid being infected or to infect others. Most of all, the organization is responsible for informing their members about the impact of the COVID-19 pandemic and taking measures that maximize rescuer safety. Research is urgently needed to better understand, develop, and implement strategies to reduce infection transmission during drowning resuscitation.

CONCLUSIONS AND RELEVANCE

This consensus document provides an overview of recommendations for water rescue organizations to improve the safety of their rescuers during the COVID-19 pandemic and balances the competing interests between a potentially lifesaving intervention and risk to the rescuer. The consensus-based recommendations can also serve as an example for other volunteer organizations and altruistic laypeople who may provide resuscitation.

Cognitive and Psychological Outcomes Following Pediatric Cardiac Arrest

Cardiac arrest is a rare event in children and adolescents. Those who survive may experience a range of outcomes, from good functional recovery to severe and permanent disability. Many children experience long-term cognitive impairment, including deficits in attention, language, memory, and executive functioning. Deficits in adaptive behavior, such as motor functioning, communication, and daily living skills, have also been reported. These children have a wide range of neurological outcomes, with some experiencing specific deficits such as aphasia, apraxia, and sensorimotor deficits. Some children may experience emotional and psychological difficulties, although many do not, and more research is needed in this area. The burden of pediatric cardiac arrest on the child's family and caregivers can be substantial. This narrative review summarizes current research regarding the cognitive and psychological outcomes following pediatric cardiac arrest, identifies areas for future research, and discusses the needs of these children for rehabilitation services and academic accommodations.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Neonatal Life Support; Education, Implementation, and Teams; First Aid Task Forces; and the COVID-19 Working Group

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

2021 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

The International Liaison Committee on Resuscitation initiated a continuous review of new, peer-reviewed published cardiopulmonary resuscitation science. This is the fifth annual summary of the International Liaison Committee on Resuscitation International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations; a more comprehensive review was done in 2020. This latest summary addresses the most recently published resuscitation evidence reviewed by International Liaison Committee on Resuscitation task force science experts. Topics covered by systematic reviews in this summary include resuscitation topics of video-based dispatch systems; head-up cardiopulmonary resuscitation; early coronary angiography after return of spontaneous circulation; cardiopulmonary resuscitation in the prone patient; cord management at birth for preterm and term infants; devices for administering positive-pressure ventilation at birth; family presence during neonatal resuscitation; self-directed, digitally based basic life support education and training in adults and children; coronavirus disease 2019 infection risk to rescuers from patients in cardiac arrest; and first aid topics, including cooling with water for thermal burns, oral rehydration for exertional dehydration, pediatric tourniquet use, and methods of tick removal. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, according to the Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations or good practice statements. Insights into the deliberations of the task forces are provided in Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces listed priority knowledge gaps for further research.

Pediatric Hypothermia: An Ambiguous Issue

Hypothermia in pediatrics is mainly about small body size. The key thermal factor here is the large surface-to-volume ratio. Although small mammals, including human infants and children, are adapted to higher heat losses through their elevated metabolic rate and thermogenic capacity, they are still at risk of hypothermia because of a small regulatory range and an impending metabolic exhaustion. However, some small mammalian species (hibernators) use reduced metabolic rates and lowered body temperatures as adaptations to impaired energy supply. Similar to nature, hypothermia has contradictory effects in clinical pediatrics as well: In neonates, it is a serious risk factor affecting respiratory adaptation in term and developmental outcome in preterm infants. On the other hand, it is an important self-protective response to neonatal hypoxia and an evidence-based treatment option for asphyxiated babies. In children, hypothermia first enabled the surgical repair of congenital heart defects and promotes favorable outcome after ice water drowning. Yet, it is also a major threat in various prehospital and clinical settings and has no proven therapeutic benefit in pediatric critical care. All in all, pediatric hypothermia is an ambiguous issue whose harmful or beneficial effects strongly depend on the particular circumstances.

Management of hypothermic submersion associated cardiac arrest in a 5-year-old child: A case report

We report a case of severe accidental hypothermia (core body temperature of 26.8 °C) in a five-year-old boy due to submersion in freezing lake water. The child was brought to the hospital intubated, in cardiac arrest rhythm of pulseless electrical activity and with dilated and nonreactive pupils. We continued with cardiopulmonary resuscitation and administrated adrenaline in boluses (10 μg/kg) and infusion (0.2 μg/kg/min). Spontaneous circulation returned after 50 minutes. Rewarming was performed with minimally invasive techniques. Post resuscitation he was admitted to the intensive care unit, where he required venovenous extracorporeal membrane oxygenation due to respiratory failure. He was discharged from the hospital neurologically intact and without organ damage on day 17 post arrest.

Fifteen-minute consultation: Drowning in children

Drowning is a significant cause of childhood morbidity and mortality globally. The underlying mechanisms vary with child development and most are modifiable to public health promotion strategies. This article serves to highlight some of the specific considerations for the clinical management of drowning in children, both prehospital and by the in-hospital paediatric resuscitation team. This includes changes to standard advanced paediatric life support in the presence of hypothermia.

Helicopter Emergency Medical Service and Hospital Treatment Levels Affect Survival in Pediatric Trauma Patients

(1) Background: Data on the effects of helicopter emergency medical service (HEMS) transport and treatment on the survival of severely injured pediatric patients in high-level trauma centers remain unclear. (2) Methods: A national dataset from the TraumaRegister DGU^® was used to retrospectively compare the mortality rates among severely injured pediatric patients (1–15 years) who were transported by HEMS to those transported by ground emergency medical service (GEMS) and treated at trauma centers of different treatment levels (levels I–III). (3) Results: In total, 2755 pediatric trauma patients (age: 9.0 ± 4.8 years) were included in this study over five years. Transportation by HEMS resulted in a significant survival benefit compared to GEMS (odds ratio (OR) 0.489; 95% confidence interval (CI): 0.282–0.850). Pediatric trauma patients treated in level II or III trauma centers showed 34% and fourfold higher in-hospital mortality risk than those in level I trauma centers (level II: OR 1.34, 95% CI: 0.70–2.56; level III: OR 4.63, 95% CI: 1.33–16.09). (4) Conclusions: In our national pediatric trauma cohort, both HEMS transportation and treatment in level I trauma centers were independent factors of improved survival in pediatric trauma patients.

Resuscitation and emergency care in drowning: A scoping review

BACKGROUND

The ILCOR Basic Life Support Task Force and the international drowning research community considered it timely to undertake a scoping review of the literature to identify evidence relating to the initial resuscitation, hospital-based interventions and criteria for safe discharge related to drowning.

METHODS

Medline, PreMedline, Embase, Cochrane Reviews and Cochrane CENTRAL were searched from 2000 to June 2020 to identify relevant literature. Titles and abstracts and if necessary full text were reviewed in duplicate. Studies were eligible for inclusion if they reported on the population (adults and children who are submerged in water), interventions (resuscitation in water/boats, airway management, oxygen administration, AED use, bystander CPR, ventilation strategies, ECMO, protocols for hospital discharge (I), comparator (standard care) and outcomes (O) survival, survival with a favourable neurological outcome, CPR quality, physiological end-points).

RESULTS

The database search yielded 3242 references (Medline 1104, Pre-Medline 202, Embase 1722, Cochrane reviews 12, Cochrane CENTRAL 202). After removal of duplicates 2377 papers were left for screening titles and abstracts. In total 65 unique papers were included. The evidence identified was from predominantly high-income countries and lacked consistency in the populations, interventions and outcomes reported. Clinical studies were exclusively observational in nature.

CONCLUSION

This scoping review found that there is very limited evidence from observational studies to inform evidence based clinical practice guidelines for drowning. The review highlights an urgent need for high quality research in drowning.

Increased winter drownings in ice-covered regions with warmer winters

Winter activities on ice are culturally important for many countries, yet they constitute a high safety risk depending upon the stability of the ice. Because consistently cold periods are required to form stable and thick ice, warmer winters could degrade ice conditions and increase the likelihood of falling through the ice. This study provides the first large-scale assessment of winter drowning from 10 Northern Hemisphere countries. We documented over 4000 winter drowning events. Winter drownings increased exponentially in regions with warmer winters when air temperatures neared 0°C. The largest number of drownings occurred when winter air temperatures were between -5°C and 0°C, when ice is less stable, and also in regions where indigenous traditions and livelihood require extended time on ice. Rates of drowning were greatest late in the winter season when ice stability declines. Children and adults up to the age of 39 were at the highest risk of winter drownings. Beyond temperature, differences in cultures, regulations, and human behaviours can be important additional risk factors. Our findings indicate the potential for increased human mortality with warmer winter air temperatures. Incorporating drowning prevention plans would improve adaptation strategies to a changing climate.

Adult Basic Life Support: International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This 2020 International Consensus on Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care Science With Treatment Recommendations on basic life support summarizes evidence evaluations performed for 20 topics that were prioritized by the Basic Life Support Task Force of the International Liaison Committee on Resuscitation. The evidence reviews include 16 systematic reviews, 3 scoping reviews, and 1 evidence update. Per agreement within the International Liaison Committee on Resuscitation, new or revised treatment recommendations were only made after a systematic review.

Systematic reviews were performed for the following topics: dispatch diagnosis of cardiac arrest, use of a firm surface for CPR, sequence for starting CPR (compressions-airway-breaths versus airway-breaths-compressions), CPR before calling for help, duration of CPR cycles, hand position during compressions, rhythm check timing, feedback for CPR quality, alternative techniques, public access automated external defibrillator programs, analysis of rhythm during chest compressions, CPR before defibrillation, removal of foreign-body airway obstruction, resuscitation care for suspected opioid-associated emergencies, drowning, and harm from CPR to victims not in cardiac arrest.

The topics that resulted in the most extensive task force discussions included CPR during transport, CPR before calling for help, resuscitation care for suspected opioid-associated emergencies, feedback for CPR quality, and analysis of rhythm during chest compressions. After discussion of the scoping reviews and the evidence update, the task force prioritized several topics for new systematic reviews.

Determination of Death in Mountain Rescue: Recommendations of the International Commission for Mountain Emergency Medicine (ICAR MedCom)

Determination of death requires specific knowledge, training, and experience in most cases. It can be particularly difficult when external conditions, such as objective hazards in mountains, prevent close physical examination of an apparently lifeless person, or when examination cannot be accomplished by an authorized person. Guidelines exist, but proper use can be difficult. In addition to the absence of vital signs, definitive signs of death must be present. Recognition of definitive signs of death can be problematic due to the variability in time course and the possibility of mimics. Only clear criteria such as decapitation or detruncation should be used to determine death from a distance or by laypersons who are not medically trained. To present criteria that allow for accurate determination of death in mountain rescue situations, the International Commission for Mountain Emergency Medicine convened a panel of mountain rescue doctors and a forensic pathologist. These recommendations are based on a nonsystematic review of the literature including articles on determination of death and related topics.

Adult Basic Life Support: 2020 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations

This2020 International Consensus on Cardiopulmonary Resuscitation(CPR)and Emergency Cardiovascular Care Science With Treatment Recommendationson basic life support summarizes evidence evaluations performed for 22 topics that were prioritized by the Basic Life Support Task Force of the International Liaison Committee on Resuscitation. The evidence reviews include 16 systematic reviews, 5 scoping reviews, and 1 evidence update. Per agreement within the International Liaison Committee on Resuscitation, new or revised treatment recommendations were only made after a systematic review.

Systematic reviews were performed for the following topics: dispatch diagnosis of cardiac arrest, use of a firm surface for CPR, sequence for starting CPR (compressions-airway-breaths versus airway-breaths-compressions), CPR before calling for help, duration of CPR cycles, hand position during compressions, rhythm check timing, feedback for CPR quality, alternative techniques, public access automated external defibrillator programs, analysis of rhythm during chest compressions, CPR before defibrillation, removal of foreign-body airway obstruction, resuscitation care for suspected opioid-associated emergencies, drowning, and harm from CPR to victims not in cardiac arrest.

The topics that resulted in the most extensive task force discussions included CPR during transport, CPR before calling for help, resuscitation care for suspected opioid-associated emergencies, feedback for CPR quality, and analysis of rhythm during chest compressions. After discussion of the scoping reviews and the evidence update, the task force prioritized several topics for new systematic reviews.

Pediatric hypothermic submersion incident - should we do chest compressions on a beating heart?

Background

Drowning is the third leading cause of unintentional injury death worldwide, with the highest rates of fatality among young children. To decide how to treat these patients prehospitally could be challenging in certain situations when uncertain about the adequacy of the patent’s circulation.

Methods/case report

We describe a 2 year old boy surviving a 15 min hypothermic submersion in a cold river. In spite of the presence of some vital signs, we decided to do full cardiopulmonary resuscitation to the hospital. The main reason was that we were uncertain about the adequacy of the spontaneous circulation, and the transport to hospital was fairly long. The patient suffered no obvious harm and the outcome was good.

Discussion

What is regarded as adequate circulation when accidentally hypothermic between 24 and 25⁰ C? A weak pulse was felt in the femoral artery with a rate of about 40–50 per minute. There were shallow, but regular respiration, and point of care ultrasound revealed a slightly dilated left ventricle and weak, but organised cardiac contractions. Despite these findings a decision was made to continue ventilations and chest compressions during helicopter transport to the University hospital.

Conclusion

In an accidentally hypothermic pediatric submersion incident we decided to do full cardiopulmonary resuscitation to the hospital despite there were signs of circulation. We did no harm to the patient. Future guideline revisions should try to clarify how to handle situations with severly accidentally hypothermic patients like this, so the good outcome that is often seen in these patients could be even better.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Outcome of Conventional Bystander Cardiopulmonary Resuscitation in Cardiac Arrest Following Drowning

INTRODUCTION

The concept of compressions only cardiopulmonary resuscitation (CO-CPR) evolved from a perception that lay rescuers may be less likely to perform mouth-to-mouth ventilations during an emergency. This study hopes to describe the efficacy of bystander compressions and ventilations cardiopulmonary resuscitation (CV-CPR) in cardiac arrest following drowning.

HYPOTHESIS/PROBLEM

The aim of this investigation is to test the hypothesis that bystander cardiopulmonary resuscitation (CPR) utilizing compressions and ventilations results in improved survival for cases of cardiac arrest following drowning compared to CPR involving compressions only.

METHODS

The Cardiac Arrest Registry for Enhanced Survival (CARES) was queried for patients who suffered cardiac arrest following drowning from January 1, 2013 through December 31, 2017, and in whom data were available on type of bystander CPR delivered (ie, CV-CPR CO-CPR). The primary outcome of interest was neurologically favorable survival, as defined by cerebral performance category (CPC).

RESULTS

Neurologically favorable survival was statistically significantly associated with CV-CPR in pediatric patients aged five to 15 years (aOR = 2.68; 95% CI, 1.10-6.77; P = .03), as well as all age group survival to hospital discharge (aOR = 1.54; 95% CI, 1.01-2.36; P = .046). There was a trend with CV-CPR toward neurologically favorable survival in all age groups (aOR = 1.35; 95% CI, 0.86-2.10; P = .19) and all age group survival to hospital admission (aOR = 1.29; 95% CI, 0.91-1.84; P = .157).

CONCLUSION

In cases of cardiac arrest following drowning, bystander CV-CPR was statistically significantly associated with neurologically favorable survival in children aged five to 15 years and survival to hospital discharge.

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.

Drowning mortality in children aged 0-14 years in Victoria, Australia: detailed epidemiological study 2001-2016

BACKGROUND

Major reductions in child drowning mortality rates have been observed historically in Victoria, Australia, for the period 1863-2000. Despite this trend, drowning remains the leading cause of unintentional child death in Victoria. This study investigates the residual fatal drowning problem in the Victorian child population (0-14 years) for the period 2001-2016.

AIMS

Describe the epidemiology of child drowning deaths in the Victorian population in 2001-2016; investigate risk factors and direct antecedents to these deaths.

METHODS

Population-based retrospective case data were extracted from the National Coronial Information System for 16 years (January 2001-December 2016), and case-by-case analysis was conducted. Associated factors were determined using univariate and Poisson analyses.

RESULTS

88 of 97 cases had information available for analysis, pools were the most frequent location (30%); 70% of all cases occurred between 08:00 and 17:00; most victims were not deliberately in the body of the water (73%), for example, the pool. Supervision lapses included carers leaving the room when the child was in the bath (16/18), siblings left to supervise the child in private pools (7/23), inadequate pool fences (8/23) or faulty/open gates (4/23), or neighbours' pool spa (4/23). Delays in finding the child occurred when searches occurred elsewhere, before the body of water (21/88) and when carers were asleep (5/88). Fourteen of the 88 children had an intellectual disability or predisposing medical condition. The grouped Poisson analysis demonstrated that age 0-4 years, male gender and rural place of residence were significant. A downward trend in drowning rate continued in this period.

DISCUSSION AND CONCLUSIONS

A case-by-case analysis of a drowned population of children identified details of risk factors and antecedents not previously described. Missing data on antecedents were common, likely resulting in undercounting. Further enhancements to systematic data collection are needed. The results support a systems approach to drowning prevention.

Pediatric Post–Cardiac Arrest Care: A Scientific Statement From the American Heart Association

Successful resuscitation from cardiac arrest results in a post–cardiac arrest syndrome, which can evolve in the days to weeks after return of sustained circulation. The components of post–cardiac arrest syndrome are brain injury, myocardial dysfunction, systemic ischemia/reperfusion response, and persistent precipitating pathophysiology. Pediatric post–cardiac arrest care focuses on anticipating, identifying, and treating this complex physiology to improve survival and neurological outcomes. This scientific statement on post–cardiac arrest care is the result of a consensus process that included pediatric and adult emergency medicine, critical care, cardiac critical care, cardiology, neurology, and nursing specialists who analyzed the past 20 years of pediatric cardiac arrest, adult cardiac arrest, and pediatric critical illness peer-reviewed published literature. The statement summarizes the epidemiology, pathophysiology, management, and prognostication after return of sustained circulation after cardiac arrest, and it provides consensus on the current evidence supporting elements of pediatric post–cardiac arrest care.

Long-Term Survival After Drowning-Related Cardiac Arrest

BACKGROUND

Long-term outcomes after drowning-related cardiac arrest are not well characterized.

OBJECTIVE

Our aims were to estimate long-term survival and identify prognostic factors in a large, population-based cohort of drowning victims with cardiac arrest.

METHODS

We conducted a population-based prospective cohort study (1974-1996) of Western Washington Drowning Registry (WWDR) subjects with out-of-hospital cardiac arrest and attempted professional resuscitation. The primary outcome was long-term survival through 2012. We tabulated Utstein-style exposure variables, estimated Kaplan-Meier curves, and identified prognostic factors with Cox proportional hazard modeling.

RESULTS

Of 2824 WWDR cases, 407 subjects (median age 17 years [interquartile range 3-33 years], 81% were male) were included. Only 54 (13%) were still alive after 1663 person-years of follow-up. Most deaths occurred after termination of initial resuscitation or during initial hospitalization. Risk of subsequent death after hospital discharge was 9.6 (95% confidence interval [CI] 5.7-15.9) per 1000 person-years. Long-term survival differed by Utstein variables (older age, illicit substance use, pre-drowning activity, submersion duration, cardiopulmonary resuscitation duration, intubation, defibrillation, and medications) and inpatient markers of illness severity (vital signs, Glasgow Coma Scale, laboratory values, shock). In adjusted analyses, older age (hazard ratio [HR] 1.01; 95% CI 1.01-1.02), epinephrine administration (HR 1.92; 95% CI 1.31-2.80), antiepileptic administration (HR 0.53; 95% CI 0.35-0.81), initial arterial pH (HR 0.49; 95% CI 0.26-0.92), and shock (HR 2.19; 95% CI 1.16-4.15) were associated with higher risk of death.

CONCLUSIONS

Most cases of drowning-related cardiac arrest were fatal, but survivors to hospital discharge had a low risk of subsequent death that was independently associated with older age and clinical evidence of shock.

Association of bystander cardiopulmonary resuscitation and neurological outcome after out-of-hospital cardiac arrest due to drowning in Japan, 2013-2016

BACKGROUND

Early initiation of cardiopulmonary resuscitation (CPR) performed by bystanders is essential in patients with out-of-hospital cardiac arrest (OHCA) due to primary cardiac cause. However, evidence about the effect of bystander CPR on neurologically favorable survival after OHCA due to drowning is scarce and controversial.

METHODS

This nationwide population-based observational study using prospectively collected government-led registry data included patients with OHCA due to drowning who were transported to an emergency hospital between 2013 and 2016. The primary outcome was one-month neurologically favorable survival defined as Glasgow-Pittsburgh Cerebral Performance Category score of 1-2. The secondary outcomes were one-month survival and prehospital return of spontaneous circulation (ROSC).

RESULTS

The full cohort (n = 12,139) comprised 6291 (51.8%) male patients, and the mean age was 73.7 (standard deviation [SD], 18.8). Of these, 5157 (42.5%) received bystander CPR, and 6982 (57.5%) did not. 4345 patients receiving bystander CPR were propensity-matched with 4345 patients not receiving bystander CPR. In the propensity score-matched cohort, bystander CPR was associated with increased chance of one-month neurologically favorable survival (0.4% vs. 0.8%; risk ratio [RR], 2.19; 95%confidence interval [CI], 1.21-3.95; P = 0.0076), one-month survival (1.1% vs. 1.7%; RR, 1.55; 95%CI, 1.09-2.22; P = 0.0150), and prehospital ROSC (2.7% vs. 3.5%; RR, 1.30; 95%CI, 1.03-1.65; P = 0.0296). Similar association was observed across a variety of sensitivity analyses. In subgroup analysis, statistically significant difference was not observed in pediatric OHCA due to drowning, although the sample size was too small (n = 218).

CONCLUSIONS

Among patients with OHCA due to drowning, bystander CPR was associated with increased chance of neurologically favorable survival.

Targeted Temperature Management in Pediatric Neurocritical Care

Targeted temperature management encompasses a range of clinical interventions to regulate systemic temperature, and includes both induction of varying degrees of hypothermia and fever prevention ("targeted normothermia"). Targeted temperature management plays a key role in the contemporary management of critically ill neonates and children with acute brain injury. Yet, many unanswered questions remain regarding optimal temperature management in pediatric neurocritical care. The introduction highlights experimental studies that have evaluated the neuroprotective efficacy of therapeutic hypothermia and explored possible mechanisms of action in several brain injury models. The next section focuses on three major clinical conditions in which therapeutic hypothermia has been evaluated in randomized controlled trials in pediatric populations: neonatal hypoxic-ischemic encephalopathy, postcardiac arrest encephalopathy, and traumatic brain injury. Clinical implications of targeted temperature management in pediatric neurocritical care are also discussed. The final section examines some of the factors that may underlie the limited neuroprotective efficacy of hypothermia that has been observed in several major pediatric clinical trials, and outlines important directions for future research.

Neurocognitive outcomes in children following immersion: a long-term study

OBJECTIVE

To investigate long-term neurocognitive outcomes after a near-drowning incident in children who were deemed neurologically intact on discharge from hospital.

DESIGN

A prospective cohort study of near-drowning children.

SETTING

95 drowning and near-drowning admissions, 0-16 years of age, from January 2009 to December 2013, to The Children's Hospital at Westmead, Sydney, NSW, Australia.

PARTICIPANTS

23 children both met the criteria and had parental consent for the study.

MAIN OUTCOME MEASURES

Identification of the long-term deficits in behaviour, executive function, motor skills, communicative skills and well-being over a 5-year period. Assessment was undertaken at 3-6 months, 1 year, 3 years and 5 years after near-drowning at clinic visits. Physical developmental screening and executive function screening were done using Behavior Rating Inventory of Executive Function-Preschool version (BRIEF-P) and BRIEF.

RESULT

95 drowning and near-drowning episodes occurred during the study period. 10 (11%) children died, 28 were admitted to the paediatric intensive care unit and 64 directly to a ward. 3 children died in emergency department, 7 children had severe neurological deficit on discharge from the hospital. 23 were subsequently recruited into the study; 5 (22%) of these children had abnormalities in behaviour and/or executive function at some during their follow-up.

CONCLUSION

Children admitted to hospital following a near-drowning event warrant long-term follow-up to identify any subtle sequelae which might be amenable to intervention to ensure optimal patient outcome.

Predictors of good neurologic outcome after resuscitation beyond 30 min in out-of-hospital cardiac arrest patients undergoing therapeutic hypothermia

Neurologically intact survival after cardiac arrest is possible even after prolonged resuscitation efforts. However, the factors associated with good neurologic outcome in these patients remain unknown. This study identifies predictors associated with good neurologic outcome after resuscitation beyond 30 min in out-of-hospital cardiac arrest (OHCA) patients treated with targeted temperature management (TTM). This multicenter, registry-based, retrospective cohort study conducted in 24 hospitals across South Korea between 2007 and 2012 includes adult (≥18 years) non-traumatic OHCA patients with prolonged (>30 min) downtime who underwent TTM treatment. Good neurologic outcomes were defined as cerebral performance category scores of ≤2. Of the 930 comatose adult cardiac arrest patients treated with TTM, 423 patients with prolonged downtime were included. A total of 76 (18.0%) had good neurologic outcome. Multivariable analysis reveal that age <65 years (OR 7.91, 95% CI 3.18-19.68), initial shockable rhythm (OR 6.31, 95% CI 3.40-11.74), and witnessed arrest (OR 3.81, 95% CI 1.73-8.45) are associated with good neurologic outcome. The sensitivity and specificity for good neurologic outcome in patients with age <65 years, shockable rhythm, and witnessed arrest are 90.8% and 41.2, 67.6 and 79.5%, and 81.6 and 41.2%, respectively. In prolonged cardiac arrest patients, initial shockable rhythm, age <65 years, or witnessed arrest are predictors for neurologic intact survival.

Review of 14 drowning publications based on the Utstein style for drowning

BACKGROUND

The Utstein style for drowning (USFD) was published in 2003 with the aim of improving drowning research. To support a revision of the USFD, the current study aimed to generate an inventory of the use of the USFD parameters and compare the findings of the publications that have used the USFD.

METHODS

A search in Pubmed, Embase, the Cochrane Library, Web of Science and Scopus was performed to identify studies that used the USFD and were published between 01-10-2003 and 22-03-2015. We also searched in Pubmed, Embase, the Cochrane Library, Web of Science, and Scopus for all publications that cited the two publications containing the original ILCOR advisory statement introducing and recommending the USFD. In total we identified 14 publications by groups that explicitly used elements of the USFD for collecting and reporting their data.

RESULTS

Of the 22 core and 19 supplemental USFD parameters, 6-19 core (27-86%) and 1-12 (5-63%) supplemental parameters were used; two parameters (5%) have not been used in any publication. Associations with outcome were reported for nine core (41%) and five supplemental (26%) USFD parameters. The USFD publications also identified non-USFD parameters related to outcome: initial cardiac rhythm, time points and intervals during resuscitation, intubation at the drowning scene, first hospital core temperature, serum glucose and potassium, the use of inotropic/vasoactive agents and the Paediatric Index of Mortality 2-score.

CONCLUSIONS

Fourteen USFD based drowning publications have been identified. These publications provide valuable information about the process and quality of drowning resuscitation and confirm that the USFD is helpful for a structured comparison of the outcome of drowning resuscitation.

Pediatric Hypothermic Submersion Injury and Protective Factors Associated with Optimal Outcome: A Case Report and Literature Review

Drowning is the 3rd leading cause of unintentional injury death worldwide, with the highest rates of fatality among young children. Submersion injuries with cardiac arrest can lead to long-term neurologic morbidity. Severe hypothermic submersion injuries have complex treatment courses and survivors have variable neurocognitive outcomes. We describe the course of a hypothermic submersion injury in a 6-year-old previously healthy boy. The description includes premorbid and post-injury neurocognitive functioning. A review of the literature of pediatric cold-water submersion injury was performed. Despite prolonged cardiopulmonary resuscitation (>100 min) and water temperature well above freezing, our patient had an optimal neurocognitive outcome following hypothermic submersion injury. Available literature is limited but suggests that increased submersion time, increased duration of resuscitation, and higher water temperatures are associated with worse outcomes. Care guidelines have been created, but outcomes related to these guidelines have not been studied. Our case highlights potential important determinants of outcome after drowning. Incident specific characteristics and therapeutic interventions should be considered when evaluating this population. Treatment guidelines based on currently available literature may fail to incorporate all potential variables, and consideration should be given to prolonged resuscitative efforts based on individual case characteristics until further data is available.

Characteristics and outcome of patients with hypothermic out-of-hospital cardiac arrest: Experience from a European trauma center

BACKGROUND

Aim of the study was to investigate patient characteristics, survival rates and neurological outcome among hypothermic patients with out-of-hospital cardiac arrest (OHCA) admitted to a trauma center.

METHODS

A review of patients with OHCA and a core temperature ≤32°C admitted to a trauma center between 2004 and 2016.

RESULTS

Ninety-six patients (mean temperature 25.8°C±3.9°C) were entered in the study, 37 (39%) of them after avalanche burial. 47% showed return of spontaneous circulation (ROSC) prior to hospital admission. Survival with Glasgow-Pittsburgh Cerebral Performance Category (CPC) scale 1 or 2 was achieved in 25% of all patients and was higher in non-avalanche than in avalanche cases (35.6% vs 8.1%, p=0.002). Witnessed cardiac arrest was the most powerful predictor of favourable neurological outcome (RR: 10.8; 95% Confidence Interval: 3.2-37.1; Wald: 14.3; p<0.001), whereas ROSC prior to admission and body core temperature were not associated with survival with favourable neurological outcome. Cerebral CT scan pathology within 12h of admission increased the risk for unfavourable neurological outcome 11.7 fold (RR: 11.7; 95% CI: 3.1-47.5; p<0.001). Favourable neurological outcome was associated lower S 100-binding protein (0.69±0.5μg/l vs 5.8±4.9μg/l, p 0.002) and neuron-specific enolase (34.7±14.2μg/l vs 88.4±42.7μg/l, p 0.004) concentrations on intensive care unit (ICU) admission.

CONCLUSIONS

Survival with favourable neurological outcome was found in about a third of all hypothermic non-avalanche patients with OHCA admitted to a trauma center.

Neurologic Outcomes Following Care in the Pediatric Intensive Care Unit

Purpose of review

With increasing survival of children requiring admission to pediatric intensive care units (PICU), neurodevelopmental outcomes of these patients are an area of increased attention. Our goal was to systematically review recently published literature on neurologic outcomes of PICU patients.

Recent Findings

Decline in neurofunctional status occurs in 3%-20% of children requiring PICU care. This proportion varies based on primary diagnosis and severity of illness, with children admitted for primary neurologic diagnosis, children who suffer cardiac arrest or who require invasive interventions during the PICU admission, having worse outcomes. Recent research focuses on early identification and treatment of modifiable risk factors for unfavorable outcomes, and on long-term follow-up that moves beyond global cognitive outcomes and is increasingly including tests assessing multidimensional aspects of neurodevelopment.

Summary

The pediatric critical care research community has shifted focus from survival to survival with favorable neurologic outcomes of children admitted to the PICU.

2015 revised Utstein-style recommended guidelines for uniform reporting of data from drowning-related resuscitation: An ILCOR advisory statement

BACKGROUND

Utstein-style guidelines use an established consensus process, endorsed by the international resuscitation community, to facilitate and structure resuscitation research and publication. The first "Guidelines for Uniform Reporting of Data From Drowning" were published over a decade ago. During the intervening years, resuscitation science has advanced considerably, thus making revision of the guidelines timely. In particular, measurement of cardiopulmonary resuscitation elements and neurological outcomes reporting have advanced substantially. The purpose of this report is to provide updated guidelines for reporting data from studies of resuscitation from drowning.

METHODS

An international group with scientific expertise in the fields of drowning research, resuscitation research, emergency medical services, public health, and development of guidelines met in Potsdam, Germany, to determine the data that should be reported in scientific articles on the subject of resuscitation from drowning. At the Utstein-style meeting, participants discussed data elements in detail, defined the data, determined data priority, and decided how data should be reported, including scoring methods and category details.

RESULTS

The template for reporting data from drowning research was revised extensively, with new emphasis on measurement of quality of resuscitation, neurological outcomes, and deletion of data that have proved to be less relevant or difficult to capture.

CONCLUSIONS

The report describes the consensus process, rationale for selecting data elements to be reported, definitions and priority of data, and scoring methods. These guidelines are intended to improve the clarity of scientific communication and the comparability of scientific investigations.

2015 Revised Utstein-Style Recommended Guidelines for Uniform Reporting of Data From Drowning-Related Resuscitation: An ILCOR Advisory Statement

BACKGROUND

Utstein-style guidelines use an established consensus process, endorsed by the international resuscitation community, to facilitate and structure resuscitation research and publication. The first "Guidelines for Uniform Reporting of Data From Drowning" were published over a decade ago. During the intervening years, resuscitation science has advanced considerably, thus making revision of the guidelines timely. In particular, measurement of cardiopulmonary resuscitation elements and neurological outcomes reporting have advanced substantially. The purpose of this report is to provide updated guidelines for reporting data from studies of resuscitation from drowning.

METHODS

An international group with scientific expertise in the fields of drowning research, resuscitation research, emergency medical services, public health, and development of guidelines met in Potsdam, Germany, to determine the data that should be reported in scientific articles on the subject of resuscitation from drowning. At the Utstein-style meeting, participants discussed data elements in detail, defined the data, determined data priority, and decided how data should be reported, including scoring methods and category details.

RESULTS

The template for reporting data from drowning research was revised extensively, with new emphasis on measurement of quality of resuscitation, neurological outcomes, and deletion of data that have proved to be less relevant or difficult to capture.

CONCLUSIONS

The report describes the consensus process, rationale for selecting data elements to be reported, definitions and priority of data, and scoring methods. These guidelines are intended to improve the clarity of scientific communication and the comparability of scientific investigations.