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

Informing Utstein-style reporting guidelines for prehospital thrombolysis: A scoping review

BACKGROUND

Rural Australians with acute myocardial infarction (AMI) face higher mortality rates due to limited access to specialised cardiac services. Paramedic-administered prehospital thrombolysis (PHT) has emerged as an alternative to primary percutaneous intervention (pPCI) for patients facing barriers or delays to cardiac care. There is variability in PHT practices among Australian ambulance services, lacking standardised definitions and outcome measures. The aim of this scoping review was to identify quality indicators and influencing factors associated with outcomes for patients receiving PHT.

METHODS

A systematic search of literature in SCOPUS and Academic Search Complete, CINAHL and Health Source: Nursing/Academic Edition databases via EBSCO (Health) was conducted following the Joanna Briggs Institute methodology. Peer-reviewed studies from the past decade were screened using search criteria relevant to prehospital thrombolysis and quality indicators. Data extraction was performed and themed using five domains from the Utstein-style template commonly known for standardised prehospital cardiac arrest reporting.

RESULTS

After removing duplicates, the search yielded 3596 articles with 28 empirical studies meeting inclusion criteria for the review. These were primarily retrospective cohort studies performed in Australia, Canada and the United States. The scoping review identified 24 clinical quality indicators and factors related to Emergency Medical Service (EMS) systems, AMI recognition and ambulance dispatch, patient variables, PHT processes and patient outcomes. These findings correlate to the Donabedian structure-process-outcome quality of care model and have utility to inform future PHT reporting guidelines for jurisdictional ambulance services.

CONCLUSIONS

Given the variability in prehospital practice across Australian ambulance services, standardised reporting on quality indicators for PHT is needed. The Utstein-style template used to report data on pre-hospital cardiac arrest, trauma and airway management could be used for quality improvement in PHT. This review presents 24 quality indicators representing system, recognition and response, patient, process, and outcomes related to PHT. These results could be used to inform a future Delphi study and Utstein-like reporting guideline for prehospital thrombolysis.

The Australian Traumatic Brain Injury Initiative: Statement of Working Principles and Rapid Review of Methods to Define Data Dictionaries for Neurological Conditions

The Australian Traumatic Brain Injury Initiative (AUS-TBI) aims to develop a health informatics approach to collect data predictive of outcomes for persons with moderate-severe TBI across Australia. Central to this approach is a data dictionary; however, no systematic reviews of methods to define and develop data dictionaries exist to-date. This rapid systematic review aimed to identify and characterize methods for designing data dictionaries to collect outcomes or variables in persons with neurological conditions. Database searches were conducted from inception through October 2021. Records were screened in two stages against set criteria to identify methods to define data dictionaries for neurological conditions (International Classification of Diseases, 11th Revision: 08, 22, and 23). Standardized data were extracted. Processes were checked at each stage by independent review of a random 25% of records. Consensus was reached through discussion where necessary. Thirty-nine initiatives were identified across 29 neurological conditions. No single established or recommended method for defining a data dictionary was identified. Nine initiatives conducted systematic reviews to collate information before implementing a consensus process. Thirty-seven initiatives consulted with end-users. Methods of consultation were "roundtable" discussion (n = 30); with facilitation (n = 16); that was iterative (n = 27); and frequently conducted in-person (n = 27). Researcher stakeholders were involved in all initiatives and clinicians in 25. Importantly, only six initiatives involved persons with lived experience of TBI and four involved carers. Methods for defining data dictionaries were variable and reporting is sparse. Our findings are instructive for AUS-TBI and can be used to further development of methods for defining data dictionaries.

Self-harm, suicide and brain death: the role of the radiologist

Suicide is a leading cause of death worldwide and takes many forms, which include hanging, jumping from a height, sharp force trauma, ingestion/poisoning, drowning, and firearm injuries. Self-harm and suicide are associated with particular injuries and patterns of injury. Many of these patterns are apparent on imaging. Self-harm or suicidal intent may be overlooked initially in such cases, particularly when the patient is unconscious or uncooperative. Correct identification of these findings by the radiologist will allow a patient's management to be tailored accordingly and may prevent future suicide attempts. The initial role of the radiologists in these cases is to identify life-threatening injuries that require urgent medical attention. The radiologist can add value by drawing attention to associated injuries, which may have been missed on initial clinical assessment. In many cases of self-harm and suicide, imaging is more reliable than clinical assessment. The radiologist may be able to provide important prognostic information that allows clinicians to manage expectations and plan appropriately. Furthermore, some imaging studies will provide essential forensic information. Unfortunately, many cases of attempted suicide will end in brain death. The radiologist may have a role in these cases in identifying evidence of hypoxic-ischaemic brain injury, confirming a diagnosis of brain death through judicious use of ancillary tests and, finally, in donor screening for organ transplantation. A review is presented to illustrate the imaging features of self-harm, suicide, and brain death, and to highlight the important role of the radiologist in these cases.

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.

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.

Cortical somatosensory evoked potential amplitudes and clinical outcome after cardiac arrest: a retrospective multicenter study

OBJECTIVE

Bilaterally absent cortical somatosensory evoked potentials (SSEPs) reliably predict poor outcome in comatose cardiac arrest (CA) patients. Cortical SSEP amplitudes are a recent prognostic extension; however, amplitude thresholds, inter-recording, and inter-rater agreement remain uncertain.

METHODS

In a retrospective multicenter cohort study, we determined cortical SSEP amplitudes of comatose CA patients using a standardized evaluation pathway. We studied inter-recording agreement in repeated SSEPs and inter-rater agreement by four raters independently determining 100 cortical SSEP amplitudes. Primary outcome was assessed using the cerebral performance category (CPC) upon intensive care unit discharge dichotomized into good (CPC 1-3) and poor outcome (CPC 4-5).

RESULTS

Of 706 patients with SSEPs with median 3 days after CA, 277 (39.2%) had good and 429 (60.8%) poor outcome. Of patients with bilaterally absent cortical SSEPs, one (0.8%) survived with CPC 3 and 130 (99.2%) had poor outcome. Otherwise, the lowest cortical SSEP amplitude in good outcome patients was 0.5 µV. 184 (42.9%) of 429 poor outcome patients had lower cortical SSEP amplitudes. In 106 repeated SSEPs, there were 6 (5.7%) with prognostication-relevant changes in SSEP categories. Following a standardized evaluation pathway, inter-rater agreement was almost perfect with a Fleiss' kappa of 0.88.

INTERPRETATION

Bilaterally absent and cortical SSEP amplitudes below 0.5 µV predicted poor outcome with high specificity. A standardized evaluation pathway provided high inter-rater and inter-recording agreement. Regain of consciousness in patients with bilaterally absent cortical SSEPs rarely occurs. High-amplitude cortical SSEP amplitudes likely indicate the absence of severe brain injury.

Cardiovascular changes induced by targeted mild hypercapnia after out of hospital cardiac arrest. A sub-study of the TAME cardiac arrest trial

AIM

Hypercapnia may elicit detrimental haemodynamic effects in critically ill patients. We aimed to investigate the consequences of targeted mild hypercapnia versus targeted normocapnia on pulmonary vascular resistance and right ventricular function in patients resuscitated from out-of-hospital cardiac arrest (OHCA).

METHODS

Pre-planned, single-centre, prospective, sub-study of the Targeted Therapeutic Mild Hypercapnia After Resuscitated Cardiac Arrest (TAME) trial. Patients were randomised to mild hypercapnia (PaCO2 = 6.7-7.3 kPa) or normocapnia (PaCO2 = 4.7-6.0 kPa) for 24 hours. Haemodynamic assessment was performed with right heart catheterisation and serial blood-gas analyses every4th hour for 48 hours.

RESULTS

We studied 84 patients. Mean pH was 7.24 (95% CI 7.22-7.30) and 7.32 (95% CI 7.31-7.34) with hypercapnia and normocapnia, respectively (P-group < 0.001). Pulmonary vascular resistance index (PVRI), pulmonary artery pulsatility index, and right atrial pressure did not differ between groups (P-group > 0.05). Mean cardiac index was higher with mild hypercapnia (P-group < 0.001): 2.0 (95% CI 1.85-2.1) vs 1.6 (95% CI 1.52-1.76) L/min/m2. Systemic vascular resistance index was 2579 dyne-sec/cm-5/ m2 (95% CI 2356-2830) with hypercapnia, and 3249 dyne-sec/cm-5/ m2 (95% CI 2930-3368) with normocapnia (P-group < 0.001). Stroke volumes (P-group = 0.013) and mixed venous oxygen saturation (P-group < 0.001) were higher in the hypercapnic group.

CONCLUSION

In resuscitated OHCA patients, targeting mild hypercapnia did not increase PVRI or worsen right ventricular function compared to normocapnia. Mild hypercapnia comparatively improved cardiac performance and mixed venous oxygen saturation.

Danish Drowning Formula for identification of out-of-hospital cardiac arrest from drowning

BACKGROUND

Accurate, reliable, and sufficient data is required to reduce the burden of drowning by targeting preventive measures and improving treatment. Today's drowning statistics are informed by various methods sometimes based on data sources with questionable reliability. These methods are likely responsible for a systematic and significant underreporting of drowning. This study's aim was to assess the 30-day survival of patients with out-of-hospital cardiac arrest (OHCA) identified in the Danish Cardiac Arrest Registry (DCAR) after applying the Danish Drowning Formula.

METHODS

This nationwide, cohort, registry-based study with 30-day follow-up used the Danish Drowning Formula to identify drowning-related OHCA with a resuscitation attempt from the DCAR from January 1st, 2016, through December 31st, 2021. The Danish Drowning Formula is a text-search algorithm constructed for this study based on trigger-words identified from the prehospital medical records of validated drowning cases. The primary outcome was 30-day survival from OHCA. Data were analyzed using multiple logistic regression.

RESULTS

Drowning-related OHCA occurred in 374 (1%) patients registered in the DCAR compared to 29,882 patients with OHCA from other causes. Drowning-related OHCA more frequently occurred at a public location (87% vs 25%, p < 0.001) and were more frequently witnessed by bystanders (80% vs 55%, p < 0.001). Both 30-day and 1-year survival for patients with drowning-related OHCA were significantly higher compared to OHCA from other causes (33% vs 14% and 32% vs 13%, respectively, p < 0.001). The adjusted odds ratio for 30-day survival for drowning-related OHCA and other causes of OHCA was 2.3 [1.7-3.2], p < 0.001. Increased 30-day survival was observed for drowning-related OHCA occurring at swimming pools compared to public location OHCA from other causes with an OR of 11.6 [6.0-22.6], p < 0.001.

CONCLUSIONS

This study found higher 30-day survival among drowning-related OHCA compared to OHCA from other causes. This study proposed that a text-search algorithm (Danish Drowning Formula) could explore unstructured text fields to identify drowning persons. This method may present a low-resource solution to inform the drowning statistics in the future.

REGISTRATION

This study was registered at ClinicalTrials.gov before analyses (NCT05323097).

Telephone-based evaluation of cognitive impairment and mood disorders in cardiac arrest survivors with good neurologic outcomes: a retrospective cohort study

This study determined the occurrence of cognitive impairment and mood disorders in out-of-hospital cardiac arrest (OHCA) survivors with good neurologic outcomes. We performed a retrospective, cross-sectional, single-center study with a total of 97 patients. We evaluated cognitive dysfunction via the Montreal Cognitive Assessment and Alzheimer's disease-8 mood disorders via the Patient Health Questionnaire-9 and the Hospital Anxiety and Depression Scale. We measured quality of life with the European Quality of Life 5-Dimension 5-Levels questionnaire. Cognitive impairment and mood disorders were common among patients with good neurologic recovery. There were 23 patients who experienced cognitive impairments (23.7%) and 28 who suffered from mood disorders (28.9%). Age (adjusted OR 1.07, 95% CI 1.02-1.12), mood disorders (adjusted OR 22.80, 95% CI 4.84-107.49) and hospital length of stay (adjusted OR 1.05, 95% CI 1.02-1.09) were independent risk factors for cognitive impairment. The occurrence of cognitive impairments (adjusted OR 9.94, 95% CI 2.83-35.97) and non-cardiac causes of cardiac arrest (adjusted OR 11.51, 95% CI 3.15-42.15) were risk factors for mood disorders. Quality of life was significantly lower in the OHCA survivors with each disorder than the healthy individuals. Routine screening and intervention are needed for OHCA survivors.

Drowning in the United States: Patient and Scene Characteristics using the novel CARES Drowning Variables

INTRODUCTION

Drowning results in more than 360,000 deaths annually, making it the 3rd leading cause of unintentional injury death worldwide. Prior studies examining drowning internationally have reviewed factors surrounding drowning however in the U.S. limited data exists. This study evaluated the novel drowning elements collected in the Cardiac Arrest Registry to Enhance Survival (CARES) during the first 2 years of data collection.

METHODS

A retrospective analysis of the CARES database identified cases of drowning etiology for the two years 2020 and 2021. Demographics and incident characteristics were collected. Characteristics included items such as body of water, precipitating event, and who extracted patients. Survival to hospital discharge and neurological outcomes were compared between groups based on who initiated CPR using Pearson's Chi-Squared tests.

RESULTS

Among 1,767 drowning cases, 69.7% were male, 47.1% white and 11.9% survived to hospital discharge. Body of water was often natural body (36.2%) or swimming pool (25.9%) and bystanders removed the patient in 42.7% of incidents. Swimming was the most common activity at time of submersion (18.6%) however in 50.2% of cases, activity was unknown or missing. When compared to EMS/First Responder initiating CPR, odds of neurologically favorable survival were significantly higher in the Bystander initiated CPR group (OR=2.85, 95% confidence interval [CI] 2.02-4.01).

CONCLUSION

In this national cohort of drowning patients in cardiac arrest, the novel CARES drowning elements provide additional detail of epidemiological factors. Bystander CPR was associated with improved neurological outcomes. Future studies utilizing the drowning elements can inform injury prevention strategies.

Mortality trends and the impact of exposure on Australian coastal drowning deaths, 2004-2021

OBJECTIVE

The aim of this study is to characterise Australian coastal drowning trends and evaluate impact of exposure on drowning risk.

METHODS

Descriptive epidemiological analysis of unintentional fatal drowning occurring July 2004-June 2021 at Australian coastal sites (beaches, rock platforms, bays, harbours, offshore locations etc.). Total population, exposed-person and exposed-person-time rates per 100,000 population were calculated by age, sex, socio-economic status, remoteness category and pre-submersion activity. Annual trends were assessed using joinpoint regression. Exposure-based rates used estimates from Surf Life Saving Australia's National Coastal Safety Survey.

RESULTS

The cumulative unintentional coastal fatal drowning rate was 0.43 per 100,000 Australian residents (95%CI: 0.41-0.45) and did not change throughout the study period (p=0.289). The exposed-person rate was 0.67 per 100,000 coastal visitors (95%CI: 0.62-0.72), and there were 0.55 coastal drowning deaths per 10 million coastal visitor hours (95%CI: 0.51-0.59). Men, older people and residents of lower socio-economic and remote areas had higher drowning rates; rock fishing and scuba diving had the highest activity exposure-based rates.

CONCLUSIONS

Education- and policy-based coastal safety interventions should focus on identified risk factors to reduce annual coastal drowning rates.

IMPLICATIONS FOR PUBLIC HEALTH

Exposure-based risk measurements are important for developing and prioritising interventions; assessments based on counts or total population measures alone may misinform prevention efforts.

Association between a Post-Resuscitation Care Bundle and the Odds of Field Rearrest after Successful Resuscitation from Out-of-Hospital Cardiac Arrest: A Pre/Post Study

OBJECTIVES

Rearrest after successful resuscitation from out-of-hospital cardiac arrest (OHCA) is common and is associated with worse patient outcomes. However, little is known about the effect of interventions designed to prevent rearrest. We assessed the association between a prehospital care protocol for immediate management after return of spontaneous circulation (ROSC) and rates of field rearrest and survival to discharge in patients with prehospital ROSC.

METHODS

This was a retrospective study of adult patients with OHCA and field ROSC within a large EMS system before (April 2017-August 2018) and after (April 2019-February 2020) implementation of a structured prehospital post-ROSC care protocol. The protocol was introduced in September 2018 and provided on-scene stabilization direction including guidance on ventilation and blood pressure support. Field data and hospital outcomes were used to compare the frequency of field rearrest, hospital survival, and survival with good neurologic outcome before and after protocol implementation. Logistic regression was used to assess the association between the post-implementation period and these outcomes, and odds ratios were reported. The association between individual interventions on these outcomes was also explored.

RESULTS

There were 2,706 patients with ROSC after OHCA in the pre-implementation period and 1,780 patients in the post-implementation period. The rate of prehospital rearrest was 43% pre-implementation vs 45% post-implementation (RD 2%, 95% CI -1, 4%). In the adjusted analysis, introduction of the protocol was not associated with decreased odds of rearrest (OR 0.87, 95% CI 0.73, 1.04), survival to hospital discharge (OR 1.01, 95% CI 0.81, 1.24), or survival with good neurologic outcome (OR 0.81, 95% CI 0.61, 1.06). Post-implementation, post-ROSC administration of saline and push-dose epinephrine increased from 11% to 25% (RD 14%, 95% CI 11, 17%) and from 3% to 12% (RD 9% 95% CI 7, 11%), respectively. In an exploratory analysis, push-dose epinephrine was associated with a decreased odds of rearrest (OR 0.68, 95% CI 0.50, 0.94).

CONCLUSIONS

Introduction of a post-ROSC care protocol for patients with prehospital ROSC after OHCA was not associated with reduced odds of field rearrest. When elements of the care bundle were considered individually, push-dose epinephrine was associated with decreased odds of rearrest.

Association between basic life support and survival in sports-related sudden cardiac arrest: a meta-analysis

AIMS

To evaluate the association of basic life support with survival after sports-related sudden cardiac arrest (SR-SCA).

METHODS AND RESULTS

In this systematic review and meta-analysis, a search of several databases from each database inception to 31 July 2021 without language restrictions was conducted. Studies were considered eligible if they evaluated one of three scenarios in patients with SR-SCA: (i) bystander presence, (ii) bystander cardiopulmonary resuscitation (CPR), or (iii) bystander automated external defibrillator (AED) use and provided information on survival. Risk of bias was evaluated using Risk of Bias in Non-randomized Studies of Interventions. The primary outcome was survival at the longest follow up. The meta-analysis was conducted using the random-effects model. The Grading of Recommendations Assessment, Development, and Evaluations (GRADE) approach was used to rate certainty in the evidence. In total, 28 non-randomized studies were included. The meta-analysis showed significant benefit on survival in all three groups: bystander presence [odds ratio (OR) 2.55, 95% confidence interval (CI) 1.48-4.37; I2 = 25%; 9 studies-988 patients], bystander CPR (OR 3.84, 95% CI 2.36-6.25; I2 = 54%; 23 studies-2523 patients), and bystander AED use (OR 5.25, 95% CI 3.58-7.70; I2 = 16%; 19 studies-1227 patients). The GRADE certainty of evidence was judged to be moderate.

CONCLUSION

In patients with SR-SCA, bystander presence, bystander CPR, and bystander AED use were significantly associated with survival. These results highlight the importance of witness intervention and encourage countries to develop their first aid training policy and AED installation in sport settings.

Outcomes of extracorporeal membrane oxygenation and cardiopulmonary bypass in children after drowning-related resuscitation

Drowning is one of the leading causes of accidental deaths in children worldwide. However, the use of long-term extracorporeal life support (ECLS) in this setting is not widely established, and rewarming is often achieved by short-term cardiopulmonary bypass (CPB) treatment. Thus, we sought to add our experience with this means of support as a bridge-to-recovery or to-decision. This retrospective single-center study analyzes the outcome of 11 children (median 23 months, minimum-maximum 3 months-6.5 years) who experienced drowning and subsequent cardiopulmonary resuscitation (CPR) between 2005 and 2016 and who were supported by veno-arterial extracorporeal membrane oxygenation (ECMO), CPB, or first CPB then ECMO. All but one incident took place in sweet water. Submersion time ranged between 10 and 50 minutes (median 23 minutes), water temperature between 2°C and 28°C (median 14°C), and body core temperature upon arrival in the emergency department between 20°C and 34°C (median 25°C). Nine patients underwent ongoing CPR from the scene until ECMO or CPB initiation in the operating room. The duration of ECMO or CPB before successful weaning/therapy withdrawal ranged between 2 and 322 hours (median 19 hours). A total of four patients (36%) survived neurologically mildly or not affected after 4 years of follow-up. The data indicate that survival is likely related to a shorter submersion time and lower water temperature. Resuscitation of pediatric patients after drowning has a poor outcome. However, ECMO or CPB might promote recovery in selected cases or serve as a bridge-to-decision tool.

Association between location of out-of-hospital cardiac arrest, on-scene socioeconomic status, and accessibility to public automated defibrillators in two large metropolitan areas in Canada and France

AIM

To compare walking access times to automated external defibrillators (AEDs) between area-level quintiles of socioeconomic status (SES) in out-of-hospital cardiac arrest (OHCA) cases occurring in 2 major urban regions of Canada and France.

METHODS

This was an international, multicenter, retrospective cohort study of adult, non-traumatic OHCA cases in the metropolitan Vancouver (Canada) and Rhône County (France) regions that occurred between 2014 and 2018. We calculated area-level SES for each case, using quintiles of country-specific scores (Q5 = most deprived). We identified AED locations from local registries. The primary outcome was the simulated walking time from the OHCA location to the closest AED (continuous and dichotomized by a 3-minute 1-way threshold). We fit multivariate models to analyze the association between OHCA-to-AED walking time and outcomes (Q5 vs others).

RESULTS

A total of 6,187 and 3,239 cases were included from the Metro Vancouver and Rhône County areas, respectively. In Metro Vancouver Q5 areas (vs Q1-Q4), areas, AEDs were farther from (79 % over 400 m from case vs 67 %, p < 0.001) and required longer walking times to (97 % above 3 min vs 91 %, p < 0.001) cases. In Rhône Q5 areas, AEDs were closer than in other areas (43 % over 400 m from case vs 50 %, p = 0.01), yet similarly poorly accessible (85 % above 3 min vs 86 %, p = 0.79). In multivariate models, AED access time ≥ 3 min was associated with decreased odds of survival at hospital discharge in Metro Vancouver (odds ratio 0.41, 95 % CI [0.23-0.74], p = 0.003).

CONCLUSIONS

Accessibility of public AEDs was globally poor in Metro Vancouver and Rhône, and even poorer in Metro Vancouver's socioeconomically deprived areas.

Augmented-Medication CardioPulmonary Resuscitation (AMCPR) trial: a study protocol for a randomized controlled trial

Objective Clinical trials on demodynamic-directed cardiopulmonary resuscitation have been limited. The aim of this study is to investigate whether Augmented-Medication CardioPulmonary Resuscitation (AMCPR) would improve the odds of return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest. Methods This is a double-blind, single-center, randomized placebo-controlled trial that will be conducted in the emergency department of a tertiary, university-affiliated hospital in Seoul, Korea. A total of 148 adult patients with nontraumatic, nonshockable, out-of-hospital cardiac arrest who have an initial diastolic blood pressure above 20 mmHg will be randomly assigned to two groups of 74 patients (a 1:1 ratio). Patients will receive an intravenous dose of 40 IU of vasopressin with epinephrine, or a placebo with epinephrine. The primary endpoint is a sustained ROSC (over 20 minutes). Secondary endpoints are enhanced diastolic blood pressure, end-tidal carbon dioxide levels, acidosis, and lactate levels during resuscitation. Discussion AMCPR is a trial about tailored medication for select patients during resuscitation. This is the first randomized control trial to identify patients who would benefit from vasopressin for achieving ROSC. This study will provide evidence about the effect of administration of vasopressin with epinephrine to increase ROSC rate. Trial registration ClinicalTrials.gov identifier: NCT03191240. Registered on June 19, 2017.

Accelerating to Practice: Defining a Competency-Based Curriculum Framework for Nursing Education Part 1

AIM

This study aims to address the transition-to-practice dilemma for novice nurse, define gaps, and lay a foundation for a curriculum framework.

BACKGROUND

The National League for Nursing has challenged and supported nurse educators in developing teaching methodologies that prepare novice nurses for professional practice. Over a decade ago, compelling research fueled a debate that continues today, with nursing education and practice research reporting lack of readiness for practice by novice nurses and the goal of identifying gaps and potential strategies for solutions.

METHOD

The Utstein-style meeting strategy consensus approach was used to refine the data gaps reported in the literature.

RESULTS

The findings from this work generated a strong foundation for a transition-to-practice curriculum framework.

CONCLUSION

The Utstein-style meeting provided for a diverse conversation across multiple perspectives. Participants worked collaboratively in real time to further illuminate and refine the data gaps and inform nursing curricula.

Characteristics and factors associated to patients discharging from hospital without an implantable cardioverter defibrillator after out-of-hospital cardiac arrest

AIMS

Guidelines recommend that in the absence of reversible cause for sudden cardiac arrest (SCA), implantable cardioverter defibrillator (ICD) should be performed to prevent further fatal event. We sought to describe the frequency and characteristics of patients discharged from the hospital without ICD after the SCA in the daily practice.

METHODS AND RESULTS

From 2011 to 2018, all SCAs related to a cardiac cause admitted alive across the 48 hospitals of Great Paris Area were prospectively enrolled. Two investigators thoroughly reviewed each medical report to ensure accuracy of the assigned diagnosis towards identifying the cause of SCA and ICD implantation. Out of the 4314 SCA admitted alive at hospital admission, 1064 cardiac-related SCA survivors were discharged alive from hospital, including 356 patients (33.5%) with an ICD and 708 (66.5%) without. The principal underlying cause of SCA among those discharged without an ICD was acute coronary syndrome (ACS; 602, 85%), chronic coronary artery disease (41, 5.8%), structural non-ischaemic heart disease (48, 6.8%), and non-structural heart disease (17, 2.4%). Among ACS-related SCA, 93.8% (602/642) discharged without an ICD. The unique factor associated with non-ICD implantation in the setting of ACS was immediate coronary angioplasty (odds ratio 4.22, 95% confidence interval 1.86-9.30, P < 0.001).

CONCLUSION

Two-thirds of SCA survivors were discharged without an ICD, mainly in the setting of ACS. The unique factor associated with non-ICD implantation among ACS was immediate coronary angioplasty emphasizing the fact that ACS definition must be precise since associated with ICD implantation or not.

Prevalence, Outcomes, and Risk Factors for Cardiorespiratory Arrest in the Intensive Care Unit: An Observational Study

Background

Cardiorespiratory arrest is defined as an abrupt halt in the cardiac mechanical activity that is accompanied by the loss of a detectable pulse, the cessation of breathing, and the loss of consciousness. The aim of this study is to create a clinical–epidemiological profile of patients who experienced cardiorespiratory arrest and were admitted to the intensive care unit to evaluate the associated factors and their impact on the prognosis of these patients.

Patients and methods

From January to December 2019, the medical records of 135 patients who received cardiopulmonary resuscitation were reviewed for this cross-sectional observational study. The information was collected according to the Utstein model.

Results

A low return of spontaneous circulation of 22.2% was observed, with a predominance of females (53.3%) and older patients (68.9%), multiple comorbidities at admission (68.4%), and asystole as the predominant rhythm. Female sex and age >60 years were statistically significant (p = 0.017), as was the association between sex and comorbidities (p = 0.036), with heart disease being the most prevalent in females (p = 0.036).

Conclusion

In this study, even though the resuscitation maneuver time (start of resuscitation following arrest) was very short and the defibrillation was performed promptly, there was a high prevalence of cardiac arrest and low survival rates after cardiopulmonary resuscitation.

How to cite this article

Menezes da Silva A, Braga AL, Cruvinel de Souza V. Prevalence, Outcomes, and Risk Factors for Cardiorespiratory Arrest in the Intensive Care Unit: An Observational Study. Indian J Crit Care Med 2022;26(6):704–709.

Neurological outcomes in adult drowning patients in China

BACKGROUND

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

OBJECTIVE

Investigate factors associated with neurological prognosis in adult drowning inpatients.

DESIGN

Multicenter medical record review.

SETTING

Tertiary health care institutions.

PATIENTS AND METHODS

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

MAIN OUTCOME MEASURES

Neurological outcomes.

SAMPLE SIZE AND CHARACTERISTICS

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

RESULT

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

CONCLUSIONS

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

LIMITATIONS

Retrospective.

CONFLICT OF INTEREST

None.

Out of hospital cardiac arrest in Western Sydney-an analysis of outcomes and estimation of future eCPR eligibility

Background

Refractory out of hospital cardiac arrest (OHCA) is associated with extremely poor outcomes. However, in selected patients extracorporeal cardiopulmonary resuscitation (eCPR) may be an effective rescue therapy, allowing time treat reversible causes. The primary goal was to estimate the potential future caseload of eCPR at historically 'low-volume' extracorporeal membrane oxygenation (ECMO) centres.

Methods

A 3-year observational study of OHCA presenting to the Emergency Department (ED of an urban referral centre without historical protocolised use of eCPR. Demographics and standard Utstein outcomes are reported. Further, an a priori analysis of each case for potential eCPR eligibility was conducted. A current eCPR selection criteria (from the 2-CHEER study) was used to determine eligibly.

Results

In the study window 248 eligible cardiac arrest cases were included in the OHCA registry. 30-day survival was 23.4% (n = 58). The mean age of survivors was 55.4 years. 17 (6.8%) cases were deemed true refractory arrests and fulfilled the 2-CHEER eligibility criteria. The majority of these cases presented within “office hours” and no case obtained a return of spontaneous circulation standard advanced life support.

Conclusions

In this contemporary OHCA registry a significant number of refractory cases were deemed potential eCPR candidates reflecting a need for future interdisciplinary work to support delivery of this therapy.

Fatal drowning statistics from the Netherlands - an example of an aggregated demographic profile

Introduction

Incompleteness of fatal drowning statistics is a familiar problem impeding public health measures. Part of the problem may be that only data on accidental drowning are used and not the full potential of accessible data.

Methods

This study combines cause-of-death certificates and public prosecutor’s court documents between 1998 and 2017 to obtain an aggregated profile. Data are also used as a basis for a trend analysis.

Results

The dataset includes 5571 drowned persons (1.69 per 100,000). The highest risk group are persons above the age of 50. Demographic differences are observed between suicide by drowning, accidental drowning, and drowning due to transportation (0.72, 0.64, 0.28 per 100.000) and between native Dutch, and Dutch with western and non-western background (1.46, 1.43, 1.76 per 100.000). Non-residents account for another 12.2%. When comparing the periods 1998–2007 with 2008–2017, the Standard Mortality declines for suicide drowning and accidental drowning among persons with a native Dutch and non-western background. Single regression analysis confirms a decrease of drowning over the full period, breakpoint analysis shows an increase in the incidence of the total number of drowning, suicide by drowning and accidental drowning starting in 2007, 2008 resp. 2012.

Discussion

Compared to the formal number of fatal accidental drowning in the Netherlands (n = 1718; incidence 0.52 per 100,000), the study identifies 350% more drowning. Differences in demographic data and the recent increase needs to be explored for public health interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-022-12620-3.

Association of Cardiac Arrest With Opioid Overdose in Transport

Introduction:

Drug overdose is the leading cause of injury-related death in the United States. It has been linked to respiratory depression and cardiac toxicity, both of which can lead to cardiac arrest. Despite this potential association, few studies have examined this relationship, particularly in transport to the hospital. The purpose of this research was to determine if there was a relationship between opioid overdose and cardiac arrest in transport.

Methods:

A sample (n = 1 000 000) was utilized from the National EMS Information System (NEMSIS) from the year 2019. A logistic regression model was used to predict cardiac arrest from dispatch reason with gender, race, and age included as controls.

Results:

Overdose-related dispatch reason was associated with an increased likelihood of cardiac arrest in transport (Odds Ratio = 1.65, 95% Confidence Interval: [1.22, 2.22]).

Conclusions:

Opioid overdose is associated with an increased incidence of cardiac arrest in transport in the United States.

Global surgery, obstetric, and anaesthesia indicator definitions and reporting: An Utstein consensus report

BACKGROUND

Indicators to evaluate progress towards timely access to safe surgical, anaesthesia, and obstetric (SAO) care were proposed in 2015 by the Lancet Commission on Global Surgery. These aimed to capture access to surgery, surgical workforce, surgical volume, perioperative mortality rate, and catastrophic and impoverishing financial consequences of surgery. Despite being rapidly taken up by practitioners, data points from which to derive the indicators were not defined, limiting comparability across time or settings. We convened global experts to evaluate and explicitly define-for the first time-the indicators to improve comparability and support achievement of 2030 goals to improve access to safe affordable surgical and anaesthesia care globally.

METHODS AND FINDINGS

The Utstein process for developing and reporting guidelines through a consensus building process was followed. In-person discussions at a 2-day meeting were followed by an iterative process conducted by email and virtual group meetings until consensus was reached. The meeting was held between June 16 to 18, 2019; discussions continued until August 2020. Participants consisted of experts in surgery, anaesthesia, and obstetric care, data science, and health indicators from high-, middle-, and low-income countries. Considering each of the 6 indicators in turn, we refined overarching descriptions and agreed upon data points needed for construction of each indicator at current time (basic data points), and as each evolves over 2 to 5 (intermediate) and >5 year (full) time frames. We removed one of the original 6 indicators (one of 2 financial risk protection indicators was eliminated) and refined descriptions and defined data points required to construct the 5 remaining indicators: geospatial access, workforce, surgical volume, perioperative mortality, and catastrophic expenditure. A strength of the process was the number of people from global institutes and multilateral agencies involved in the collection and reporting of global health metrics; a limitation was the limited number of participants from low- or middle-income countries-who only made up 21% of the total attendees.

CONCLUSIONS

To track global progress towards timely access to quality SAO care, these indicators-at the basic level-should be implemented universally as soon as possible. Intermediate and full indicator sets should be achieved by all countries over time. Meanwhile, these evolutions can assist in the short term in developing national surgical plans and collecting more detailed data for research studies.

General health condition of patients hospitalized after an incident of in-hospital or out-of hospital sudden cardiac arrest with return of spontaneous circulation

Background

Sudden cardiac arrest (SCA) is one of the main reasons for admission to the intensive care unit (ICU), which influences discharge in a good neurological state.

Hypothesis

To analyze patients who had recovery of spontaneous circulation (ROSC) during hospitalization in the ICU using the Glasgow Outcome Scale (GOS).

Methods

The study group comprised 78 patients after SCA (35 after out‐of‐hospital cardiac arrest [OHCA] and 43 after in‐hospital cardiac arrest [IHCA]) with ROSC who were admitted to the ICU of Regional Hospital No. 5 in Sosnowiec from January 1, 2016 to December 31, 2016. GOS was used to assess neurological status. Basic anthropological data, with, arterial blood pH, lactate concentration (LAC), and catecholamine treatment were also collected.

Results

In the study group, 32.1% (n = 25/78) of patients survived until ICU discharge and 30.8% (n = 24/78) until discharge from the hospital. SCA in cardiac mechanism was more common in OHCA than in the IHCA group (OHCA vs. IHCA: 85.7% vs. 62.8%, p = .02). There was no statistically significant difference between the two groups for neurological status assessed using GOS. There was no statistically significant difference between LAC or arterial blood pH and survival to ICU discharge, survival to hospital discharge, or mortality. The need for using catecholamines increased the mortality rate (GOS 1) (p < .001).

Conclusions

Most patients after RSOC were assigned to a group other than GOS 1, and 25% of all subjects belonged to GOS 4–5. Treatment with catecholamines was more common in patients who do not survive hospital or ICU discharge.

Rationale, development and implementation of the ReACanROC registry for out-of-hospital cardiac arrests in France and Canada

France and Canada prehospital systems and care delivery in out-of-hospital cardiac arrests (OHCAs) show substantial differences. This article aims to describe the rationale, design, implementation and expected research implications of the international, population-based, France-Canada registry for OHCAs, namely ReACanROC, which is built from the merging of two nation-wide, population-based, Utstein-style prospectively implemented registries for OHCAs attended to by emergency medical services. Under the supervision of an international steering committee and research network, the ReACanROC dataset will be used to run in-depth analyses on the differences in organisational, practical and geographic predictors of survival after OHCA between France and Canada. ReACanROC is the first Europe-North America registry ever created to meet this goal. To date, it covers close to 80 million people over the two countries, and includes approximately 200 000 cases over a 10-year period.

Incidence, characteristics and risk factors for perioperative cardiac arrest and 30-day-mortality in preterm infants requiring non-cardiac surgery

STUDY OBJECTIVE

To determine 30-day-mortality, incidence and characteristics of perioperative cardiac arrest as well as the respective independent risk factors in preterm infants undergoing non-cardiac surgery.

DESIGN

Retrospective observational Follow-up-study.

SETTING

Bielefeld University Hospital, a German tertiary care hospital.

PATIENTS

Population of 229 preterm infants (age < 37th gestational week at the time of surgery) who underwent non-cardiac surgery between 01/2008-12/2018.

MEASUREMENTS

Primary endpoint was overall 30-day-mortality. Secondary endpoints were the incidence of perioperative cardiac arrest and identification of independent risk factors. We performed univariate and multivariate analyses and calculated odds ratios (OR) for risk factors associated with these endpoints.

MAIN RESULTS

30-day-mortality was 10.9% and perioperative mortality 0.9%. Univariate risk factors for 30-day-mortality were perioperative cardiac arrest (OR,12.5;95%CI,3.1 to 50.3), comorbidities of lungs (OR,3.7;95%CI,1.2 to 11.3) and gastrointestinal tract (OR,3.5;95%CI,1.3 to 9.6); sepsis (OR,3.6;95%CI,1.4 to 9.5); surgery between 22:01-7:00 (OR,7.3;95%CI,2.4 to 21.7); emergency (OR,4.5;95%CI,1.6 to 12.4); pre-existing catecholamine therapy (OR,5.0;95%CI,2.1 to 11.9). Multivariate logistic regression indicated that perioperative cardiac arrest (OR,13.9;95%CI,2.7 to 71.3), low body weight (weight < 1000 g: OR,26.0;95%CI,3.2 to 212; 1000-1499 g: OR,10.3; 95%CI,1.1 to 94.9 compared to weight > 2000 g), and time of surgery (OR,5.9;95%CI,1.6 to 21.3) for 22:01-7:00 compared to 7:01-15:00) were the major independent risk factors of mortality. Incidence of perioperative cardiac arrests was 3.9% (9 of 229;95%CI,1.8 to 7.3). Univariate risk factors were congenital anomalies of the airways (OR,4.7;95%CI,1.2 to 20.3), lungs (OR,4.7;95%CI,1.2 to 20.3) and heart (OR,8.0;95%CI,2 to 32.2), pre-existing catecholamine therapy (OR,59.5;95%CI,3.4 to 1039), specifically, continuous infusions of epinephrine (OR,432;95%CI,43.2 to 4318).

CONCLUSIONS

30-day-mortality and the incidence of perioperative cardiac arrest of preterms undergoing non-cardiac surgery were higher than previously reported. The identified independent risk factors may improve interdisciplinary perioperative risk assessment, optimal preoperative stabilization and scheduling of optimal surgical timing.

The epidemiology of drowning among Saudi children: results from a large trauma center

BACKGROUND

Drowning is the third leading cause of unintentional death among children worldwide. Although natural waters pose a risk of drowning in low-income countries, swimming pools are more prevalent in high-income countries. In Saudi Arabia, injuries and drowning are a significant threat to population health. Local data is limited, which affects an understanding of the extent of the burden and the development of prevention strategies.

OBJECTIVE

Determine the epidemiological characteristics, risk factors, and clinical outcomes of drowning among children.

DESIGN

Retrospective chart review.

SETTING

Patients admitted to the tertiary care unit of a hospital in Riyadh.

PATIENTS AND METHODS

Data was collected on children who drowned (age 0-14) between January 2015 and August 2020. Cases were identified from the electronic health record system where the diagnosis was drowning. Differences in characteristics and outcomes between nonfatal cases with no neurological damage and fatal cases with neurological damage were analyzed.

MAIN OUTCOME MEASURE

Drowning mortality and morbidity.

SAMPLE SIZE

99.

RESULTS

Of the 99 drowning cases, 22 (22.2%) had a fatal outcome or resulted in neurological damage. The most-reported drowning site was private pools (82%). The majority of cases involved children younger than the age of two (54%). Eighty-four cases (84.8%) occurred on holidays. Cardiopulmonary resuscitation was performed in 61 (61.6%) of cases. A significant association was found between the delay in initiating resuscitation and an unfavorable outcome (P<.01). A high Glasgow Coma Scale score upon admission was a predictor of normal recovery (P<.01).

CONCLUSION

These findings warrant investment to increase public awareness of the risks of leaving children unsupervised in swimming pools. In addition, there is a need to ensure early resuscitation of drowning victims by promoting life support courses in order to facilitate positive outcomes.

LIMITATIONS

The study was conducted in one tertiary center located in a non-coastal city so the results may not be generalizable.

CONFLICT OF INTEREST

None.

Utstein Style for emergency care - the first 30 years

BACKGROUND

Utstein Abbey near Stavanger in Norway, hosted a meeting in 1990 on guidelines for the uniform reporting of data from out-of-hospital cardiac arrest. In this paper we describe the last 30 years of the Utstein style.

METHODS

A systematic literature search identified publications from Utstein-style meetings or groups using the Utstein format.

RESULTS

30 outputs were found, describing primarily resuscitation structure, process and outcome measures. They originated from all over the world and from multiple medical disciplines. Some were co-published in multiple journals.

CONCLUSIONS

The meeting at Utstein Abbey in 1990 has had a sustained and far-reaching impact, particularly in resuscitation science, implementation and outcomes. The Utstein format will continue to evolve following the key principles from the original meeting and with the ultimate aim of improving patient care and outcomes.

An underappreciated cause of ocean-related fatalities: A systematic review on the epidemiology, risk factors, and treatment of snorkelling-related drowning

Aim

Snorkelling is a popular aquatic activity which may result in fatal and non-fatal drowning. However, little is known about the scale of injury, factors impacting risk and strategies for prevention. This review assesses the current literature on snorkelling-related drowning with the aim of assessing available data, improving safety recommendations and reducing the global mortality burden.

Methods

A systematic review of peer-reviewed literature in English, Spanish and Portuguese language published between 1 January 1980 and 31 October 2020 was conducted using the PRISMA guidelines. CINAHL Complete, Embase, Medline (Ovid), PubMed, SafetyLit, SportDiscus and grey literature were searched to identify studies reporting the incidence of fatal and non-fatal snorkelling-related drowning, or associated risk factors, prevention strategies, treatments or casualty characteristics. Quality was assessed using the NIH Quality Assessment Tool.

Results

Forty-three studies were included (26 reporting population data, 17 case series), of which 27 (62.8%) studies reported data from Australia. Incidence was reported as about 8% of total ocean-related drownings. Case series documented 144 fatalities over 17 years. Frequent casualty characteristics include male (82.6%), pre-existing heart disease (59.4%), tourists (73%) who were inexperienced (71.0%), and lack of a buddy system (89.6%). Two at-risk profiles identified were older adult tourists with pre-existing medical conditions and local, experienced spearfishers. Twenty-two expert recommendations were developed to improve the safety of snorkellers related to individuals, tourism companies, government agencies and diving organisations.

Conclusion

Snorkelling-related drownings are not infrequent, and there are many opportunities to improve the safety of this activity based on available data.

Incidence and characteristics of drowning in Sweden during a 15-year period

AIM

Drowning is a global health problem and deeper knowledge about the extent and causes is of utmost importance for implementing preventative actions. The aim of this study was to describe the incidence and characteristics of drowning in Sweden over time, including both non-fatal and fatal cases.

METHODS

All cases identified as drowning (ICD-10 coding) at a national level in Sweden between 2003-2017 were collected. Three sources of data from the Swedish National Board of Health and Welfare were extracted via the Cause of Death Register and the National Patient Register.

RESULTS

Over 15 years, a total of 6609 cases occurred, resulting in an annual incidence of 4.66 per 100 000. The median age was 49 years (IQR 23-67) and 67% were males. Non-fatal drownings represented 51% (n = 3363), with an overall non-fatal to fatal ratio of 1:1, this being 8:1 for children (0-17 years of age). Non-fatal cases were more often female (36% vs. 30%; p < 0.001), younger 30 (IQR 10-56) vs. 60 (IQR: 45-72) (p < 0.001) and of unintentional nature (81% vs. 55%; p < 0.001). The overall incidence decreased over time from 5.6 to 4.1 per 100 000 (p < 0.001). The highest rate of 30-day survival was found in females 0-17 years (94%, 95% CI 91.1-95.5) and the lowest in males >66 years (28.7%, 95% CI 26.2-31.2). Although the incidence in children 0-4 years increased from 7.4 to 8.1 per 100 000 (p < 0.001), they demonstrated the highest non-fatal to fatal ratio (13:1).

CONCLUSION

Drowning is declining but remains a consistent and underestimated public-health problem. Non-fatal drowning cases represent about half of the burden and characteristics differ from fatal drowning cases, being younger, more often female and of unintentional nature.

Coastal drowning: A scoping review of burden, risk factors, and prevention strategies

Objective

Coastal drowning is a global public health problem which requires evidence to support safety initiatives. The growing multidisciplinary body of coastal drowning research and associated prevention countermeasures is diverse and has not been characterised as a whole. The objective of this scoping review was to identify key concepts, findings, evidence and research gaps in the coastal drowning literature to guide future research and inform prevention activities.

Methods

We conducted a scoping review to identify peer reviewed studies published before May 2020 reporting either (i) fatal unintentional coastal drowning statistics from non-boating, -disaster or -occupational aetiologies; (ii) risk factors for unintentional fatal coastal drowning; or (iii) coastal drowning prevention strategies. Systematic searches were conducted in six databases, two authors independently screened studies for inclusion and one author extracted data using a standardised data charting form developed by the study team.

Results

Of the 146 included studies, the majority (76.7%) were from high income countries, 87 (59.6%) reported coastal drowning deaths, 61 (41.8%) reported risk factors, and 88 (60.3%) reported prevention strategies. Populations, data sources and coastal water site terminology in the studies varied widely; as did reported risk factors, which most frequently related to demographics such as gender and age. Prevention strategies were commonly based on survey data or expert opinion and primarily focused on education, lifeguards and signage. Few studies (n = 10) evaluated coastal drowning prevention strategies.

Discussion

Coastal drowning is an expansive, multidisciplinary field that demands cross-sector collaborative research. Gaps to be addressed in coastal safety research include the lack of research from lower resourced settings, unclear and inconsistent terminology and reporting, and the lack of evaluation for prevention strategies. Advancing coastal drowning science will result in a stronger evidence base from which to design and implement effective countermeasures that ultimately save lives and keep people safe.

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.

Need for consistent beach lifeguard data collection: results from an international survey

BACKGROUND

Lifeguards are integral to beach safety and collect data which is used for a variety of purposes, although guidelines and best practice have yet to be established. This study served to identify and characterise existing beach lifeguard service provider (BLSP) data collection procedures in order to identify the degree of uniformity and areas for improvement.

METHODS

The 'International Beach Lifeguard Data Collection and Reporting' online survey was distributed via the International Drowning Researchers' Alliance to BLSP supervisors and managers. The survey included questions on beach conditions and lifeguard activity data collection practices, and respondent's opinions on their own BLSP's methods.

RESULTS

Variability in data collection practices was evident in surveys obtained from 55 lifeguard leaders in 12 countries. Discrepancies exist in definitions for 'rescue' among BLSPs, a significant amount of information related to beach conditions are recorded and beach visitation is primarily obtained by visual estimate. Respondents expressed challenges with getting frontline staff to collect information in the field and ensuring reporting consistency between recorders. They identified rescue victim demographic factors as key data they would like to collect in the future.

CONCLUSIONS

Inconsistencies in lifeguard data collection present challenges to operations, safety education and prevention efforts, research and policy relying on these data. Variation in definitions, methods and collected variables generally restricts analysis to a single BLSP with limited generalisability to other beach settings. Some gaps in lifeguard data collection may soon be addressed by technology, but developing uniform, internationally acceptable standards and definitions should be prioritised.

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.

Exploring the burden of fatal drowning and data characteristics in three high income countries: Australia, Canada and New Zealand

BACKGROUND

Drowning is a leading and preventable cause of death that has suffered an attention deficit. Improving drowning data in countries would assist the understanding of the full extent and circumstances of drowning, to target interventions and evaluate their effectiveness. The World Health Organization identifies data collection as a key strategy underpinning effective interventions. This study compares unintentional fatal drowning data collection, management and comparison using the databases of Australia, Canada and New Zealand.

METHODS

Cases of fatal unintentional drowning between 1-January-2005 and 31-December-2014 were extracted. Cases were combined into a single dataset and univariate and chi square analysis (p < 0.01) were undertaken. Location and activity variables were mapped and combined. Variables consistently collected across the three countries were compared to the ILCOR Drowning Data Guideline. The authors also recommend variables for a minimum core dataset.

RESULTS

Of 55 total variables, 19 were consistent and 13 could be compared across the three databases. When mapped against the ILCOR Drowning Data Guideline, six variables were consistently collected by all countries, with five compared within this study. The authors recommend a minimum core dataset of 11 variables including age, sex, location, activity, date of incident, and alcohol and drug involvement). There were 8176 drowning deaths (Australia 34.1%, Canada 55.9%, New Zealand 9.9%). All countries achieved reductions in crude drowning rates (Australia - 10.2%, Canada - 20.4%, New Zealand - 24.7%). Location and activity prior to drowning differed significantly across the three countries. Beaches (X² = 1151.0;p < 0.001) and ocean/harbour locations (X² = 300.5;p < 0.001) were common in Australia and New Zealand, while lakes/ponds (X² = 826.5;p < 0.001) and bathtubs (X² = 27.7;p < 0.001) were common drowning locations in Canada. Boating prior to drowning was common in Canada (X² = 66.3;p < 0.001).

CONCLUSIONS

The comparison of data across the three countries was complex. Work was required to merge categories within the 20% of variables collected that were comparable, thus reducing the fidelity of data available. Data sources, collection and coding varied by country, with the widest diversity seen in location and activity variables. This study highlights the need for universally agreed and consistently applied categories and definitions to allow for global comparisons and proposes a core minimum dataset.

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.

The International Liaison Committee on Resuscitation-Review of the last 25 years and vision for the future

2017 marks the 25th anniversary of the International Liaison Committee on Resuscitation (ILCOR). ILCOR was formed in 1992 to create a forum for collaboration among principal resuscitation councils worldwide. Since then, ILCOR has established and distinguished itself for its pioneering vision and leadership in resuscitation science. By systematically assessing the evidence for resuscitation standards and guidelines and by identifying national and regional differences, ILCOR reached consensus on international resuscitation guidelines in 2000, and on international science and treatment recommendations in 2005, 2010 and 2015. However, local variation and contextualization of guidelines are evident by subtle differences in regional and national resuscitation guidelines. ILCOR's efforts to date have enhanced international cooperation, and progressively more transparent and systematic collection and analysis of pertinent scientific evidence. Going forward, this sets the stage for ILCOR to pursue its vision to save more lives globally through resuscitation.