Submersion Victims Research Articles

First aid and prognosis following drowning accidents. Results of a retrospective study of 115 cases

In 115 cases of submersion the initial findings of the rescue team, the patients status in the emergency room and the course of clinical treatment were analyzed retrospectively. Submersion accidents happened preferably in February, March and in the summertime from May to August. Most of the accidents took place in public waters or public baths (85.2%). Children below 10 years of age were involved in 34.8% of the submersion accidents. 57 patients were near drowned and 58 patients were drowned. The prognosis of patients with detectable heartbeat at the site of the accident depends on the primary pulmonary lesion. If respiratory insufficiency is recognized early and treated aggressively by intubation and mechanical ventilation with PEEP, these patients have an excellent prognosis. Only one patient with detectable heartbeat died, typically, after delayed treatment of respiratory failure. 55 patients recovered completely; one patient was suffering from a lesion of the n. medianus. Contrariwise, the prognosis of patients without detectable heartbeat is mainly determined by the consequences of hypoxaemia and is, overall, poor. Though resuscitation succeeds in 50% of submersion victims, only one out of four successfully resuscitated patients survived with little or no neurologic damage. Severe hypothermia may improve the prognosis of submersion victims. Thus, there are no useful parameters that would accurately predict the individual course of a submersion victim.

Cardiopulmonary Resuscitation-Reply

In Reply. —Our study does not contradict the AHA guidelines recommending the Heimlich maneuver for use only for suspected foreign body obstruction in the submersion victim. 1 While bystander CPR was not associated with improved outcome in drowning, the majority of study victims (78%) had received bystander CPR, making comparison difficult between the bystander and no-bystander groups. Moreover, these two groups included victims with both short and long submersion durations. Most submersion victims' fates are determined by the duration of their submersion; we recommended that future studies evaluating an intervention should assess and control for submersion duration. The statement that there are no controlled studies supporting CPR in submersion victims is incorrect. A recent study compared the outcome of submersion victims treated with varying degrees of CPR and controlled for submersion duration. 2 All victims receiving some degree of CPR did better than those who had none; the ones who

Near drowning

a) To report the neurologic outcome of a series of near-drowning victims treated with supportive management without aggressive cerebral resuscitation; and b) to identify patient characteristics that indicate prognosis and guide therapy at the scene, the Emergency Department, and in the intensive care unit (ICU). Retrospective review of all near-drowning patients requiring admission to the ICU over a 6-yr period (1/1/82 to 12/31/88). Hospital records were examined for the circumstances of submersion and rescue, patient condition on arrival in the Emergency Department and ICU, treatments, hospital course, and ultimate outcome. Emergency departments of the referring hospital and ICU of Children's Hospital. Forty-four pediatric submersion victims were treated with therapy limited to the support of vital functions. Three patients who met cold-water drowning criteria were excluded from the analysis for predictors of neurologic outcome. None. In our warm-water near-drowning patients, 56% survived neurologically intact, 32% survived in a persistent vegetative state, and the remaining 32% died. Unreactive pupils in the Emergency Department and a Glasgow Coma Score of < or = 5 on arrival to the ICU were the best independent predictors of poor neurologic outcome (odds ratio and 95% confidence intervals 374 [17 to 16,000] and 51 [5 to 2,200], respectively). However, no predictor was absolute and two nonhypothermic patients who arrived to the Emergency Department without vital signs, requiring cardiopulmonary resuscitation and cardiotonic medications, had full neurologic recovery. Our results cast further doubt on the utility of aggressive forms of cerebral monitoring and resuscitation and emphasize the need for initial full resuscitation in the Emergency Department.

Drowning issues in resuscitation

Submersion injury is so often lethal because it inflicts severe hypoxia. To prevent hypoxic end-organ damage to the heart and brain, the goals of resuscitation are immediate ventilation and oxygenation. Issue 1: Should submersion victims receive the Heimlich maneuver? The pathophysiologic assumptions for this intervention are that water in the airway is obstructive, thus precluding ventilation, and that aspiration of water is the major injury. Anecdotal case reports describe improved ventilation of some victims who failed prior ventilatory efforts. However, animal and human studies support that aspirated water is rapidly absorbed, does not preclude ventilation and intubation, and is best treated rapidly with positive pressure ventilation. With inadequate data to support benefit from the Heimlich maneuver and concern that the Heimlich maneuver would delay initiation of ventilation, basic life support procedures are recommended in managing the airway of the submersion victim. Issue 2: What is the role of prehospital care? Outcomes of submersion victims treated with rapid, aggressive prehospital care show that the window for medical intervention for the submersion victim is in the prehospital setting, not in the emergency department or intensive care unit. The submersion victim should be provided advanced cardiac life support, including intubation as needed, as soon as possible.

Pediatric Submersions: Prehospital Predictors of Outcome

This retrospective cohort study was conducted to test prehospital prognostic indicators in pediatric submersion victims. The authors studied all less than 20 years old victims submerged in the non-icy waters of King County, WA who were treated by Seattle or King County Emergency Medical Services between 1985 and 1989 and were hospitalized or died. Seventy-seven victims were identified from emergency medical services incident logs, hospital discharge records, and medical examiner's registries. Outcome predictors were correlated with the victim's condition at hospital discharge. Of 29 victims in cardiac arrest, 13 had return of spontaneous circulation following field resuscitation. Of these, 6 (21%) survived, with mild (n = 2) and severe (n = 4) neurologic impairment at hospital discharge. The best outcome predictors were obtained in the field. These were, for death or severe neurologic impairment, submersion durations > 10 minutes (6/6) and resuscitation durations > 25 minutes (17/17), and for good outcome, sinus rhythm (37/37), reactive pupils (43/43), and neurologic responsiveness (40/40) at the scene. Field-determined factors were reproducibly good outcome predictors. Aggressive emergency medical services may save the lives of pediatric victims in cardiac arrest following short submersion durations. The data support pronouncing dead in the field those pediatric victims of non-icy submersions who do not respond to advanced life support within 25 minutes.

A simple flow-chart for optimal treatment of submersion victims

A simple flow-chart for optimal treatment of submersion victims

Successful resuscitation of a cold water submersion victim with the use of cardiopulmonary bypass

Successful resuscitation of a cold water submersion victim with the use of cardiopulmonary bypass

Outcome and predictors of outcome in pediatric submersion victims receiving prehospttal care in king county, Washington : Quan L, Wentz KR, Gore EJ, et al. Pediatrics. 1990;86: 586.

Outcome and predictors of outcome in pediatric submersion victims receiving prehospttal care in king county, Washington : Quan L, Wentz KR, Gore EJ, et al. Pediatrics. 1990;86: 586.

Water Temperature and Drowning

To the Editor.— We read with interest the report by Quan et al.1 The authors described normal or near-normal neurologic outcomes after cardiopulmonary arrest in 8 of 38 victims. We are encouraged by these results and agree that early, effective cardiopulmonary resuscitation is the most effective treatment for pediatric submersion victims. Several additional factors, however, must be considered when interpreting the results of this study. Quan et al describe the King County, Washington climate as "temperate" and note that "submersion victims in this region did not receive the potentially beneficial rapid cooling that icy waters may provide."

Submersion incidents: a review of 39 cases and development of the submersion outcome score

The optimal treatment of the submersion victim continues to be revised and debated. Accurate analysis of therapeutic response to resuscitation after submersion will require a validated prognostic scale. The patient population is very heterogenous, with few cases presenting at many sites. We selected 11 potential predictive variables to be reviewed in 39 submersion incidents. These included the five variables comprising the Orlowski score. Three ‘physiologic’ variables were identified which, in combination, also predict neurologic outcome: pH less than or equal to 7.10, PaO2/PAO2 ratio less than or equal to 0.35, and anion gap greater than or equal to 15 mEq−1. Refinement and validation of a submersion outcome score limited to variables accurately ascertained at presentation will facilitate comparison of treatment protocols.

Outcome and predictors of outcome in pediatric submersion victims receiving prehospital care in King County, Washington: Quan L, Wentz K, Gore E, et al Pediatrics 86: 586–593 Oct 1990

Outcome and predictors of outcome in pediatric submersion victims receiving prehospital care in King County, Washington: Quan L, Wentz K, Gore E, et al Pediatrics 86: 586–593 Oct 1990

Submersion in The Netherlands: Prognostic indicators and results of resuscitation

To analyze prognostic indicators and the outcome of resuscitation in submersion victims (drowning and near drowning). Retrospective study. Intensive and Respiratory Care Unit. Between January 1, 1979, and December 31, 1985, 87 submersion victims were admitted. The files of 83 victims were available for statistical analysis. There were 66 male victims and 17 female victims; the average age was 31.4 +/- 25.8 years. There were ten salt water and 73 fresh water submersions. Predictors for better survival potentials were a young age, submersion of less than ten minutes, no signs of aspiration, and a central body temperature of less than 35 C at admission. We did not detect factors that accelerated a decrease in core body temperature at admission and assume that lethal hypoxia had preceded protective hypothermia in our submersion victims. The Orlowski score had a predictive value but at the same time we found nonindependent indicators in this score. Neurologic outcome in our patients, who were not treated according to a brain protection protocol, was not worse than the outcome published by authors who have used such a protocol. Thirty-three percent of the victims with a cardioventilatory arrest (15) and all victims with a ventilatory arrest (11) survived resuscitation and were discharged. Five nonarrest victims died due to late complications. This study shows that no indicator at the rescue site and in the hospital is absolutely reliable with respect to death or survival.

Prehospital Care for Victims of Submersion

In this issue of Pediatrics is a study1 that represents a milestone in the growth and development of Emergency Medical Services for Children systems. Linda Quan and co-workers provide us with a study of victims of submersion who were less than 20 years of age and who received care during a 10-years interval in an Emergency Medical Services unit and required hospitalization or died. Because the majority of these submersions occurred in the urban setting of King Country with the rapid response of Emergency Medical Services units and reliable recording of cardiopulmonary resuscitation (CPR) data, the study results are impressively complete.

Outcome and Predictors of Outcome in Pediatric Submersion Victims Receiving Prehospital Care in King County, Washington

Predictors of outcome in pediatric submersion victims treated by Seattle and King County's prehospital emergency services were studied. Victims less than 20 years old were identified from hospital admissions and paramedic and medical examiners' reports. The proportion of fatal or severe outcomes in patients were compared with various risk factors. Of 135 patients, 45 died and 5 had severe neurologic impairment. A subset of 38 victims found in cardiopulmonary arrest had a 32% survival rate, with 67% of survivors unimpaired or only mildly impaired. The two risk factors that occurred most commonly in victims who died or were severely impaired were submersion duration greater than 9 minutes (28 patients) and cardiopulmonary resuscitation duration longer than 25 minutes (20 patients). Both factors were ascertained in the prehospital phase of care. Submersion duration was associated with a steadily increasing risk of severe or fatal outcomes: 10% risk (7/67) for 0 to 5 minutes, 56% risk (5/9) for 6 to 9 minutes, 88% risk (21/25) for 10 to 25 minutes, 100% risk (4/4) for greater than 25 minutes. None of 20 children receiving greater than 25 minutes of cardiopulmonary resuscitation escaped death or severe neurologic impairment. Our rates for saving all victims, particularly victims in cardiopulmonary arrest, are considerably higher than has been reported before the children. Prompt prehospital advanced cardiac life support is the most effective means of medical intervention for the pediatric submersion victim. Prehospital information provided the most valuable predictors of outcome.

Resuscitation of cold water immersion victims with cardiopulmonary bypass

Severe anoxia due to prolonged submersion generally portends a poor prognosis. However, several victims of cold water submersion have been revived from marked hypothermia and have completely recovered. Resuscitative measures include cardio-respiratory support and rewarming the victim. During rewarming, the victim is susceptible to life- threatening complications, particularly due to prolonged cardiac arrest or dysrhythmias that may lead to cardiovascular collapse. Certain rewarming methods can be used to quickly raise the body temperature. Cardiopulmonary bypass not only provides the most rapid and controlled rewarming, but also maintains cardiovascular stability until a normal cardiac rhythm and adequate cardiac function is established. We report the first use of cardiopulmonary bypass to resuscitate three victims of cold water submersion. Despite the successful outcome of two of our patients, cardiopulmonary bypass in the present setting remains an experimental technique that merits further study.

Resuscitation of Submersion Casualties

Submersion accidents are an important public health problem in this country and worldwide, and they present a special challenge to emergency personnel. Submersion injury affects multiple systems but most notably involves the lungs, where ventilation-perfusion mismatching and intrapulmonary shunting result in hypoxemia, acidosis, and generalized anoxic injury. Resuscitation of the victims of submersion casualties should be directed at restoring respiration, improving oxygenation, correcting acidosis, and treating concomitant problems such as hypothermia, drug and alcohol intoxication, or cervical spinal trauma. With expeditious and proper treatment, most submersion victims have a good prognosis.

Radiologic Identification of Unknown Human Remains

During the 15 months from April 1978 through July 1979, 3964 cases were referred to the City of St. Louis, Office of the Medical Examiner. Of these, 71 (1.8%) required investigation to establish identification (ID). All cases were rigorously investigated to establish the most scientifically sound ID possible. In addition to evidence from the scene, fingerprint, dental, and X-ray studies were attempted. Fifty (80.4%) individuals were scientifically identified, 17 (24%) were circumstantially identified, and 4 (5.6%) remain unidentified. Thirty (60%) of the 50 scientific IDs were by comparison of premortem and postmortem radiographs. Positive ID was accomplished in 22 cases of decomposition, 4 fire victims, 2 inadvertent body misidentifications, 1 submersion victim, and 1 suicide. Although all regions of the body were useful for ID, chest, skull, and abdominal radiographs were most frequently helpful. Anatomic, disease, and postsurgical features provided the unique features necessary for identification.

RESUSCITATION AND TREATMENT FOLLOWING SUBMERSION

In resuscitation from drowning it must be remembered that when breathing movements are absent no time must be wasted in attempts to drain the lungs. Reoxygenation must be started immediately with exhaled air. Positive pressure ventilation with oxygen should be substituted as soon as possible. It should be continued in victims of sea water submersion until a blood specimen can be examined and any plasma deficiency corrected. In fresh water drowning intermittent positive pressure ventilation combined with closed chest cardiac massage is a preliminary to external electrical defibrillation. Prevention of delayed death depends upon the management of massive hemolysis, hypervolemia, electrolyte imbalances, aspiration pneumonitis, and myocardial failure.

Drowning treated with intermittent positive pressure breathing.

A standardized dog experiment was designed to simulate human victims of submersion who seem to first develop laryngospasm, followed by flooding of the lungs. The tracheal tube of lightly anesthetized dogs was clamped until the onset of apnea. The lungs were then flooded for 30 seconds with fresh water or sea water, or apnea was permitted to continue for a comparable period without flooding. Resuscitation was attempted with intermittent positive pressure breathing (IPPB), utilizing room air. All control dogs (obstructive asphyxia, without flooding) survived. Freshwater drowning caused mild arterial hypotension, severe rise in venous pressure and bradycardia, followed by sudden ventricular fibrillation in 1–4 minutes in spite of IPPB. Sea-water drowning caused severe arterial hypotension, slight rise in venous pressure and bradycardia. IPPB led to partial reoxygenation and partial restoration of circulation. When IPPB was discontinued all dogs started breathing spontaneously, but within a few minutes developed asystole with pulmonary edema. Submitted on January 25, 1960