DrowningDrowning

Jana Stockwell, MDJana Stockwell, MD

StatisticsStatistics

• 1995 data:1995 data:– >1000 kids <14 years old drown>1000 kids <14 years old drown– 60% <4 years old60% <4 years old

• 2000 CDC data:2000 CDC data:– 3,281 unintentional drownings in USA (adults & 3,281 unintentional drownings in USA (adults &

kids)kids)– averaging 9 people/day - not including boating-averaging 9 people/day - not including boating-

related incidents  related incidents 

• 2003 CDC data:2003 CDC data:– For every child who drowns, 3 need ED care for For every child who drowns, 3 need ED care for

non-fatal submersion injuriesnon-fatal submersion injuries– >40% of these children require hospitalization>40% of these children require hospitalization

2002 World Congress on 2002 World Congress on DrowningDrowning

• Drowning = process resulting in primary Drowning = process resulting in primary respiratory impairment from respiratory impairment from submersion/immersion in a liquid mediumsubmersion/immersion in a liquid medium

• RegardlessRegardless of survival of survival

• Drowning without aspiration does Drowning without aspiration does notnot occuroccur

• Terms which are “out”Terms which are “out”– Dry, wet, active, silent, secondary, near-Dry, wet, active, silent, secondary, near-

drowningdrowning

1989-1998 CDC data1989-1998 CDC data

>75%ile of National avg

50-75%ile of National avg

25-50%ile of National avg

<25%ile of National avg

Groups at Risk (2001 data)Groups at Risk (2001 data)

• Males: 78% of drownings in the United Males: 78% of drownings in the United StatesStates

• Children: 859 children ages 0-14 years Children: 859 children ages 0-14 years died from drowningdied from drowning– Drowning rates have slowly declinedDrowning rates have slowly declined– 2nd-leading cause of injury-related death for kids ages 1-2nd-leading cause of injury-related death for kids ages 1-

14 years  14 years 

• African Americans: age-adjusted drowning African Americans: age-adjusted drowning rate for African Americans was 1.4 X higherrate for African Americans was 1.4 X higher(CDC 2003)

Morbidity & MortalityMorbidity & Mortality

• 15% of children admitted for drowning die 15% of children admitted for drowning die in the hospitalin the hospital

• As many as 20% of drowning survivors As many as 20% of drowning survivors suffer severe, permanent neurological suffer severe, permanent neurological disabilitydisability

Drowning modalitiesDrowning modalities

• Infants (age <1) - Infants (age <1) - bathtubs, buckets & bathtubs, buckets & toiletstoilets

• Children ages 1-4 years Children ages 1-4 years - swimming pools, hot - swimming pools, hot tubs & spastubs & spas

• Children ages 5-14 Children ages 5-14 years - swimming pools years - swimming pools & open water sites& open water sites

(Brenner 2001)(Brenner 2001)

Bucket drowningsBucket drownings

• ~300 children in the US ~300 children in the US since 1984since 1984

• 7-15 months of age7-15 months of age

• 24 to 31 inches tall24 to 31 inches tall

• Bucket may contain Bucket may contain water or nasty cleaning water or nasty cleaning fluidfluid

Tub drowningsTub drownings

• Approximately 10% of childhood Approximately 10% of childhood drowningsdrownings

• Typically lacking adult supervisionTypically lacking adult supervision

• Do tub seats help?Do tub seats help?

Bathtub seats - Bathtub seats - ? or ? or ??• Not intended or marketed as safety devicesNot intended or marketed as safety devices• Bathtub drowning deaths of infants aged 6-10 Bathtub drowning deaths of infants aged 6-10

mo from 1994-1998mo from 1994-1998• 40 infant drowning deaths associated 40 infant drowning deaths associated withwith bath bath

seatsseats• 78 deaths 78 deaths notnot associated with bath seats associated with bath seats• ~45% of infants in this age group use bath seats~45% of infants in this age group use bath seats• Data suggests seats either have no effect or they Data suggests seats either have no effect or they

may provide some slight protection against may provide some slight protection against unintentional bathtub drowning risksunintentional bathtub drowning risks

• Odds ratio 0.6 [95% CI 0.4-0.9]Odds ratio 0.6 [95% CI 0.4-0.9]

Data: US Consumer Product Safety Commission & National Center for Health Statistics for US resident Data: US Consumer Product Safety Commission & National Center for Health Statistics for US resident infants (1994-1998)infants (1994-1998)

Tub seat useTub seat use

Baby swim classesBaby swim classes

• Done to “teach” babies to floatDone to “teach” babies to float

• No reported drownings in classNo reported drownings in class• Several reports of hyponatremic Several reports of hyponatremic

seizures following class seizures following class (How was school (How was school today?)today?)

• False sense of security?False sense of security?

Pool/Spa drowningsPool/Spa drownings

• Most residential pool drownings are in kids <4 yo Most residential pool drownings are in kids <4 yo • 3,000 pool drownings require hospital ED 3,000 pool drownings require hospital ED

treatment each yeartreatment each year– last seen inside the homelast seen inside the home– missing from sight <5 minutesmissing from sight <5 minutes– in the care of one or both parents at the time of the in the care of one or both parents at the time of the

drowningdrowning

• >50% occur in the child's >50% occur in the child's home poolhome pool• 1/3 occur at homes of friends, neighbors or family1/3 occur at homes of friends, neighbors or family• Since 1980, ~230 kids <4 yrs in spas & hot tubsSince 1980, ~230 kids <4 yrs in spas & hot tubs

(Present 1987, Brenner 2001)(Present 1987, Brenner 2001)

Cochran Review – Pool Cochran Review – Pool fencingfencing• Meta analysis of case–control studies Meta analysis of case–control studies

evaluating pool fencingevaluating pool fencing• Results:Results:

– Pool fencing significantly reduces the risk of drowningPool fencing significantly reduces the risk of drowning• Odds ratio (OR) for the risk of drowning or near drowning in a fenced Odds ratio (OR) for the risk of drowning or near drowning in a fenced

pool compared to an unfenced pool is 0.27 (95% CI 0.16 – 0.47)pool compared to an unfenced pool is 0.27 (95% CI 0.16 – 0.47)– Isolation fencing (enclosing pool only) is superior to perimeter Isolation fencing (enclosing pool only) is superior to perimeter

fencing (enclosing property and pool)fencing (enclosing property and pool)• OR for the risk of drowning in a pool with isolation fencing compared OR for the risk of drowning in a pool with isolation fencing compared

to a pool with three – sided fencing is 0.17 (95% CI 0.07 – 0.44). to a pool with three – sided fencing is 0.17 (95% CI 0.07 – 0.44).

• In-ground swimming pools without In-ground swimming pools without complete 4-sided isolation fencing are 60% complete 4-sided isolation fencing are 60% more likely to be involved in drownings than more likely to be involved in drownings than those with 4-sided isolation fencingthose with 4-sided isolation fencing

Boat-related drowningsBoat-related drownings

• 2002 Coast Guard data, all ages:2002 Coast Guard data, all ages:– 5,705 boating incidents: 4,062 injured, 750 5,705 boating incidents: 4,062 injured, 750

killedkilled– 70% of fatalities due to drowning70% of fatalities due to drowning– 30% of fatalities due to trauma, hypothermia, 30% of fatalities due to trauma, hypothermia,

CO poisoning, or other causesCO poisoning, or other causes– Alcohol was involved in 39% of fatalitiesAlcohol was involved in 39% of fatalities– Open motor boats - 41%Open motor boats - 41%– Personal watercraft – 28%Personal watercraft – 28%

AlcoholAlcohol

• Involved in 25-50% of teen and adult Involved in 25-50% of teen and adult deaths associated with water recreationdeaths associated with water recreation (Howland 1995; Howland & Hingson 1988)(Howland 1995; Howland & Hingson 1988)

• Alcohol influences balance, coordination, Alcohol influences balance, coordination, and judgment, and its effects are and judgment, and its effects are heightened by sun exposure and heatheightened by sun exposure and heat (Smith (Smith and Kraus 1988)and Kraus 1988)

• Relative risk of drowning was 31.8 in Relative risk of drowning was 31.8 in persons with a markedly elevated alcohol persons with a markedly elevated alcohol level (>21.7 mmol/L) and 4.6 for levels level (>21.7 mmol/L) and 4.6 for levels <21.6 mmol/L<21.6 mmol/L (Cummmings JAMA 281:2198, 1999) (Cummmings JAMA 281:2198, 1999)

The event, part 1The event, part 1

• Voluntary breath-holdingVoluntary breath-holding• Aspiration of small amounts into Aspiration of small amounts into

larynxlarynx• Involuntary laryngospasmInvoluntary laryngospasm• Swallow large amountsSwallow large amounts• Laryngospasm abates (due to Laryngospasm abates (due to

hypoxia)hypoxia)• Aspiration into lungsAspiration into lungs

The event, part 2The event, part 2

• Decrease in satsDecrease in sats

• Decrease in cardiac outputDecrease in cardiac output

• Intense peripheral Intense peripheral vasoconstrictionvasoconstriction

• HypothermiaHypothermia

• BradycardiaBradycardia

• Circulatory arrest, while VF rareCirculatory arrest, while VF rare

• Extravascular fluid shifts, Extravascular fluid shifts, diuresisdiuresis

Diving reflexDiving reflex

• Bradycardia, apnea, vasoconstrictionBradycardia, apnea, vasoconstriction

• Relatively quite weak in humansRelatively quite weak in humans– better in kidsbetter in kids

• Occurs when the face is submerged in Occurs when the face is submerged in very cold water (<20°C)very cold water (<20°C)

• Extent of neurologic protection in humans Extent of neurologic protection in humans due to diving reflex is likely very minimaldue to diving reflex is likely very minimal

Pathogenesis 1Pathogenesis 1

• Asphyxia, hypoxemia, hypercarbia, & Asphyxia, hypoxemia, hypercarbia, & metabolic acidosismetabolic acidosis

• Fresh water vs salt water - little difference Fresh water vs salt water - little difference (except for drowning in water with very (except for drowning in water with very high mineral content, like the Dead Sea)high mineral content, like the Dead Sea)

• HypoxemiaHypoxemia– Occlusion of airways with water & particulate debrisOcclusion of airways with water & particulate debris– Changes in surfactant activityChanges in surfactant activity– BronchospasmBronchospasm– Right-to-left shunting increasedRight-to-left shunting increased– Physiologic dead space increasedPhysiologic dead space increased

Pathogenesis 2Pathogenesis 2

• Cardiac arrhythmiasCardiac arrhythmias

• Hypoxic encephalopathyHypoxic encephalopathy

• Renal insufficiencyRenal insufficiency

• Global brain anoxia & potential diffuse Global brain anoxia & potential diffuse cerebral edemacerebral edema

Findings at autopsyFindings at autopsy

• Wet, heavy lungsWet, heavy lungs

• Varying amounts of hemorrhage and edemaVarying amounts of hemorrhage and edema

• Disruption of alveolar wallsDisruption of alveolar walls

• ~70% of victims had aspirated vomitus, ~70% of victims had aspirated vomitus, sand, mud, and aquatic vegetationsand, mud, and aquatic vegetation

• Cerebral edema and diffuse neuronal injuryCerebral edema and diffuse neuronal injury

• Acute tubular necrosisAcute tubular necrosis

Signs & symptomsSigns & symptoms

• 75% of kids who develop sxs do so within 75% of kids who develop sxs do so within 7 hours of event7 hours of event

• Coma to agitated alertnessComa to agitated alertness• Cyanosis, coughing, and the production of Cyanosis, coughing, and the production of

frothy pink sputumfrothy pink sputum• Tachypnea, tachycardiaTachypnea, tachycardia• Low-grade feverLow-grade fever• Rales, rhonchi & less often wheezesRales, rhonchi & less often wheezes• Signs of associated trauma to the head Signs of associated trauma to the head

and neck should be sought and neck should be sought

Prevalence of concomitant Prevalence of concomitant traumatic injuriestraumatic injuries• 143 drowned & near-143 drowned & near-

drowned kidsdrowned kids• Median age 3.8 years (1 Median age 3.8 years (1

mo – 18.7 yrs)mo – 18.7 yrs)• 30% with pre-existing 30% with pre-existing

diseasedisease– CHD, sz, MR/CP, DDCHD, sz, MR/CP, DD

• 5% with traumatic injuries5% with traumatic injuries– All boysAll boys– Older, mean age 13.5 yearsOlder, mean age 13.5 years– 6 of 7 had C-spine injury 6 of 7 had C-spine injury

from divingfrom diving(H Shofer, Ann Emerg Med 2004)

Labs & testsLabs & tests

• Very mild electrolyte Very mild electrolyte changeschanges

• Moderate leukocytosisModerate leukocytosis• Hct and Hgb usually normal Hct and Hgb usually normal

initallyinitally– Fresh water aspiration, the Fresh water aspiration, the

Hct may fall slightly in the Hct may fall slightly in the first 24 hrs due to hemolysisfirst 24 hrs due to hemolysis

– Increase in free Hgb without a Increase in free Hgb without a change in Hct is commonchange in Hct is common

• DIC occasionallyDIC occasionally• ABG – metabolic acidosis & ABG – metabolic acidosis &

hypoxemiahypoxemia

• EKGEKG– Sinus tachycardia & Sinus tachycardia &

nonspecific ST-segment nonspecific ST-segment and T-wave changesand T-wave changes

– Reverts to normal within Reverts to normal within hourshours

– Ominous - ventricular Ominous - ventricular arrhythmias, complete arrhythmias, complete heart blockheart block

• CXRCXR– May be normal initially May be normal initially

despite severe despite severe respiratory disturbancesrespiratory disturbances

– Patchy infiltratesPatchy infiltrates– Pulmonary edemaPulmonary edema

Therapy for the lungsTherapy for the lungs

• CPAP or PEEPCPAP or PEEP

• Aerosolized β-agonists for bronchospasmAerosolized β-agonists for bronchospasm

• BronchoscopyBronchoscopy

• Prophylactic antibiotics have Prophylactic antibiotics have notnot been been shown to be beneficialshown to be beneficial

• Steroids:Steroids:– No controlled human studies to support useNo controlled human studies to support use– Animal models and retrospective studies in Animal models and retrospective studies in

humans have failed to demonstrate benefithumans have failed to demonstrate benefit

SurfactantSurfactant

• BeneficialBeneficial– Porcine surfactant Porcine surfactant

(Curosurf) 0.5 ml/kg (Curosurf) 0.5 ml/kg (40 mg/kg) IT for (40 mg/kg) IT for ARDS 8h after ARDS 8h after freshwater near-freshwater near-drowning in a 12yo drowning in a 12yo (Acta Anaesthesiol Scand (Acta Anaesthesiol Scand 2004) 2004)

• Not beneficialNot beneficial– Submerged rabbitsSubmerged rabbits(A Anker, Acad Emerg Med 1995)(A Anker, Acad Emerg Med 1995)

– KidsKids(F Perez-Benavides, Ped Emerg Care (F Perez-Benavides, Ped Emerg Care

1995)1995)

Brain therapyBrain therapy

• ICP monitoring - ICP monitoring - not indicatednot indicated, typically irreversible , typically irreversible hypoxic cellular injuryhypoxic cellular injury

• Brain CT – Brain CT – not indicated,not indicated, unless TBI suspected unless TBI suspected• Mild hyperventilation?Mild hyperventilation?• Osmotherapy – Osmotherapy – not indicatednot indicated• Corticosteroids (dexamethasone) - Corticosteroids (dexamethasone) - no proven no proven

benefitbenefit• Seizures - treat aggressivelySeizures - treat aggressively• Shivering or random, purposeless movements can Shivering or random, purposeless movements can

increase ICPincrease ICP• Hypothermia and barbiturate coma - highly Hypothermia and barbiturate coma - highly

controversial & controversial & unlikely to benefitunlikely to benefit the patient the patient (31 (31 comatose kids, J Modell, NEJM 1993)comatose kids, J Modell, NEJM 1993)

Bad prognostic indicatorsBad prognostic indicators

• Submerged >10 Submerged >10 minmin

• Time till BLS >10 Time till BLS >10 minmin

• CPR >25 minCPR >25 min

• Initial GCS <5Initial GCS <5

• Age <3 yearsAge <3 years

• CPR in ERCPR in ER

• Initial ABG pH <7.1Initial ABG pH <7.1

• Initial core temp Initial core temp <33<33oo

Will the child die?Will the child die?

Neurologic prognosisNeurologic prognosis

• Absence of spontaneous respiration is an Absence of spontaneous respiration is an ominous sign associated with severe ominous sign associated with severe neurologic sequelaeneurologic sequelae

• Permanent neurologic sequelae persist in Permanent neurologic sequelae persist in ~20% of victims who present comatose~20% of victims who present comatose– Minimal brain dysfunction, spastic Minimal brain dysfunction, spastic

quadriplegia, extrapyramidal syndromes, optic quadriplegia, extrapyramidal syndromes, optic and cerebral atrophy, and peripheral and cerebral atrophy, and peripheral neuromuscular damageneuromuscular damage

Cold vs icy water immersionCold vs icy water immersion

• Usually hypothermia is an Usually hypothermia is an unfavorable signunfavorable sign

• Several case reports of dramatic Several case reports of dramatic neurologic recovery after prolonged neurologic recovery after prolonged (10-150 min) icy water submersions(10-150 min) icy water submersions– Freezing-temperature water (<5°C)Freezing-temperature water (<5°C)– Core body temperature less than 28-30°C, or Core body temperature less than 28-30°C, or

much lowermuch lower

• For hypothermia to be protective, For hypothermia to be protective, core body temperature must fall core body temperature must fall rapidlyrapidly, decreasing cellular metabolic , decreasing cellular metabolic rate, before significant hypoxemia rate, before significant hypoxemia beginsbegins

Hypothermia easier in kidsHypothermia easier in kids• High BSA/mass ratio and High BSA/mass ratio and subcutaneous subcutaneous

fat insulationfat insulation• Moderate hypothermiaModerate hypothermia (core 32-35°C) (core 32-35°C)

VOVO22 due to shivering thermogenesis & due to shivering thermogenesis & increased sympathetic toneincreased sympathetic tone

• Severe hypothermiaSevere hypothermia (core <32°C) (core <32°C) shivering stops & the cellular metabolic shivering stops & the cellular metabolic rate rate (~7%/°C) (~7%/°C)

Hypothermia & brain Hypothermia & brain protectionprotection• Effective in protecting the brain and other Effective in protecting the brain and other

organs from anoxia for 75-110 min in organs from anoxia for 75-110 min in controlled circumstances where core body controlled circumstances where core body temperature is cooled first to 18°C and temperature is cooled first to 18°C and then the heart is stoppedthen the heart is stopped– Deep hypothermic circulatory arrest (DHCA)Deep hypothermic circulatory arrest (DHCA)

• Once cell death from hypoxemia occurs Once cell death from hypoxemia occurs (~5-6 min), no protective hypothermic (~5-6 min), no protective hypothermic effect or improve recoveryeffect or improve recovery

Hypothermia – surface Hypothermia – surface coolingcooling• Surface cooling alone is cannot Surface cooling alone is cannot core temp fast enough core temp fast enough

to yield protectionto yield protection

• Cooling rate in drowning victims is difficult to estimate as Cooling rate in drowning victims is difficult to estimate as patient may also be swallowing or breathing in cold patient may also be swallowing or breathing in cold waterwater

• Cardiac anesthesia literature:Cardiac anesthesia literature:– Surface cooling of anesthetized naked infants with ice packs and ice cold Surface cooling of anesthetized naked infants with ice packs and ice cold

water decreases rectal temperature by ~2.5 °C in the first 10 minuteswater decreases rectal temperature by ~2.5 °C in the first 10 minutes– Another 32 minutes for the temperature to fall to 24-26°CAnother 32 minutes for the temperature to fall to 24-26°C– During surface cooling in flowing water at 1°C the nasopharyngeal During surface cooling in flowing water at 1°C the nasopharyngeal

temperature of a naked infant (4 kg) falls 1°C every 5 minutestemperature of a naked infant (4 kg) falls 1°C every 5 minutes

• Hypothermic protection involving surface cooling only Hypothermic protection involving surface cooling only would seem to require submersion in icy (not cold) waterwould seem to require submersion in icy (not cold) water

Does aspiration of icy water Does aspiration of icy water will accelerate the cooling will accelerate the cooling process?process?

• 80-90% of animals & human submersion 80-90% of animals & human submersion victims in warm or cold water drownings victims in warm or cold water drownings aspirate very little (<2.2 ml/kg)aspirate very little (<2.2 ml/kg)

• Theoretically, a very large quantity of icy water Theoretically, a very large quantity of icy water would have to be aspirated or swallowedwould have to be aspirated or swallowed

• Immersion in icy water results in involuntary Immersion in icy water results in involuntary reflex hyperventilation and a decreased breath reflex hyperventilation and a decreased breath holding ability to <10 sec, increasing the holding ability to <10 sec, increasing the likelihood of aspiration and rebreathing of icy likelihood of aspiration and rebreathing of icy water in some victimswater in some victims

Ice water submersion - dogsIce water submersion - dogs• Rapid & violent hyperventilation lasts ~70 secRapid & violent hyperventilation lasts ~70 sec• Control animals submerged (ice water, head Control animals submerged (ice water, head

out of the water) carotid artery temp fell 0.8°C out of the water) carotid artery temp fell 0.8°C in 2 minin 2 min

• Completely submerged dogs temp fell ~8.0°C Completely submerged dogs temp fell ~8.0°C during the first 2 min in both ice-water (4°C)during the first 2 min in both ice-water (4°C)

• Rectal temp Rectal temp lagged behind lagged behind in carotid in carotid temptemp

• Victims of ice-water submersions more likely to Victims of ice-water submersions more likely to have involuntary breathing & aspirationhave involuntary breathing & aspiration

• Brain may be cooled to a protective level Brain may be cooled to a protective level (~<30°C) (~<30°C) providedprovided the water aspirated was the water aspirated was icy & cardiac output lasts long enough for icy & cardiac output lasts long enough for sufficient heat exchange to occursufficient heat exchange to occur

Cold water submersion - Cold water submersion - humanshumans• Few cold water victims have significant brain Few cold water victims have significant brain

protectionprotection• Hypothermia is more commonly an Hypothermia is more commonly an unfavorableunfavorable

prognostic signprognostic sign• King County, WA King County, WA (water is cold, but rarely icy)(water is cold, but rarely icy)

– Hypothermic protection has Hypothermic protection has notnot been observed been observed– 92% of good survivors had initial core temp of >34°C92% of good survivors had initial core temp of >34°C– 61% of those who died or had severe neurologic injury 61% of those who died or had severe neurologic injury

had core temp <34°Chad core temp <34°C• Finnish study:Finnish study:

– Median water temp 16°CMedian water temp 16°C– Submersion duration <10 minutes had greatest Submersion duration <10 minutes had greatest

sensitivity in predicting good outcome, even in kidssensitivity in predicting good outcome, even in kids

Re-warmingRe-warming

• Re-warm 1-2Re-warm 1-2ooC per hour to range 33-36C per hour to range 33-36ooCC• Mild (32-35Mild (32-35oo) passive rewarming) passive rewarming• Moderate (28-32Moderate (28-32oo))

– Shivering failsShivering fails– J waveJ wave– Active internal/external rewarming (not extremities)Active internal/external rewarming (not extremities)

• Severe (<28Severe (<28oo))– Appears dead, pupils dilated/NRAppears dead, pupils dilated/NR– VFib, extreme brady, pulselessVFib, extreme brady, pulseless– Deep rectal or esophageal tempsDeep rectal or esophageal temps– Maintain CPR until core temp >32Maintain CPR until core temp >32oo

Warm water data - siteWarm water data - site

• 274 patients274 patients• Age 6 months-15 years (mean 32 mos, Age 6 months-15 years (mean 32 mos,

median 24 mos)median 24 mos)• 63% males63% males• Submersion witnessed in 12% casesSubmersion witnessed in 12% cases• Submersion site data (126 patients)Submersion site data (126 patients)

– 80% backyard pool or spa80% backyard pool or spa– 11% in a bathtub11% in a bathtub– 5% in a lake or pond5% in a lake or pond– 3% in other sites3% in other sites

Warm water data - responseWarm water data - response

• Bystander resuscitation – 80% patientsBystander resuscitation – 80% patients

• Average EMS respose time - 6.8 minutesAverage EMS respose time - 6.8 minutes

• Upon EMS arrivalUpon EMS arrival– 76 (28%) children were in cardiac arrest76 (28%) children were in cardiac arrest– 13 (5%) with PEA13 (5%) with PEA

• Paramedic CPR - 87/89 childrenParamedic CPR - 87/89 children

• 18 (20% of those w/ CPR) no longer needed CPR in 18 (20% of those w/ CPR) no longer needed CPR in EDED

• Paramedics intubated 19 childrenParamedics intubated 19 children

• Epinephrine in 30 patientsEpinephrine in 30 patients

Warm water outcomesWarm water outcomes

• CardiacCardiac– 71 (80% of those in arrest @ scene) arrived to 71 (80% of those in arrest @ scene) arrived to

ED in cardiac arrestED in cardiac arrest– 13 PEA13 PEA– 5 deteriorated & required CPR5 deteriorated & required CPR– All 89 received Epi - (average duration 8.9 All 89 received Epi - (average duration 8.9

minutes, range 2 to 105 minutes)minutes, range 2 to 105 minutes)• 41 (46% of codes) survived (8 intact, 33 vegetative)41 (46% of codes) survived (8 intact, 33 vegetative)• Longest CPR duration in an intact survivor was 47 Longest CPR duration in an intact survivor was 47

minutesminutes

• RespiratoryRespiratory– 125 (46%) patients were intubated125 (46%) patients were intubated– 7 were apneic, 26 were breathing but comatose7 were apneic, 26 were breathing but comatose

Warm water outcomesWarm water outcomes• CNSCNS

– Persistent deficits in 15 of the 185 functionally intact Persistent deficits in 15 of the 185 functionally intact survivorssurvivors

– Initial ED GCS 3 in 100 kidsInitial ED GCS 3 in 100 kids• 14 survived intact14 survived intact

– 165 patients having GCS 4 upon arrival in the ED165 patients having GCS 4 upon arrival in the ED• 2 survived in PVS2 survived in PVS• all others survived intactall others survived intact

• 51 patients who subsequently died51 patients who subsequently died– Withdrawal 22Withdrawal 22– Brain death 23Brain death 23All intact survivors demonstrated functional recovery within All intact survivors demonstrated functional recovery within

48 hours48 hours

Warm water survival in kidsWarm water survival in kids• 6 studies reported functional recovery 17% (overall 6 studies reported functional recovery 17% (overall

average) of victims who required CPR in the EDaverage) of victims who required CPR in the ED• Withholding or withdrawal of therapy from kids who Withholding or withdrawal of therapy from kids who

have low probability of functional survival after warm have low probability of functional survival after warm water submersion injury has been suggestedwater submersion injury has been suggested– Failure to respond to advanced life support within 25 minutesFailure to respond to advanced life support within 25 minutes– Lack of purposeful movements or normal brain stem function @ Lack of purposeful movements or normal brain stem function @

24 hrs24 hrs– Anecdotal experience with spectacular recoveries & the small Anecdotal experience with spectacular recoveries & the small

numbers of severely injured patients in most studies raises numbers of severely injured patients in most studies raises uncertainty about their predictive accuracyuncertainty about their predictive accuracy

• Graf et al. suggested that outcome for pediatric Graf et al. suggested that outcome for pediatric submersion victims can be predicted with 4 measures: submersion victims can be predicted with 4 measures: coma, absence of pupillary light reflex, admission blood coma, absence of pupillary light reflex, admission blood glucose concentration (high) and sexglucose concentration (high) and sex

RecommendationsRecommendations• Pre-hospital resuscitation, including early Pre-hospital resuscitation, including early

intubation, ventilation, vascular access, and intubation, ventilation, vascular access, and administration of advanced life support administration of advanced life support medicationsmedications

• Continued resuscitation and stabilization in Continued resuscitation and stabilization in the EDthe ED

• Full supportive care in the ICU for a minimum Full supportive care in the ICU for a minimum of 48 hrsof 48 hrs

• Consider withdrawal of support if no Consider withdrawal of support if no neurologic improvement is detected after 48 neurologic improvement is detected after 48 hourshours– Ancillary testing such as brainstem evoked Ancillary testing such as brainstem evoked

responses, EEG, and MRI (not CT) may prove responses, EEG, and MRI (not CT) may prove helpful to corroborate the neurologic examinationhelpful to corroborate the neurologic examination

Pediatrics, 1997 Christenson, Jansen, PerkinsPediatrics, 1997 Christenson, Jansen, Perkins

You can’t make this stuff upYou can’t make this stuff up

• 67 year old with pulmonary fibrosis67 year old with pulmonary fibrosis

• S/P lung resectionS/P lung resection

• On ward, with OOn ward, with O22

• POD#2 developed distress, to ICU, POD#2 developed distress, to ICU, intubated, ARDS…intubated, ARDS…

• Finally extubates…Finally extubates…

(CHEST 2001; 120:1021-1022)(CHEST 2001; 120:1021-1022)

Part deaux – a better historyPart deaux – a better history

• Day after extubation, RN noticed patient's friend Day after extubation, RN noticed patient's friend attempting to submerge the patient's face in a attempting to submerge the patient's face in a water-filled basinwater-filled basin

• On questioning, patient indicated that he was On questioning, patient indicated that he was aspirating water to clean sinuses and lungs, aspirating water to clean sinuses and lungs, explaining that this was a daily routine for explaining that this was a daily routine for cleaning airways in his familycleaning airways in his family

• He noted that on POD 1, while performing this He noted that on POD 1, while performing this ritual, he had a severe coughing and choking ritual, he had a severe coughing and choking spell while his face was submergedspell while his face was submerged

• This "technique" was witnessed by the housestaff, This "technique" was witnessed by the housestaff, but not reported until directly questioned but not reported until directly questioned