AHA ACEP ECC Textbook - Lippincott Williams and Wilkins edition Dr John M. Field M.D.
Authors: Dr. David Szpilman – Brazil Fire Department of Rio de Janeiro, Maritime Groupment, Head of Drowning Resuscitation Center in Barra da Tijuca; Hospital Municipal Miguel Couto – Head of Adult Intensive Care Unit; Founder and Ex- President of Brazilian Life Saving Society – SOBRASA; Member of Board of Director and Medical Committee of International Life-saving Federation, and Brazilian Resuscitation Council Associate.
Dr. Anthony J Handley – United Kingdom Honorary Consultant Physician & Cardiologist, Colchester, UK; Chief Medical Adviser, Royal Life Saving Society UK; Honorary Medical Officer, Irish Water Safety; Honorary Medical Adviser, International Life Saving Federation of Europe; Chairman, BLS/AED Subcomittee Resuscitation Council (UK).
Dr. Joost Bierens - Netherlands Department of anesthesiology, VU University Medical Center Amsterdam, the Netherlands; Professor in Emergency Medicine; Member of Medical Committee of International Life-saving Federation; Advisory Board Member Maatschappij tot Reding van Drenkelingen; (The Society to Rescue People from Drowning; founded in 1767); Medical Advisor The Royal Netherlands Sea Rescue Institution.
Dr. Linda Quan - USA Attending physician-Emergency Services, Children’s Hospital Regional Medical Center, Seattle Washington, USA; Professor, Division of Pediatric Emergency Medicine, Department of Pediatrics, University of Washington School of Medicine, Seattle, WA, USA; Member of American Red Cross Advisory Council on First Aid and Safety.
Dr. Rafael Vasconcellos - Brazil Fire Department of Rio de Janeiro, Medical Pre-Hospital Care, Teaching Department; Medical Rescue Team – Amil Resgate; Intervention Cardiologist.
Corresponding Address: David Szpilman - Av. das Américas 3555, bloco 2, sala 302, Barra da Tijuca - Rio de Janeiro – RJ - Brazil 22793-004. Phone: 055 021 99983951 Fax: 24307168 [email protected]
CHAPTER – DROWNING INTRODUCTION EPIDEMIOLOGY DROWNING DEFINITION AND TERMINOLOGY PATHOPHYSIOLOGY DROWNING CHAIN OF SURVIVAL – prevention to hospital Prevention Recognition & Alarming of incident Rescue and Basic Water Life Support (BWLS) On-land Basic Drowning Life Support (BDLS) Advanced Drowning Life Support (ADLS) on site Hospital OUTCOME AND SCORING SYSTEMS UNIFORM CLINICAL REPORTING OF DROWNING REFERENCES
CHAPTER – DROWNING INTRODUCTION On a sunny weekend day, a family was invited to a barbecue at a friend´s swimming pool. Suddenly, the mother noticed her four year-old boy was missing. After about 7 minutes he was found at the bottom of the pool and brought up to the pool´s edge. He appeared dead and no one knew what else to do.
This scenario is usual in many countries and transforms a happy time to a very dramatic moment and a future for every one involved of profound loss and grief, but also guilt for failure to protect, or even intense anger at those who did not provide adequate supervision or medical care.
Drowning is an injury whose treatment may involve many layers of personnel from laypersons, lifeguards, and pre-hospital care providers as well as highly specialized hospital staff. Care of the drowning victim is unique in that bystanders or rescuers need specific skills that allow them to help the victim without becoming another victim. Furthermore, the rescuer’s role is critical since the opportunity for a good outcome rests almost entirely with care provided at the scene. If rescue and first aid from bystanders fail, delayed medical treatment can not compensate any more for the obtained hypoxic injuries, even when more advanced therapies are started.
Interest in drowning rescue and resuscitation has existed for hundred of years and drove the development of the first resuscitation instruments, research, protocols, education and systems. At that time and now, drowning is one of the most frequent causes of injury deaths. For the current resuscitation community the main focus is on those with cardiac disease. This chapter will advocate that resuscitation of drowning victims should remain in the focus of the resuscitation community, at least for those who frequent privately or professionally aquatic environments. This is 80% of the earth surface. Although drowning tended to become a neglected, public health problem (1), it just recently has again started to receive the attention it deserves.
At a medical and societal level, it must be recognized that every drowning related death or hospitalization signals the failure of prevention.
EPIDEMIOLOGY • Drowning is responsible for more than 500,000 deaths around the world. • In the age group of 5 to 14 years, drowning is the leading cause of death worldwide among males and the fifth leading cause for females. • Worldwide, it is the leading killer of children 1-17 years in Asia. • Numbers of drowning rescues are unknown but vary widely depending on different geographic, cultural and economic resources available.
Each year, drowning is responsible for more than 500,000 deaths around the world (2). These figures are an underestimation of the real figures. Especially in developing countries many drowning deaths are unreported (table 1(3)). Numbers of drowning vary widely depending on different geographic, cultural and economic resources. In some European countries many drowning deaths are intentional injuries, due to suicide, while in Australia, USA and Brazil the majority of drowning deaths are unintentional injuries. In USA, an estimated 40 to 45% of deaths happen during swimming (4). Mortality and, less frequently, hospitalization following drowning are the most commonly reported indicators of drowning injury.
Age, gender, alcohol use, socioeconomic status (income, education, and ethnicity), exposure, risk behavior and lack of supervision are key risk factors for drowning. Considering all ages, males die 5 times more often from drowning than females. Young children, teenagers and older adults are the ages at highest risk of drowning. Worldwide drowning is the leading cause of death in the age group of 5 to 14 years among males and the fifth leading cause among females (5) and it is the leading killer of children 1-17 years in Asia. (6).
In USA, drowning is the seventh leading cause of unintentional injury deaths for all ages and the second leading cause of all injury deaths in children aged 1-14 years (7). Many of these injuries occur in recreational water settings, including pools, spas/hot tubs, and natural water settings (e.g., lakes, rivers, or oceans). During 2001-2002, an estimated 4,174 persons on average were treated annually in U.S. Emergency Departments for nonfatal unintentional drowning injuries in recreational settings, and 3,372 persons died in 2001. Children aged less than 4 years of age accounted for nearly 50% of the ED visits, and children aged 5-14 years an additional 25%. An estimated 75% of nonfatal injuries occurred in pools, whereas 70% of the fatalities occurred in natural water settings. Approximately 53% of ED-treated patients required hospitalization or transfer to another hospital for more specialized care (8).
In Brazil in 2003 with a population of 176 million inhabitants, 6,688 died (3.8/100,000 inhabitants) by drowning, the second leading cause of death for all causes among ages 1 to 14 years. The preponderance of drowning deaths (88%) was unintentional. Fatal drowning involved mostly 20-29 year-old individuals (22,1%), followed by 15-19 (16%), 30-39 (15%), 10-14 (11%), 40-49 (9%), 1-4 (8%) and 5-9 (7%). There was no sex distinction in death rates under 1 year of age, but males drowned 8.7 times more in those ages 20 to 29 (9). As one of the largest year around aquatic recreational areas in the world, Brazil provides a model for the development of a first responder system for drowning to compare with EMS systems in other countries. From 1984, a tremendous emphasis on lifesaving occurred when firefighters assumed the role of life guarding the beaches and in-land water spots around the country and many more professionals are available on duty. The development of a large cadre of these professionals on duty on beaches led to creation, in 1995, of the Brazilian Lifesaving Society supported by the International Lifesaving Federation (ILS) - the most important World Water Safety organization. A recently research on that matter analyzed the trends on drowning from 1979 to 2003 in Brazil (10). The effect of this initiative was a 30% reduction in drowning death rates from 1979 (5,42/100.000) to 2003 (3,78). Most of the decrease in death rates occurred from 1995 (4,91) to 2003 (3,78), suggesting that two interventions associated with maturation of the system - more lifeguards on duty and prevention campaigns - led to the dramatic decrease in drowning deaths (Graphic 1).
On Rio de Janeiro beaches, drowning predisposing conditions are discernable in 13% of all drowning cases; the most common is use of alcohol (37%), then convulsions (18%), trauma (including boating accidents; 16.3%), cardiopulmonary diseases (14.1%), skin diving and SCUBA diving (3.7%), diving resulting in head or spinal cord injuries, and others (e.g., homicide, suicide, syncope, cramps, or immersion syndrome (11.6%) (11). This highlights that 87% of drownings occur with no reasons other than a negligent attitude of adults with themselves and with their children.
In countries where beach culture is prevalent, the need for larger numbers of lifeguards on duty yearly around allows more prevention activity but also better documentation of rescues and fewer deaths. But in certain locations with the same beach characteristics, where resources are not available, lifeguard are scarce and the number of rescue are low comparing with number of death. As much as drowning prevention is done and more lifeguard are on duty the less people died in water. Different lifeguard associations have create their unique nomenclature to report, which make more difficult the understanding of what is happen on drowning. One of the most difficult tasks for the International Lifesaving Federation (ILS) is to create a single and unique nomenclature and terminology to compare and mainly to identify what can be done to improve the save of life on water environment. The German Life Saving Society (DLRG), a 62,000 lifeguards association working on coast, at inland waters and in public swimming pools, report 1,079 persons saved from drowning, 8,253 water sport activists cases helped in emergency situation, 44,346 first aid attendance in and at the water, which 606 died, in 2006 (DRLG, annual report for the year 2006). Surf Life Saving Australia (SLSA) reported for the season 2004-5, 14,601 rescues, 37,647 people who received first aid, and 544,789 preventative actions, with 58 death by drowning (251 rescues to 1 death) (SLSA – Report for the season 2004-5). In 2006, United States Lifesaving Association (USLA) reported 56,612 rescues on the shores of US beaches with 90 deaths (629 rescues to 1 death). On Rio de Janeiro beaches, in 2003, 14,584 rescues were done reporting 24 deaths by drowning (607 rescues to 1 death) and one death for each 10 drownings admitted for medical care in the Drowning Resuscitation Center (DRC), a pre-hospital facility focus on drowning and trauma.
DROWNING: DEFINITION AND TERMINOLOGY • “Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid”. • The term “near-drowning” is abandoned. Confusing terms, like ‘dry’ drowning and secondary drowning are eliminated. • The drowning process is a continuum beginning when the patient’s airway is below the surface of the liquid, usually water, which - if uninterrupted - may lead or not to death.
Definition of drowning has been a huge problem for a long period. There was no consensus in literature and among different water safety and health organizations, experts in the field and lay-persons (12). Terms and definitions were awkward and confusing and include sudden death, hypothermia, and diseases which occurred in water. At the same time, some definitions excluded true cases of drowning which needed hospitalization and died later from complication of drowning such as pneumonia, Adult Respiratory Distress Syndrome (ARDS) or ischemic encephalopathy. Therefore, the global burden of drowning has not only been wrongly measured through imprecisely national statistics but also through inadequate terms and definitions. Based on this needs, a Task Force on Epidemiology of Drowning (TFED) was established in 1998 within a dedicated framework of the World Congress on Drowning (WCOD) and provoke a lively electronic discussion with contributions from many experts around the world. The TFED released a paper on the website from the beginning of 2002 including all arguments of this discussion. As part of the scientific program of the WCOD, four discussion sessions were held based on this discussion paper. This procedure led to a consensus and the adoption of the following definition by all conference attendees in June 2002: “Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid”. According to this new definition, the drowning process is a continuum beginning with respiratory impairment, for example when the patient’s airway is below the surface of the liquid or when there is a splash of waves in the face. A patient can be rescued at any time during the process and given appropriate resuscitative measures in which case, the process of drowning is interrupted. Any submersion or immersion incident without evidence of liquid aspiration or respiratory impairment should be considered a water rescue. The terms “near-drowning”, “dry’ drowning and secondary drowning (delayed onset of respiratory distress) are eliminated. Immersion or submersion is a way to drown and not the name of the disease (13).
PATHOPHYSIOLOGY • Hypoxia is the most determinant factor in drowning severity and reversal of primary hypoxia and prevention of secondary hypoxia are the determinant factors to outcome. • Ventricular fibrillation is infrequent and is usually due to hypoxia and acidosis. • In drowning, apnea comes first, and if the victim is not ventilated soon enough, then circulatory arrest will ensue. • In drowning survivors, permanent and severe neurologic sequelae usually occur only following cardiac arrest. • Difference between drowning in fresh and salt water has only significance for epidemiological purpose for planning prevention campaign. • Humans rarely aspirate sufficient water to provoke significant electrolyte disturbances and usually do not need initial electrolyte correction.
There are several scenarios’ that can lead to drowning. These scenarios include the 2- years old toddler who crawls into the water, where he will disappear without any sign of distress and the young athletic swimmer who comes in a rip-current and after a exhausting struggle finally submerges. Despite some differences between drowning in fresh and salt water, from a clinical and therapeutic perspective, there are no important differences in humans. The common significant pathophysiological mechanism in all these scenarios of drowning is hypoxia (14).
When there is no way to keep the airways out of water, intentional breath holding is the first automatic response. Water in the mouth is spelt out or swallowed. When after some time a breath is taken, this may result in a first involuntary water aspiration and consequently coughing or rarely laryngospasm, leading to hypoxia. If laryngospasm occurs, the onset of hypoxia will terminates it rapidly. If not, water is gradually but in a short time aspirated into the lungs, disturbing the ability to obtain oxygen. Consciousness is lost or deteriorates and progressive hypoxia leads to apnea followed by cardiac arrest. Involuntary apnea in face of hypoxia can be the result of a very low oxygen dioxide (CO2) secondary to hyperventilation stress of being drowning, a way to obtain more oxygen, which usually failure. The higher the hyperventilation the longer apnea will persist. This whole process of drowning can last from 1 minute to some times hours.
The respiratory distress of drowning is not a function of water composition but the pulmonary response to the water aspirated. The aspiration of either fresh or salt water can produces, pending on the amount, surfactant destruction, alveolitis and a noncardiogenic pulmonary edema resulting in an increased intrapulmonary shunt and hypoxia (15). In animal research, the aspiration of 2.2 ml of water per kilogram of body weight decreases the arterial oxygen pressure (PaO2) to approximately 60 mm Hg within 3 minutes (16). In humans, as little as 1 to 3 ml/kg of water aspiration produces profound alterations in pulmonary gas exchange and decreases pulmonary compliance by 10% to 40% (15). Humans rarely aspirate sufficient water to provoke significant electrolyte disturbances and victims usually do not need initial electrolyte correction (17). Ventricular fibrillation (VF) in humans is probably most common as a primary event on drowning involving elderly in bath tubs, and in rare individuals with prolonged QT syndromes. More commonly it occurs due to hypoxia and acidosis and not to hemolysis and hyperkalemia. VF may occur during resuscitation due mostly to the use of epinephrine. Decreased cardiac output, arterial hypotension, increased pulmonary arterial pressure and pulmonary vascular resistance are the results of hypoxia. Hypoxia produces a well-established sequence of cardiac deterioration, with tachycardia, bradycardia, then a pulseless phase of ineffective cardiac contractions (PEA phase), followed by complete loss of cardiac rhythm and electrical activity (asystole) (15), the final common pathway.
A victim can be rescued at any time during the drowning process and may not require any intervention at all or may receive appropriate resuscitative measures, in which case the drowning process is interrupted. The victim may recover from the initial resuscitation efforts, with or without subsequent therapy aimed at eliminating hypoxia, hypercarbia, and acidosis, and restoring normal organ function. It should be noted that the heart and brain are the two organs at greatest risk for permanent, detrimental changes from relatively brief periods of hypoxia. Permanent damage occurs only in case of cardiac arrest. The development of post-hypoxic encephalopathy with or without cerebral edema is the most common cause of sequelae and death in hospitalized drowning victims. However all organ system can be involved in the post-drowning period including Disseminated Intravascular Coagulopathy (DIC) and Acute Tubular Necrosis (ATN).
DROWNING CHAIN OF SURVIVAL - prevention to hospital (Figure (18)) • Drowning has a unique chain of survival that includes a critical action of rescue, which must take place prior to initiation of Basic Life Support. • Prevention remains the most powerful intervention in the chain of survival. Every rescue conducted represents a failure of prevention. • Any health professional must be aware of how to help a drowning victim without becoming a second victim. • Scene resuscitation is the window of opportunity for saving lives • Cardiopulmonary arrest from drowning has the highest survival rates compared to other causes of out of hospital pediatric cardiac arrest (19). • In-water resuscitation (ventilation only) can increase by more than threefold a victim’s chance of survival without sequelae. • Vomiting is a common complication and can result in further aspiration and impairment of ventilation. • The Automated External Defibrillator plays a minor role in the resuscitation of drowning since ventricular fibrillation is rare.
1. Prevention Despite the emphasis on immediate treatment, the most effective intervention on drowning is prevention. Prevention remains the most powerful tool and multifaceted prevention programs are estimated to be effective in preventing more than 85% of current annual drownings (20, 21). Drowning prevention is multifaceted and involves education, technology, and legislation. In high income countries, children ages <5 years have the highest drowning rates and drown in swimming pools into which they fall in while unsupervised. Fencing swimming pools with 4-sided fencing with unclimbable fences with self closing, self latching gates have proven to be the most effective drowning prevention intervention for this age group. Legislation requiring installation of these barriers has been adopted in several countries. However, enforcement of these laws is key to maximizing their effectiveness but adequate supervision of children is the prevention goal to achieve. Supervision must be defined as the complete attention of an adult, who is unimpaired by alcohol, drugs, or distraction, at hand and capable of rescue. The increasing presence of life guards in Brazil was associated with decreasing drowning deaths. Their function is used to base on rescue, but it changes to prevention now-a-days and their presence decrease risk taking behaviors. Open water drowning prevention is more problematic as it involves older children and adults involved in a wide variety of activities. Open water drowning prevention has received less attention since most open water drowning victims die without medical interface. Life jackets are a technology that should decrease drowning deaths. In the USA and Canada, greater than 85-90% of boat related drowning deaths were people who were not wearing life jackets. Some countries have legislation requiring children to wear life jackets while on small boats. However, adult males in small boats are those who die and are not required to wear them. Swimming or water survival skills may also prevent deaths. Recent experience in low income countries teaching school age children to dog paddle for a few yards has decreased deaths. Another subpopulation at risk for drowning is those who have seizures. At all ages, drowning deaths occur in those with a history of seizures. Most occur in the bath tub or during recreational swimming. Prevention for this group would be to shower instead of using bath tubs and to swim where there is a lifeguard (table 2(22)).
2. Recognition & Alarming of Incident The key initial step in treatment of drowning is to recognize that some one is drowning. Contrary to popular opinion the victim does not wave or call for help and usually drowns unnoticed (23). A typically victim that drowns when swimming is a male young adult who may be initially embarrassed to cry for help and whose decision to ask for help is made too late, when his arms and legs are exhausted to do any movement and breathing instinctively takes precedence. While drowning, the victim is typically in an upright posture, with eyes just above the water surface, with arms extended laterally, thrashing and slapping powerless on the water surface, in an effort to get his airway above the water. Exhaustion will cause the inability to scream for help. Bystanders may not recognize that the victim is struggling and may assume that the victim is playing and splashing in the water. The victim may submerge and surface his or her head several times during this struggling activity. Children who can not swim struggle for only 10 to 20 seconds before final submersion and adults may be able to struggle for up to 60 seconds (23).
In swimming pools, the typical notice of a drowning victim is when he or she is observed under the water surface. This can happen not often in spite of good surveillance of pool lifeguards. The most effective way of pool surveillance still remains unclear and is currently under scientific investigations. Legally compulsory fencing and drowning detection systems can help to reduce the number of pool drowning.
At the moment drowning is recognized, it is essential to activate the emergency system to dispatch lifeguards and pre-hospital medical team to the scene and take immediately action.
3. Rescue and Basic Water Life Support (BWLS) Rescuers should be aware to not become the second victim. If possible, potential rescuers stay out of the water and use techniques like “throw before you go” and “reach (with long objects) before you assist” or can advise the victim on how to get out of this situation (i.e.; choosing a better way to escape, swim, float or reassuring the assistance coming).
Decision when to provide BWLS (18) is based on the victim’s consciousness level. The victim who is panicking and struggling to breathe can drown their would-be rescuer. It is always best to approach a struggling victim with an intermediary object or from the back-side. Lifeguards use rescue or torpedo buoys for this purpose that also can be used as a flotation devices to keep the head and the airways out of the water (23). Other objects like a plastic refreshment pet, a foam car seat and other children floatation device can be used on those situations. For the conscious victim, rescue involves bringing the victim to land without any further medical care (24).
The most important step in BWLS is the immediate institution of ventilation which has usually ceased by the time the victim becomes unconscious. Cardiac arrest ensues within minutes if apnea is not corrected. In-water resuscitation providing ventilation only can increase by more than threefold a victim’s chance of survival without sequelae. This is possible in well defines circumstances when the rescuer has the support on the ground by standing or a floatation device. In these circumstances, rescuers should check ventilation and attempt to provide mouth-to-mouth for 1 minute. Victims in only respiratory arrest usually respond after a few artificial breaths. If no response, assume the victim is in cardiac arrest and rescuer should go directly with the victim out of the water. Assessment for pulse in the water does not serve a purpose. External cardiac compressions cannot be performed effectively in the water and must be delayed until the victim is out of the water (24).
A few studies have described the frequency of in-water cervical spine injuries (CSI). A retrospective evaluation of over 46,000 water rescues on sand beaches demonstrated an incidence of CSI of 0,009% (25). In another retrospective survey of more than 2,400 drownings attended in a pre-hospital setting, less than 0.5% had a cervical spine injury. All who were injured had a history of obvious trauma from diving, falling from height, or a motor vehicle accident (26). Furthermore, valuable time spent immobilizing the cervical spine in an unconscious victim with no signs of trauma, could lead to a hypoxic and cardiopulmonary deterioration and ultimately to death. Considering the reported low incidence of CSI and the risk of wasting a precious time, routine cervical spine immobilization of water rescues, without strong evidence of a traumatic injury, is not recommended (25,26). Rescuers who suspect a spinal cord injury should: Float the supine victim in a horizontal position allowing the airway to be out of to water and check if there is spontaneously breathing: If there is no spontaneous breathing, the airways is opened and resuscitation (mouth-to-mouth) is started, while maintaining the head in a neutral position as much as possible. The jaw thrust has been also shown to allow small movement of the cervical spine. If there is spontaneous breathing, the hands of the rescuer can be used to stabilize the neck of the victim in a neutral position. If possible the victim is kept floating with the help of a back support device before moving the victim to a dry place. Align and support the head, neck, chest, and body if the victim must be moved or turned (14).
4. On-land Basic Drowning Life Support (BDLS) The technique of removing a victim from the water depends on the circumstances where the drowning has occurred and level of consciousness. Preferably a vertical position should be adopted to prevent vomiting and further airway complications. If the victim is exhausted, confused or unconscious transport should be in as near a horizontal position as possible but with the head still maintained above body level with the exception of immersion in cold water when victim should be kept horizontal as possible. The airway must be kept open all the time (27).
When on the land, the first procedure is to place the victim in a position parallel to the waterline, as horizontal as possible, supine, far enough away from the water to avoid incoming waves but not so far as to waste time on transportation. If conscious, reposition the victim supine with head up. If breathing and unconscious place the victim in recovery position (lateral decubitus) (27). In a 10-year study in Australia, vomiting occurred in more than 65% of victims who needed rescue breathing and in 86% of those who required both rescue breathing and chest compressions (28). Even in victims who required no interventions after water rescue, vomiting occurred in 50% once the victims had reached shore. The presence of vomit in the airway can result in further aspiration and impairment of oxygenation by obstruction of the airways and it can also discourage rescuers from attempting mouth-to-mouth resuscitation (28). Positive pressure ventilation will force water from the airways into the pulmonary circulation where it is absorbed while this appropriate intervention will simultaneously provide what the victim needs: ventilation and oxygenation. Specific efforts to expel water from the airway and lungs are hazardous. The abdominal thrust (Heimlich) maneuver should never be used as a means of expelling water from the lungs – it is ineffective and carries significant risks of vomiting and other injuries. Attempts at active drainage by placing the victim head down increases the risk of vomiting more than fivefold, and leads to a small but significant increase in mortality (19%) when compared with keeping the victim in a horizontal position (27). If vomiting occurs, turn the victim’s mouth to the side and remove the vomitus with a finger sweep, a cloth or use suction.
One of the most difficult medical decisions a lifeguard or an emergency health professional must make is how to treat a drowning victim appropriately. The most life- threatening situation, cardiopulmonary or an isolated respiratory arrest comprise only 0.5% of all rescues (11). Most cases are however less dramatic and many potential interventions can be considered. The questions that arise are: Should rescuers administer oxygen, should an ambulance be called, should the drowned person be transported to a hospital, or observe for a time at the site? To address these questions, a classification system was developed in Rio de Janeiro (Brazil) in 1972 to assist lifeguards, ambulance personnel, and physicians at the scene. The update of the classification system in 1997 (11) was based on analysis of 41,279 rescues between 1972 and 1991 of which 2,304 (5.5%) were drownings and needed medical attention. The classification system was revalidated in 2001 by a 10-year study with 46,080 rescues (29). This classification (algorithm 1) (11) allows determination of needed levels of support from the scene to the hospital, recommended treatment and shows the likelihood of death based on the severity of injury. The severity of the drowning victim is assessed by an on-scene rescuer, EMT or physician using clinical variables and to an ED professional receiving the victim at the hospital (11).
5. Advanced Drowning Life Support (ADLS) on site (Algorithm 1) (11) Different from past thoughts, the best recommendation for drowning is to bring the medical equipment to the victim instead of the victim to the ambulance in order to decrease time to intervention (stay and play). Advanced medical treatment is given according to drowning classification (11).
Dead body – Victim with submersion time over 1 hour in non-icy waters or with obvious physical evidence of death (rigor mortis, putrefaction or dependent lividity). Recommendation is to not start resuscitation.
Grade 6 - Cardiopulmonary Arrest - Resuscitation started by layperson or lifeguard must be continued by advanced life support personnel at the scene until successful. An exception is the moderate and severe hypothermic victim who should be transported while receiving resuscitation to a hospital where advanced warming measure can be accomplished. The first priority in a cardiopulmonary arrest is adequate oxygenation and ventilation. Medical staff must keep doing cardiac compression while starting artificial ventilation using bag and facemask with 15 liters of oxygen until cuffed oro- tracheal tube can be inserted. Suctioning the airways to intubation is usually necessary to visualize the glottis and Sellick maneuver on this situation can be of an additional help. Once intubated, victims can be oxygenated and ventilated effectively despite copious pulmonary edema fluid. In spite of massive foam production after intubation, additional suctioning is not needed and actual can be regarded as an elementary mistake in these situations. If possible Positive End Expiratory Pressure (PEE) should be used at the beginning for better oxygenation.
External defibrillation may have a role to monitoring, at the site, the cardiac rhythm. If the victim is hypothermic (< 34oC), CPR should continue even if in asystole. Tympanic temperature is the better way to check body temperature at this situation. Although VF is uncommon, adults may develop VF possibly as a consequence of coronary artery disease or advanced life-support therapies, such as epinephrine. Peripheral venous access is the preferred route for drugs. Although some drugs can be administered endotracheally, drug doses and absorption in the setting of copious pulmonary edema fluid may render them ineffective (23). The adrenaline dose for resuscitation remains controversial perhaps even more so in drowning, where the time elapsed to start resuscitation can be much longer. Both beneficial and toxic physiological effects of epinephrine administration during CPR have been shown in animal and human studies. Initial or escalating high-dose epinephrine has occasionally improved initial return of spontaneous circulation and early survival. Higher doses of epinephrine have not improved long-term survival and neurological outcome in general causes, when used as initial therapy. Nor have higher doses definitively been shown to cause harm. Therefore, high-dose epinephrine is not recommended in general causes for routine use but can be considered if 1-mg doses fail (30). Some drowning specific studies have shown high dose epinephrine provides no improvement in neurological outcome and may possibly worsen the victim’s outcome. However, other studies report that high epinephrine doses in drowning improve chances to resuscitate (11, 31) and its use can be recommended until proven inappropriate by better multicenter research based on the Utstein-Style guidelines. One recommendation on that is to use a first dose of 0.01mgr/kg I.V after 3 minutes of CPR (30) and if no response is achieved increase to 0.1mgr/kg each 3 to 5 min. of CPR (14).
Grade 5 - Respiratory arrest is usually reversed with a few mouth-to-mouth ventilations. Then follow protocols for grade 4. When the victim remains in apnea, mechanical ventilatory support is required.
Grade 4 - Acute pulmonary edema with hypotension - Oxygen with positive pressure ventilation support is the first-line therapy. Initially some of these victims will able to maintain adequate arterial blood gases (ABG) by an abnormally high respiratory rate or effort. Early intubation and mechanical ventilation is always indicated, as patient is consuming large amounts of energy breathing and is likely to tire (23). Oxygen should be administered by facemask with 15 liters per minute until a cuffed orotracheal tube can be inserted by rapid sequence induction. At this point, patients should be kept with drugs (sedative, analgesic and muscular blockers if needed) to tolerate intubation and artificial mechanical ventilation with a Tidal Volume of at least 5 ml/kgr of body weight. Oxygen inspired fraction (FiO2) can start at 100% but as soon as possible should be reduced to 0.45 or less. A positive end expiratory pressure (PEEP) should be added initially at a level of 5 cm H2O and then by 2 to 3 cm H2O increments until the desired intra-pulmonary shunt (QS:QT) of 20% or less, or PaO2:FiO2 of 250 or more is achieved. If low blood pressure is not corrected after the administration of oxygen and mechanical ventilation, a rapid crystalloid infusion (regardless of drowning water type) should be administered (15, 23).
Grade 3 - Acute pulmonary edema without hypotension – Some victims (28%) keep their arterial oxygen saturation above 90% with the use of 15 liters of oxygen by facemask and can tolerate no-invasive ventilatory support. Most, however, 72%, need intubation and mechanical ventilation and should follow the protocols for grade 4 (11).
Grade 2 - Abnormal auscultation with rales in some pulmonary fields – Most victims (93%) need only 5 liters of oxygen by nasal cannula.
Grade 1 - coughing with normal lung auscultation - victims do not need any oxygen or respiratory assistance.
Rescue – No coughing, foam, or difficulty breathing - Evaluate and release from the accident site without further medical care if there is no associated disease or condition.
6. Hospital In severe cases (grades 5 and 6) hospital attendance is possible only if an adequate and prompt BLS and ALS pre-hospital was available. If this is not the case, appropriate approach is to step back and follow the ALS on accident site protocols. Hospitalization care is recommended for grades 2 to 6. Decision making in the emergency department about admission to an ICU or hospital bed versus observation in an emergency department or discharge home should include a thorough history of the drowning incident and previous illness, a physical examination and a few diagnostic studies, including chest radiography and ABG measurement. Electrolytes, blood urea nitrogen, creatinine, and hemoglobin also should be assessed serially, although perturbations in these laboratory tests are unusual. For adolescents and adults a toxicological screen for suspected alcohol or drug ingestion is also warranted. Grade 3 to 6 victims should be admitted to an ICU for close observation and therapy. Patients grade 2 can be observed in emergency room for 6 to 24 hours, but grade 1 and rescue cases with no complains or associated illness should be released home. Table 3 shows general mortality rates for each grade of severity, hospitalization need, and in-hospital mortality rates (11).
Patients grade 4 to 6 usually, except in rare situation, will arrives from pre-hospital ALS care in mechanical artificial ventilation with acceptable oxygenation. If not, emergency room MD should step back and follow grade 4 ventilation protocols. Grade 3 depends on clinical evaluation in the field. Once the desired oxygenation is achieved at a given level of positive airway pressure, that level of PEEP should be maintained unchanged for 48 hours before attempting to decrease it to allow adequate surfactant regeneration. During that time if the patient begins to breath on his own without fighting, continuous positive airway pressure (CPAP) plus ventilatory pressure support mode (PSV) can be introduced. In selected cases, CPAP may be provided only by mask (e.g., in cooperative adolescents) or nasal cannula (in infants who are obligate nasal breathers), but usually this is not tolerated by the patients and pulmonary edema usually necessitates intubation. A clinical picture very similar to acute respiratory distress syndrome (ARDS) is common after significant drowning episodes (grade 3 to 6). The difference is that the acute respiratory distress seen with drowning has a much faster time to recovery and usually has no pulmonary sequalae. Management is similar to that of other patients with ARDS, including efforts to minimize volutrauma and barotrauma. Lung salvage involving permissive hypercapnia probably is not suitable for drowning victim grade 6 with significant hypoxic-ischemic brain injury, however. Instead, mild to moderate hyperventilation, aiming for a PaCO2 in the range of 30 to 35 mm Hg probably is indicated, together with other therapeutic measures to control cerebral edema.
In patients who are hemodynamically unstable or have severe pulmonary dysfunction (grade 4 to 6), pulmonary artery catheterization or other correlate non-invasive technique can improve the ability to assess and treat the victim. Colloid solutions should only be used for refractory hypovolemia when replacement with crystalloid was not enough to restore blood pressure promptly. No evidence exists to support the routine administration of hypertonic solutions and transfusions for drowning in fresh water, or the use of hypothonic solutions in salt-water drownings (15, 23). Pulmonary artery catheterization or other less invasive techniques also enable the clinician to monitor cardiac function, pulmonary function, and tissue adequacy of oxygenation and perfusion and to assess the response of these parameters to various therapies. Echocardiography to assess cardiac function and ejection fractions can help guide the clinician in deciding on inotropic agents, vasopressors or both, if volume crystalloid replacement had failed. Some studies have shown that cardiac dysfunction with low cardiac output is common just after severe drowning cases (grades 4 to 6) (15). Important supportive measures include Foley catheter placement to monitor urine output. Low cardiac output is associated with high pulmonary capillary occlusion pressure, high central venous pressure, and high pulmonary vascular resistance and can persist for days after reoxygenation and reperfusion. The result is the addition of cardiogenic pulmonary edema to the noncardiogenic pulmonary edema. Despite a depressed cardiac output, furosemide therapy is not a good idea. One study even has suggested that volume infusion benefits drowning victims. Studies suggest that dobutamine infusion to improve cardiac output is the most logical and potentially beneficial therapy.
Metabolic acidosis occurs in 70% of patients arriving at the Hospital (17). It should be corrected when PH is < 7.2 or the bicarbonate <12mEq/l. if the victim has adequate ventilatory support (10). Significant depletion of bicarbonate is rarely present in the first 10 to 15 minutes of CPR, contraindicating its use initially (30).
Usually, pools and beaches don’t have high enough bacterial counts to promote pneumonia just after the incident (32). If the victim needs mechanical respiratory assistance the incidence of secondary pneumonia increases from 34 to 52% in the third or fourth day of hospitalization when pulmonary edema usually is almost resolved (33). Vigilance for not only pulmonary, but also other septic complications is important. Prophylactic antibiotics are of doubtful value in the intensive care management and tend to select out only more resistant and more aggressive organisms. An altered chest x-ray should not be interpreted as pneumonia, because it is usually the result of pulmonary edema and aspirated water in the alveoli and bronchi. A preferable approach is daily monitoring of tracheal aspirates with Gram stain, culture, and sensitivity. At the first sign of pulmonary infection, usually after the first 48 to 72 hours, as gauged by prolonged fever, sustained leukocytosis, persistent or a new pulmonary infiltrates, and leukocyte response in the tracheal aspirate, antibiotic therapy is selected on the basis of predominant organism and their sensitivities. Fiberoptic bronchoscopy may be useful for bacterial evaluating through quantitative cultures, for determining the extent and severity of airway injury in cases of solid aspiration, and in rare occasion for therapeutic clearing of sand, gravel and others solids. Likewise, corticosteroids for pulmonary injury are, at best, of doubtful value and probably should not be used, except for bronchiospasm. A persistent systemic inflammatory response has being reported in the first 24 hours after successful resuscitation with scarce response to different approaches and explains the very common low grade fever that is seen in this time period.
The clinician must be aware of and constantly vigilant for potential complications of therapy and underlying pulmonary injury, namely, volutrauma and barotraumas (32). Spontaneous pneumothoraces are common (10%) secondary to positive pressure ventilation and local areas of hyperinflation. Any sudden change in hemodynamic stability after mechanical ventilation should be considered a pneumothorax or other barotrauma until proved otherwise. After a secure airway is guaranteed, a nasogastric tube placement reduces gastric distention and prevents further aspiration. Rarely, drowning victims who seem healthy on assessment in the emergency department, including having normal chest radiography, develop fulminant pulmonary edema as late as 12 hours after the incident. Whether this late-onset pulmonary edema is a delayed acute respiratory distress syndrome (ARDS) is unclear, but none of the authors have seen any of this complication.
Renal insufficiency or renal failure is rare in drowning victims but can occur secondary to anoxia, shock, or hemoglobinuria.
Despite aggressive management, severe neurological sequelae, from no self help skills to persistent vegetative state, are problematic in the management of grade 6. In fact, pediatric intensive care units report that drowning survivors are among their most devastated survivors. The most important complication of drowning injury is the anoxic-ischemic cerebral insult that occurs in pos-resuscitation cases. Most late deaths and long-term sequelae of drowning are neurologic in origin (32). Although the highest priority is restoration of spontaneous circulation, every effort in the early stages after rescue should be directed at resuscitating the brain and preventing further neurologic damage. These steps include all measures to provide adequate oxygenation (SatO2 > 92%) and cerebral perfusion (medium arterial pressure around 100 mmHg). Any victim who remains comatose and unresponsive after successful CPR or deteriorates neurologically should undergo careful and frequent neurologic function assessment for the development of cerebral edema and should: Use the head of the bed by 300 (if there is no hypotension), avoid jugular vein compressions and situations that could provoke Valsalva maneuver; Secure a good mechanical ventilation without unnecessary effort; make an appropriate respiratory toilet without provoking hypoxia; treat the convulsive crises and the unnecessary muscular waste; avoid metabolic sudden corrections; Avoid anything that will increase intracraneal pressure (ICP), including urinary retention, pain, hypotension or hypoxia before prolong sedation or muscular relaxant; and maintain as much as possible the blood glucose concentration monitored and in normoglycemic values (8). Continuous monitoring of core and/or brain (tympanic) temperature is mandatory in the emergency department and intensive care unit (and in the pre-hospital setting if possible). Drowning victims with restoration of adequate spontaneous circulation who remain comatose should not be actively rewarmed to temperature values >32-34oC. If core temperature exceeds 34 oC, hypothermia (32-34oC) should be achieved as soon as possible and sustained for 12-24 hours. Hyperthermia should be prevented at all times in the acute recovery period. Unfortunately, studies that have evaluated the results of cerebral resuscitation measures in drowning victims have failed to demonstrate that therapies directed at controlling intracranial hypertension and maintaining cerebral perfusion pressure (CPP) improve outcome. These studies have shown poor outcomes (i.e., death or moderate to profound neurologic sequelae) when the intracranial pressure was 20 mm Hg or more and the CPP was 60 mm Hg or less, even when therapies are directed at controlling and improving these pressures. More research is needed to evaluate specific efficacy of neuro-resuscitative therapies in drowning victims.
New therapeutic interventions for drowning victims, such as extracorporeal membrane oxygenation, artificial surfactant, nitric oxide, and liquid lung ventilation, and early initiation of mild hypothermia are still in the investigational stage.
OUTCOME AND SCORING SYSTEMS Almost all (95%) of drowning grade 1 to 5 victims return home safely without sequelae (11). Although grade 3 to 6 has potential to provoke multisystem organ failure (17), grade 6 victims are at major risk. Questions like “how can we know who we should make the effort to resuscitate; how long we should continue CPR; how different should be the treatment and what we should expect as life quality after successful resuscitation? Need to be answered. Both at the rescue site and in the hospital, no one indicator for grade 6 can reliably predict outcome (34).
Opinions on indications for starting and prolonging resuscitation vary. Multiple studies although have established that outcome is almost solely determined by a single fate factor - duration of submersion (table 4) (11, 24, 28, 32, 35, 36, 37, 38, 39). However the effect of rapidly induced hypothermia may alter the value of submersion time as an outcome predictor. Body heat exchanges very quickly in the water environment. Rapid cooling may be achieved by contact with large body surface area by waters whose temperature is usually lower than human, and often flowing so that conductive cooling is enhanced. Based on one reported case who had the longest submersion time (66 minutes) with recovery (23), the recommendation is to initiate resuscitation without delay in every victim without carotid palpable pulse who has been submerged for less than one hour in very cold or icy water, or does not present obvious physical evidence of death (rigor mortis, putrefaction or dependent lividity). However, the concept that long time submersion and successful resuscitation is only possible in cold or icy water has been challenged by several anecdotal drowning cases in warm water with survival without sequelae (11, 35, 36). Basic and advanced life support professionals enable victims to achieve their best outcome possible given the duration of cardiopulmonary arrest (submersion time included). Based on a report of a drowning victim successful resuscitated after 2 hours of CPR (32), effort should stop only if asystole persists after rewarming the victim above 340C. “No one is dead until warm and dead” (Southwick & Dalglish). However, in the NW USA, where drowning most often occurs in cold but not icy waters, one large study of 194 hospitalized children and adolescents, an age group most easily cooled during a submersion, had no survivors who required more than 25 minutes of CPR by EMS.(40).
After successful CPR, is crucial to stratify neurological severity, which will allow comparing different therapeutic approaches. Various prognostic scoring systems have been developed to predict which patient will do well with standard therapy and which are likely to have a significant cerebral anoxic encephalopathy and will require aggressive measures to protect the brain. The most powerful predictor is the consciousness level related to the Glasgow Coma Scale at the period immediately after resuscitation (first hour). Alert patients should survive; most comatose patients will die. (Conn & Modell Neurological Classification) (11, 41, 42) (table 5). Because of delay of 2 to 6 hours between rescue and transfer from the scene to an outlying emergency facility to an ICU, many patients with severe anoxic-ischemic cerebral insults and coma have had multiple determinations of neurological status and level of consciousness before definitive therapy is begun. In the comatose patient, clinical and laboratory indicators of brain stem death such as absent papillary reflex and lack of spontaneous breathing, as measured by severe acidosis and severe hyperglycemia predict death or severe neurologic sequeleae, including persistent vegetative state (40). Prognostic variables are important in counseling family members of drowning victims in the early stages after the incident and mostly in deciding which patients are likely to have a good outcome with standard supportive therapy and which victims should be candidates for more aggressive cerebral resuscitation therapies (37).
UNIFORM CLINICAL REPORTING OF DROWNING (algorithm 2) Standardization of definition, terminology, nomenclature and classification of drowning is extremely important to distingue different pathologies from drowning and to let all know of what severity of drowning we are referring to. It allows comparing statistics from different parts of the world from any lifeguard service, pre-hospital or hospital facility.
“Drowning represent a tragedy that all too often was preventable. Perhaps the majority are the end result of common sense violations, alcohol consumption, and neglect of responsible childcare. This picture needs a radical preventive intervention”
REFERENCES 1. Murray CJL. Quantifying the burden of disease: the technical basis for disability- adjusted life years. Bull World Health Organ 1994;72:429-445 2. Peden M, McGee K and Sharma K. The Injury Chart Book: A Graphical Overview of the Global Burden of Injuries. Geneva: World Health Organization, 2002. 3. World Drowning Report, International Life Saving Federation, International Journal of Aquatic Research and Education, 2007, 1, 381-401 4. Branche CM, “What is really happening with Drowning Rates in the United States?” Drowning- New Perspectives on Intervention and Prevention – Edited by Fletemeyer J. R. and Freas S.J., CRC Press, 1998, P31-42. 5. World Health Organization. Bulletin report on A Injury-a leading cause of the global burden of disease@. WHO, 1998. 6. Peden MM, McGee K. The epidemiology of drowning worldwide. Injury Control and Safety Promotion. 2003. 10(4): p195-9. 7. CDC. Web-based Injury Statistics Query and Reporting System (WISQARS). Available at http://www.cdc.gov/ncipc/wisqars. 8. J Gilchrist, K Gotsch, G Ryan; Nonfatal and Fatal Drownings in Recreational Water Settings - United States, 2001-2002; National Center for Injury Prevention and Control, CDC, Morbidity and Mortality weekly report, June 4, 2004 / 53(21);447-452. 9. Szpilman D, Drowning in Brazil – 179,000 deaths in 25 Years - Are we stepping down? World Water Safety Congress, Porto, Portugal, September 2007 10. Szpilman D, Goulart PM, Mocellin O, Silva A, Guaiano OP, Barros M, Alves AS, Morato M, Cerqueira J, Vilela JJM, Smicelato CE, Araújo RT, Pedroso JP, Krüger L, Barros E, Cerqueira A, Sales RC, Silva NS; 12 years of Brazilian Lifesaving Society (Sobrasa) – Did we make any difference? World Water Safety, Matosinhos – Portugal 2007, Book of Abstracts, ISBN: 978-989-95519-0-9, p207-8. 11. Szpilman D. Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1831 cases. Chest 1997;112;issue 3 12. Szpilman D, Orlowski, JP, Cruz-Filho FES, Elmann J. HEY “Near-drowning”, You’ve Been Messing Up Our Minds! World Congress on Drowning, Amsterdam 2002, Book of Abstracts, P114. 13. Szpilman D. Definition of drowning and other water-related injuries. Final paper, June 2002. HYPERLINK "http://www.drowning.nl" www.drowning.nl 14. Special Resuscitation Situations; Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care (ECC); Circulation, August 22, Vol 102, No 8, 2000. 15. Orlowski JP, Abulleil MM, Phillips JM: The hemodynamic and cardiovascular effects of near-drowning in hypotonic, isotonic, or hypertonic solutions. Ann Emerg Med 18:1044-1049, 1989. 16. Modell JH, Moya F, Newby EJ, Ruiz BC, Showers AV (1967); The effects of fluid volume in seawater drowning; Ann Intern Med 67:68-80. 17. Szpilman D, Afogamento, Revista Bras. Med. Esporte – Vol 6, N4 – Jul/Ago, 2000, P131-144. 18. Szpilman D, Morizot-Leite L, Vries W, Scarr J, Beerman S, Martinhos F, Smoris L, Lofgren B; First aid courses for the aquatic environment; section 6 (6.7) Resucitation, in Hand Book on Drowning:Prevention, Rescue and Treatment,edited by Joost Bierens,Springer-Verlag, 2005, pg 342-7. 19. Donoghue AJ, Nadkarni V, Berg RA, Osmond MH, Wells G, Nesbitt L, Stiell IG; CanAm Pediatric Cardiac Arrest Investigators. Out-of-hospital pediatric cardiac arrest: an epidemiologic review and assessment of current knowledge. Ann Emerg Med. 2005 Dec;46(6):512-22. Epub 2005 Aug 8. 20. Quan L, Liller K, Bennett E. Water related injuries of children and adolescents. In: Injury Prevention for Children and Adolescents: Research, Practice, and Advocacy. Liller K ed. Washington DC. American Public Health Association, 2006. 21. Quan L, Bennett E, Branche CM. Interventions to Prevent Drowning. In. Handbook of Injury and Violence Prevention. Doll, L.S., Bonzo, S.E, Sleet, D.A. & Mercy, J.A. (editors); Haas, E.N. (managing editor). pp.81-96. New York, NY; Springer, 2007. 22. Szpilman D, Orlowski JP, Bierens J. Drowning. In: Fink M, Abraham E, Vincent JL, Kochanek P (ed). Textbook of Critical Care, 5th edition - Chapter 88; Pg 699-706; Elsevier Science 2004. 23. Orlowski JP, Szpilman D, “Drowning - Rescue, Resuscitation, and Reanimation” Pediatric Critical Care: A New Millennium, W. B. Saunders Company Pediatric Clinics of North America - V48, N3, June 2001. 24. Szpilman D, Soares M. In-water resuscitation — is it worthwhile? Resuscitation 2004;63:25-31. 25. Wernick P, Fenner P and Szpilman D; Immobilization and Extraction of Spinal Injuries; section 5(5.7.2) Rescue – Rescue Techniques, in Hand Book on Drowning: Prevention, Rescue and Treatment, edited by Joost Bierens, Springer-Verlag, 2005, pg 291-5. 26. Watson RS, Cummings P, Quan L, Bratton S, et al. Cervical spine injuries among submersion victims. J Trauma. 2001;51:658-62. 27. Szpilman D and Handley A; Positioning the Drowning Victim; section 6(6.6) Resucitation, in Hand Book on Drowning:Prevention, Rescue and Treatment, edited by Joost Bierens, Springer-Verlag, 2005, pg 336-341. 28. Manolios N, Mackie I. Drowning and near-drowning on Australian beaches patrolled by life-savers: a 10-year study, 1973-1983. Med J Aust. 1988;148:165-7, 170- 171. 29.Szpilman D, Elmann J, Cruz-Filho RES. Drowning classification: a revalidation study based on the analysis of 930 cases over 10 years. World Congress on Drowning, Amsterdam 2002, Book of Abstracts, pg 66. 30. Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care (ECC); Circulation, August 22, Vol 102, No 8, p129, 2000. 31. Nichter MA, Everett PB: Childhood near-drowning: Is cardiopulmanry resuscitation always indicated? Crit Care Med 1989; 17: 993-995. 32. Orlowski JP: Drowning, near-drowning, and ice water submersion. Pediatr Clin North Am 34:92, 1987. 33. Berkel M, Bierens JJLM, Lierlk et al; Pulmonary Oedema, Pneumonia and Mortality in Submersions Victims. A Retrospective study in 125 patients. Int. C. Md 1996; 22; 101-107. 34. Bierens JJLM, Velde EA; Berkel M, Zanten JJ, Submersion in the Netherlands; prognostic indicators and results of resuscitation. Annals of Emerg Medicine 1990; 19: 1390-5. 35. Szpilman D; A case report of 22 minutes submersion in warm water without sequelae; section 6(6.15) Resucitation, in Hand Book on Drowning:Prevention, Rescue and Treatment, edited by Joost Bierens, Springer-Verlag, 2005, pg 375-376. 36. Allman FD, Nelson WB, Gregory AP, et al: Outcome following cardiopulmonary resuscitation in severe near-drowning. Am J Dis Child 140: 571-75,1986. 37. Orlowski JP: Prognostic factors in pediatric cases of drowning and near-drowning. Journal of the College of Emergency Physicians 8:176-179, 1979. 38. Cummings P, Quan L. Trends in unintentional drowning: the role of alcohol and medical care. JAMA. 1999;281:2198-202) 39. Cummins RO, Szpilman D. Submersion. In Cummins RO, Field JM, Hazinski MF, Editors. ACLS-the Reference Textbook; volume II: ACLS for Experienced Providers. Dallas, TX; American Heart Association; 2003. Pages 97-107. 40. Graf WD, Cummings P, Quan L, Brutocao D: Predicting outcome in pediatric submersion victims. Ann Emerg Med September 1995;26:312-319. 41. Modell JH. Drowning: current concepts. N Engl J Med 1993;328(4):253-256. 42. Conn AW, Modell JH, Current Neurological considerations in near-drowning (editorial). Can Anaesth. Soc. J. 1980; 27: 197.
TABLES, FIGURES AND ALGORITHM Developed Sub-Saharan Latin Middle Asia and Total countries Africa America East Pacific Data available 55 4 29 9 18 115 Data not available 2 42 4 12 17 77 Total 57 46 33 21 35 192 Table 1 - Global Coverage of Death Registration Data (WHO presentation: “Mortality and causes of death”) (3).
XXXXXXXXXXXXXXXXXXXXXXXXXXXXX Drowning death in Brazil Death/100.000 inhabitants
Death/100.000 inhab 7
6
5
4
3
2
1
0
9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 7 8 8 8 8 8 8 8 8 8 8 9 9 9 9 9 9 9 9 9 9 0 0 0 0 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 9 0 0 0 0 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 1 2 2 2 2 Years Graphic 1 – Drowning death trends on Brazil from 1979 to 2003, selecting 3 different periods (10).
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Figure 1 – Drowning Chain of Survival (18) (attached in TIFF)
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Watch children carefully, 84% of drownings occur because of bad adult supervision. Begin swimming lessons from 2 years old but be very careful at this time. Avoid inflatable swimming aids such as "floaties" They can give a false sense of security. Use lifejacket! Never try to help rescue someone without able to do it. Many people died trying to do so. Avoid drinking alcohol and heaving lunch before swimming. Don’t dive in shallow water – cervical spine injury can happen. BEACHES POOLS and Similar Always swim in a lifeguard-supervised area. Over 65% of deaths occur in fresh water, even on the Ask the lifeguard for safe places to swim or play. coast. Read and follow warning signs posted on the beach. Fence off your pool and include a gate. Recommended Do not overestimate your swimming capability – fencing approved can decrease drowning by 50 a 70%. 45% of drowning victims thought they knew how to Avoid toys around the pool, is very attractive to swim. children. Swim away from piers, rocks and stakes Whenever infants or toddlers are in or around water, Take lost children to the nearest lifeguard tower be within arm's length, providing "touch supervision". Over 80% of drowning occurs in rip currents (the Turn off motor filters when using the pool. rip is usually the most falsely calm deeply place Always use portable phones in pool areas, so you are between two sand bars). If caught in a rip, swim not called away to answer. transversally to the sand bar or let it take you away Don’t try to do hyperventilation to increase the without fighting and wave for help If you are submersion time. fishing on rocks be cautions about waves that may Use warning sign of shallow water on the pool. sweep you into the ocean. Learn CPR. Over 42% of pools owner are not aware Keep away from marine animals. about first aid techniques – Be careful! Table 2 (22)
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX CLASSIFICATION, MORTALITY and HOSPITAL NEEDS (n = 1831^) GRADE No. Overall Mortality(%) Admission to Hospital (%) Hospital Mortality (%) Rescue 38.976 0 (0.0%) 0 (0.0%) 0 (0.0%) 1 1189 0 (0.0%) 35(2.9%) 0(0.0%) 2 338 2 (0.6%) 50(14.8%) 2(4.0%) 3 58 3 (5.2%) 26(44.8%) 3(11.5%) 4 36 7 (19.4%) 32(88.9%) 7(19.4%) 5 25 11 (44%) 21(84%)(@) 7(33.3%) 6 185 172 (93%) 23(12.4%)(@) 10(43.5%) Total 1.831(&) 195 (10.6%) 187 (10.2%)* 29 (15.5%) P < 0.0001 TABLE 3 - (^) Overall mortality was 10.6%(1); (&) The rescues cases were excluded. (*) Need of overall hospitalization (10.2%) in ND/D cases in association with the grade and mortality. Mortality in the hospital was 15.5%. (@) Four patients grade 5 and 162 grade 6, out of this table, were pronounced dead and thus taken directly to the morgue (11).
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ALGORITHM 1 - Drowning Classification Algorithm - Advanced Cardiac Life Support (ADLS) (11). (file attached in PDF, TIFF)
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Probability of Neurologically Intact Survival to Hospital Discharge Based on Duration of Submersion
Duration of submersion (minutes) Death or severe neurological impairment 0 to <5 minutes 10% 5 to <10 minutes 56% 10 to <25 minutes 88% > 25 minutes 100%
Table 4 - Note in these data how 5 more minutes of submersion in the 5 to <10 min group increases mortality almost 6 times compared to the 0 to <5-minute group (Extrapolated on many different published data 11, 24, 28, 32, 35, 36, 37, 38, 39)
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NEUROLOGIC PROGNOSTIC SCORE Pos successful CPR on Drowning A – FIRST HOUR B – AFTER 5 to 8 h Alert - 10 Alert - 9.5 Confused - 9 Confused - 8 Torpor - 7 Torpor - 6 Coma with normal brainsteam - 5 Coma with normal brainsteam - 3 Coma with abnormal brainsteam - 2 Coma with abnormal brainsteam - 1 A + B RECOVERY WITHOUT SEQÜÊLAE Excellent (>= 13) > = 95% Very good (10-12) 75 to 85% Good (8) 40 to 60% Regular (5) 10 to 30% Poor (3) < = 5% Table 5 – Clinical Prognostic Score for the immediate period pos successful CPR, based on Glasgow Coma Score (Elaborated by Szpilman 1998, based on 11, 41, 42 references).
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UNIFORM CLINICAL REPORTING OF DROWNING
DROWNING An event that results in respiratory distress(&) due to submersion/immersion in liquid. Hypoxia results in death at the scene or in ED. NO respiratory distress RESCUE DEATH No resuscitation attempted (morgue) Released to home
Classify the severity Cough with normal Cardiopulmonary pulmonary Arrest auscultation Grade 6 Isolated Acute pulmonary Grade 1 respiratory Acute pulmonary edema without Rales in some Arrest edema with hypotension pulmonary fields Grade 5 hypotension Grade 3 Grade 2 Grade 4
Worse to lighter severity
The ultimate outcome should be reported whether it be survival without any residual organ damage or whether the patient has a continuing morbidity which should be identified and quantified. (&) Respiratory distress - altered pulmonary auscultation or cough or documented hypoxia.
Algorithm 2 - Guidelines for uniform Clinical Reporting of Drowning (Unpublished data - Szpilman – 2002)