Drowning: Epidemiology, Prevention, Pathophysiology, Resuscitation, and Hospital Treatment

Emergencias 2019;31:270-280

SPECIAL ARTICLE Drowning: epidemiology, prevention, pathophysiology, resuscitation, and hospital treatment

Cristian Abelairas-Gómez1,2, Michael J. Tipton3, Violeta González-Salvado2,4, Joost J. L. M. Bierens5

This narrative review discusses the evidence relevant to key aspects of drowning, which is defined by the World Authors’ affiliation: Health Organization as the process of respiratory difficulty caused by submersion/immersion in liquid. The length of 1Research Group CLINURSID and Faculty of Education Sciences, time the victim is submerged is a key factor in survival and neurologic damage. Although respiratory distress and Universidade de Santiago de hypoxia are the main events, other complications affecting various systems and organs may develop. Drowning is one Compostela, Spain. 2 of the main causes of accidental death worldwide, yet deaths from drowning are underestimated and morbidity is Instituto de Investigación Sanitaria (IDIS) of Santiago de unknown. Prevention is essential for reducing both mortality and morbidity, but if prevention fails, the speed of Compostela, Spain. access to and the quality of prehospital and hospital care will determine the prognosis. It is therefore essential to 3Extreme Environments Laboratory, Department of Sport understand the factors and mechanisms involved in these emergencies. and Exercise Science, University Keywords: Risk factors. Mortality. Respiratory distress syndrome, adult. Cardiac arrest. Case management. of Portsmouth, Portsmouth, United Kingdom. Cardiopulmonary resuscitation. Prognosis. Survival. 4Cardiology Service, Complejo Hospitalario Universitario de Santiago, CIBERCV, Universidade El ahogamiento: epidemiología, prevención, fisiopatología, reanimación de la de Santiago de Compostela, víctima ahogada y tratamiento hospitalario Santiago de Compostela, Spain. 5Research Group Emergency and Disaster Medicine, Vrije El objetivo de esta revisión narrativa fue elaborar un documento que trate los aspectos clave del ahogamiento de Universiteit Brussel, Brussels, acuerdo con la evidencia científica disponible. El ahogamiento se define como el proceso de sufrir dificultades respira- Belgium. torias por sumersión/inmersión en un líquido. El tiempo de sumersión es un factor clave en la supervivencia y daño Corresponding author: neurológico. Aunque el distrés respiratorio e hipoxia es el cuadro predominante, pueden presentarse otras complica- Cristian Abelairas-Gómez ciones que afecten a distintos sistemas y aparatos. El ahogamiento es una de las principales causas de muerte acci- Facultad de Ciencias de la Educación, Universidade dental en el mundo. Sin embargo, la mortalidad por ahogamiento está infraestimada y la morbilidad desconocida. La de Santiago de Compostela prevención es el factor clave para la reducción de la mortalidad y morbilidad, pero si esta falla, la rapidez y calidad Av/Xoán XXIII, s/n. del tratamiento tanto prehospitalario como hospitalario determinarán el pronóstico. Por tanto, resulta fundamental 15782 Santiago de Compostela, A Coruña, Spain conocer los factores y mecanismos particulares implicados en esta emergencia. Palabras clave: Factores de riesgo. Mortalidad. Síndrome de dificultad respiratoria del adulto. Parada cardiaca. E-mail: [email protected] Manejo de atención al paciente. Reanimación cardiopulmonar. Pronóstico. Supervivencia. Article information: Received 29-01-2019 Accepted: 30-03-2019 Online: 1-7-2019

Editor in charge: Juan González del Castillo

Every hour of every day, more than 40 people lose considered in the study of drowning according to cu- their lives by drowning.” The World Health rrent evidence: epidemiology, prevention, physiopatho- Organization’s (WHO) 2014 World Drowning Report logy and treatment of the drowned victim. begins by saying that drowning is among the top ten causes of death among children and young people in almost every region in the world1. Epidemiology Drowning is a cause of death that was associated with lower rates of financing and publications than esti- Drowning is one of the leading causes of uninten- mated on the basis of mortality2, which translates into a tional death in the world. About 372,000 deaths are pronounced discrepancy between the relevance of the reported each year, 90% of which occur in developing problem and the still scarce volume of information avai- countries according to WHO statistics based on the lable. Fortunately, the number of publications and ini- International Classification of Diseases (ICD) codes1. The tiatives aimed at increasing knowledge about and pre- change from the ninth to the tenth version of the ICD, venting this important cause of death is increasing, and its subsequent reviews and the inclusion of a fourth even the so-called Drowning Survival Chain3 has been character in the event location registry codes resulted created. This review of the literature aims to bring to- in a substantial increase in the accuracy of the drow- gether in a single document the main factors to be ning mortality registry. However, in a study that

270 Abelairas-Gómez C, et al. Emergencias 2019;31:270-280

Table 1. Number of deaths in Spain in 2016 and 2017 related to drowning and submersion 2016 2017 W M Total W M Total V90-V94 Water transport accident 0 10 10 3 21 24 V90 Boat accident causing drowning and submersion 0 7 7 3 16 19 V92 Drowning and submersion related to transport by water, no accident 0 3 3 0 5 5 to the vessel W65-74 Accidental drowning and submersion 95 344 439 88 387 475 W65 While in the bathtub 2 1 3 0 1 1 W67 While in a swimming pool 11 8 19 10 21 31 W68 Fall in a swimming pool 0 4 4 5 10 15 W69 While in natural waters 32 110 142 33 134 167 W70 After fall in natural waters 0 31 31 4 45 49 W73 Other specified drownings and submersions 0 12 12 4 23 27 W74 Unspecified drowning and submersion 50 178 228 32 153 185 X71 Intentionally self-inflicted injury by drowning and submersion 43 73 116 44 62 106 X92 Drowning and submersion aggression 0 0 0 0 1 1 Y21 Drowning and submersion, of unspecified intent 1 1 2 1 1 2 Total 139 428 567 136 472 608 M: men; W: women. analyzed 52 countries, only 23 used ICD-10 with the sex and location of the event. In this sense, men are fourth character4. In another study that analyzed 69 twice as likely to drown as women, more than half the countries, many drowning deaths were recorded with victims are under 25 years of age and mortality in codes referring to unspecified situations or locations, low-income countries is three times higher than in hi- calling into question the quality of the information re- gh-income countries1. However, since drowning is a ported in 1 out of 7 countries5. The WHO itself ack- multifactorial event, its epidemiology varies from coun- nowledges that drowning mortality is underestimated try to country. Thus, suicide was the cause of 36% of and can be 50% higher than that reported in develo- drownings between 1988 and 2012 in Ireland10; be- ped countries and five times higher in developing tween 2008 and 2012 in Canada, 65.6% of drownings countries1. related to boating accidents did not carry any flotation In Spain, the National Statistics Institute (INE) has material11; alcohol consumption was present in more reported a total of 5,848 deaths due to “accidental than 70% of unintentional drownings between 1970 drowning, submersion and suffocation” between 2016 and 2000 in Finland12; and people over 65 accounted and 2017, of which 1,175 were specifically related to for 17.3% of drownings in Australia between 2002 and submersion (Table 1). However, the number of deaths 201213. Epilepsy has even been shown to multiply the and the ICD classification system could be insufficient risk of drowning up to tenfold14. This heterogeneity in to know exactly the epidemiology due to scarce infor- epidemiological determinants highlights the need for mation in medical reports, insufficient training of the adequate recording systems that allow for greater preci- forensic services or lack of resources5. In addition, Spain sion. However, a study recording drownings in swim- is one of the countries with the worst quality of regis- ming pools in France showed that up to nine different tration regarding the fourth character of the ICD-104. services were responsible for recording the information, The reasons include the complexity of the procedures making it difficult to make a rigorous assessment of the through which information circulates, from the event to number and causes of drowning15. its final registration, and the time between the autopsy The consolidation of the registry and collaboration and the definitive results6. According to INE data, more tools of different local, national and international bodies than 25% of registered deaths occurred “in an unspeci- would greatly contribute to a greater precision on the fied place”, which added to events categorized as epidemiological knowledge of drowning. In an attempt “other unspecified drownings and submersions”, results to improve the quality of registration, the recommen- in a lack of relevant information in almost half the ca- dations for recording data on drowning resuscitation ses. Other epidemiological reports on drowning in (Utstein style) include in their latest update the inclu- Spain have considered only press reports7 or have not sion of cases of patients treated only by first responders taken into account all drowning events8. On the other and those in which hospital referral has not been hand, some studies have attempted to delve deeper necessary16. into the description of the drowned victim profile, such as a multicentre study of 21 Spanish hospital emergency departments that identified children under 6 years of Drowning Prevention age as a risk subgroup among minors9. However, this type of study is not common. Most drowning deaths could be prevented with Based on international literature, three variables preventive measures1, regarded as key to fighting this seem to influence the number of drowning deaths: age, cause of death (Figure 1). The lack of education on pre-

271 Abelairas-Gómez C, et al. Emergencias 2019;31:270-280

Install Provide TEACH SAFE PLACES BARRIERS (e.g., a nursery) away from water to restrict access to water. (e.g., a nursery) away from water school-aged children basic for preschool children, notions ofwith trained caregivers with trained caregivers SWIMMING, WATER SAFETY AND LIFESAVING

TRAIN Establish and enforce IMPROVE THE people around about RECREATIVE, COMMERCIAL MANAGEMENT OF FLOOD LIFESAVING AND AND PASSENGER RISKS RESUSCITATION NAVIGATION SAFETY at local and national levels REGULATIONS

Figure 1. Preventive measures proposed by the World Health Organization. Figure of reference 1, used with the permission of the World Health Organization. vention and aquatic safety is one of the greatest risks, thout the duty of care successfully rescued 343 vic- so training in basic swimming techniques, safety in the tims24. As the authors point out, the fact that more aquatic environment and school-age rescue have been than 90% of children in the Netherlands learn to swim identified as priority measures17. Unique teaching of could be a key factor explaining this success. swimming techniques could increase the risk of drow- In addition to the training of the general popula- ning due to increased exposure to water and overconfi- tion, adequate training of the group responsible for en- dence leading to swimming in dangerous places18. The suring safety in aquatic areas, lifeguards, accompanied inclusion of these contents in the school curriculum by research seeking the best evidence-based training, is would make it easier to reach a large part of the popu- essential. In Spain, lifeguard training has recently begun lation, but requires an increase in the budget for educa- to be regulated, albeit heterogeneously. This means tion and the modification of established structures. that, while in some communities such as Galicia and Some examples are Switzerland, where after ten years Catalonia the contents and duration of the training are of negotiations with the Ministry of Education its imple- pre-set and controlled, in other regions these aspects mentation was achieved in most German-speaking can- depend exclusively on the criteria of the training entity. tons19, or Bangladesh, where some 100,000 children Another measure considered of great importance, between the ages of 1 and 12 were trained with a posi- especially for children, is the installation of barriers that tive economic balance comparing the cost of the trai- limit access to aquatic areas. It is estimated that 75% of ning programme and the cost of mortality and morbi- deaths of young children in swimming pools could be dity20. This was possible thanks to the PRECISE prevented by a fence surrounding the pool17. This (Prevention of Child Injury through Social-Intervention should be complemented by parental supervision25. In a and Education) programme, whose most notable ac- study carried out in Spain, one in five drowned children tions were the increase in supervision of children aged was not supervised, and in two out of three cases in 1-5, the teaching of swimming and basic rescue techni- which they were supervised, an oversight was ques to the population aged 4-12 and the implementa- admitted9. tion of community education programmes20. Consumption of alcoholic beverages or other drugs In addition, training people in techniques of aquatic is another major risk factor1 because it increases the domain and lifesaving could help reduce drowning dea- number of reckless behaviors and reduces the ability to ths of both victims and potential rescuers17,21-23. It is not swim and stay afloat due to its effects on psychomotor uncommon for people without a duty of care to die tr- and cognitive functions. In addition, this consumption ying to rescue a victim, in which overconfidence, lack could trigger potentially fatal mechanisms in this situa- of training to assess all factors on the scene and lack of tion, such as arrhythmias26. Alcohol and the absence of knowledge of rescue techniques constitute a dangerous flotation devices are factors particularly associated with combination. Between 2002 and 2007, 27 people died drowning deaths in boating accidents27. For this reason, in Australia trying to rescue drowning victims21; in 2009 policies and legislation are needed to establish and im- in Turkey 31 people22 and in 2013 in China more than plement regulations to ensure safety in this context17. 5023. This contrasts with data from a Dutch study docu- Progress in drowning prevention requires political menting that between 1999 and 2004, 503 people wi- will and technical assistance. Thus, a national water se-

272 Abelairas-Gómez C, et al. Emergencias 2019;31:270-280

curity plan, together with the integration of these con- water swallowing are limited, it has been reported that tents into the school curriculum, would be a major ingested water favors vomiting30, with the consequent contribution in the fight against drowning. In Spain, risk of bronchoaspiration. prevention campaigns arise from initiatives of entities When the laryngospasm ceases, water is introduced closely related to the aquatic environment or lifesaving, into the respiratory tract. In a simplified form, water which should have more government support that entering the lungs triggers an inflammatory response would provide them with greater funding and that leads to pulmonary exudate and decreased disten- outreach. sibility, generating atelectasis. Moreover, in a subacute way, the aspirated water damages locally the alveo- lo-capillary membrane, particularly the alveolar cells Physiopathology of drowning type II, with the consequent stop in the production of surfactant and contribution to atelectasis. The reduction At the World Drowning Congress (Amsterdam, of the gas exchange zone hinders the arrival of oxygen Netherlands, 2002) drowning was defined as “the pro- to the capillaries during rescue breath, maintaining tis- cess of suffering breathing difficulties by immersion in a sue hypoxia. As a consequence, there is a marked in- liquid”28. If the person is rescued, the drowning process crease in the ventilation-perfusion discordance and the is interrupted and the person survives, it is called right-left short-circuit is favoured. If the person is not non-fatal drowning; if the person dies at any point in rescued, water aspiration continues and hypoxia will the process, it would be called fatal drowning29. lead to loss of consciousness. The physiopathology of drowning is related to two As for the differences between fresh and salt water concepts: immersion (upper airways above the surface aspiration, there are studies suggesting that the dama- of the water) and submersion (upper airways below the ge caused by salt water aspiration is significantly grea- surface of the water). Both events also differ in the phy- ter than that caused by fresh water32. Salt water, due to siological responses they trigger30. Immersion triggers a its greater osmolarity compared to plasma, attracts fluid series of cardiorespiratory responses linked to changes from the pulmonary circulation to the alveolus, thus fa- in central and peripheral temperatures, which depend vouring pulmonary edema, hypovolaemia and haemo- on the temperature of the water. Submersion is related concentration30,33. On the other hand, fresh water, be- to another series of cardiorespiratory and autonomic ing hypotonic, passes rapidly from the alveoli to the nervous system responses, in addition to those derived circulation, diluting pulmonary surfactant and contribu- from hypoxia due to eventual aspiration of water, ting to hypervolemia, hemolysis and electrolytic altera- which largely determines pathophysiology. In its sim- tions34. In both cases, in addition to increasing the ven- plest version, drowning is a respiratory problem derived tilation-perfusion discordance, the homeostasis of the from the immersion/submersion in a liquid that causes internal environment is altered due to plasma variations the rhythm of a healthy heart to be gradually reduced of the electrolytes, and the severity of the complications until stopped by tissue hypoxia. However, the comple- will depend on the volume of water aspirated. The me- xity of the physiopathology of drowning, how the body chanism of lung damage produced is a complex pro- responds during immersion and submersion, and the cess that requires further experimental and post-mor- most appropriate resuscitation mechanisms make up a tem research33. field that still requires further study. In terms of cardiac electrical activity throughout the When a person is unable to keep the airways out of drowning process, the appearance of ventricular tachy- the water, water going into the oral cavity may be ex- cardia has been reported, followed by extreme brady- pelled or swallowed29. Although the next conscious res- cardia, pulseless electrical activity and, finally, asystole35. ponse is to hold one’s breath, over time the respiratory However, in practice, the process may vary depending musculature is stimulated by hypercapnia (increased on the circumstances of the incident and the characte-

CO2 concentration) and hypoxemia (decreased O2) un- ristics of the victim, with the exact pathophysiological til breathing occurs involuntarily30. After this reflex brea- mechanisms still largely unknown. A study published in thing, which allows water to enter the lungs via the 2012 addresses the so-called “autonomic conflict” as an airway, two involuntary defence mechanisms are trigge- explanation for possible arrhythmias during cold water red: cough and laryngospasm. The latter has been des- immersion/submersion36. This conflict derives from the cribed as an explanation for the finding of drowned simultaneous stimulation of the parasympathetic and victims with macroscopically dry lungs, although it was sympathetic divisions of the autonomous nervous sys- widely criticized for its failure as hypoxia increases. tem (Figure 2). Contact with cold water stimulates the Further research showed that macroscopically dry lungs sympathetic system and induces tachycardia, hyperven- were not at the microscopic level. In fact, in a 2004 tilation, peripheral vasoconstriction and increased blood study, more than 98% of the drownings analyzed pressure. On the other hand, the diving reflex -endoge- showed signs of water aspiration, advocating the su- nous defence mechanism to preserve life in hypoxia30-, ppression of the term dry-drowning31. originated by immersion/submersion and cooling of the During the laryngospasm phase, large quantities of oronasal region, triggers parasympathetic stimulation water are introduced via the digestive tract31. Although and induces bradycardia36. This nervous conflict will ge- known data on the incidence and clinical relevance of nerate arrhythmias in the 10 seconds after reflex brea-

273 Abelairas-Gómez C, et al. Emergencias 2019;31:270-280

Cold and wet face Cutaneous cold Hold your breath receptors

RespuestaResponse al shockto cold frío Diving reflex shock Attempting to hold breath

Parasympathetic Sympathetic stimulation stimulation (Affects the SA and AV mainly(Afecta affects principalmente the SA and nodes(Afecta to the a losmyocardium) nodos a los nodosAV nodes) SA y AV) SA y AV y al miocardio)

Bradycardia Tachycardia

Inability to hold Inability to hold your your breath breath AUTONOMIC CONFLICT

Canalopathies (LQTS) Ischemic heart disease

Atherosclerosis Arrhythmias Hypertrophic cardiomyopathy

Alterations of the QT interval Acquired long QT syndrome (drug-induced) Predisposing factorsreceptors Figure 2. Autonomic conflict proposed by Shattock MJ and Tipton MJ et al.36. thing, which could become fatal. After cessation of exacerbates neurological damage, while cold water acts continued breathing, arrhythmias have also been obser- as a protective factor, as it produces a cooling of the ved in subjects while diving in cold water, suggesting brain, reducing its metabolism and oxygen demand37. that reflex breathing could be, in itself, an arrhythmo- Considering the victim’s body temperature as a referen- genic trigger36. The impact of the “autonomous con- ce for his core temperature and trying to establish a re- flict” could be underestimated due to the impossibility lationship with prognosis has its limitations. The entry of analyzing the post mortem heart rate and detecting of cold water through the respiratory tract cools the possible fatal arrhythmias in a drowned victim36. The heart, circulating blood and carotid arteries, producing factors that provoke, attenuate and promote “autono- selective cerebral cooling37,40 due to the increase in car- mous conflict”, and those that particularly favour the diac output directed to the brain due to peripheral va- appearance of fatal arrhythmias are aspects that require soconstriction and cerebral vasodilatation derived from further study37. Figure 2 reflects some predisposing fac- hypercapnia40. This mechanism will persist until respira- tors, highlighting cardiac diseases with an important tory and cardiac movements cease (approximately 70 arrhythmic substrate sensitive to physical activity in wa- seconds after submersion)37,40. Brain metabolism is re- ter, such as certain channelopathies (LQTS1)38 or ische- duced by approximately 5-6% for each degree centi- mic heart disease. grade of temperature lost29,41, having been reduced by Regarding the neurophysiology of drowning, much 50% to 22 ˚C and 75% to 18 ˚C41. of the information assumed comes from experimental models of cardiorespiratory arrest (CRA) although the mechanism of hypoxia in CRA is different. While in CRA Resuscitation of the drowned victim due to ventricular fibrillation the cerebral circulation is immediately interrupted, in drowning cerebral hypoxia The European Resuscitation Council establishes an is progressive39. The duration of hypoxia and water algorithm taking into account the particularities of temperature are external determinants of brain damage drowning (Figure 3)41. The drowned victim dies mainly and survival: the longer duration of cerebral hypoxia from oxygen deficiency, so the priority in drowning is

274 Abelairas-Gómez C, et al. Emergencias 2019;31:270-280

oxygenation and ventilation. For this reason, cardiopul- Does not respond and does not breathe normally monary resuscitation (CPR) should begin with rescue breaths, ensuring adequate oxygenation, rather than compression41, with good airway management being a key aspect. Call for help and alert the emergency services (112) Two different scenarios can be identified: resuscitation in the aquatic environment and resuscitation on land. Since it is possible for the drowned victim to res- Open airway pond only with rescue breaths, it is recommended that with a drowned victim in the aquatic environment, rescue breaths begin before extraction to the mainland if 29,41,42 there is sufficient safety and training . The real pos- Give 5 breaths with oxygen supplement sibility of effective rescue breath in the aquatic environ- if possible ment has been documented, which, on the other hand, increases rescue time43. For this reason, it is recommended that the victim be removed as quickly as possible if he or she does not show signs of life after rescue brea- If there are no signs of life start CPR 30:2 thing in water29. The use of semi-rigid vessels would contribute to reducing intervention times, as well as providing the possibility of rescue breaths and compres- Apply an AED and follow the instructions sion on board44. Once on land, there are different techniques to Figure 3. Drowned victim resuscitation algorithm proposed by the open the airways, oxygenate and ventilate a drowned European Resuscitation Council (adapted from Truhlárˇ et al.41). victim in a CRA situation. In manikin simulation studies, mouth-to-mouth breathing has been shown to be more effective and faster than other noninvasive ventilation pulseless ventricular tachycardia accounted for less than methods45. However, the face mask and auto-inflam- 10%. Therefore, it is recommended to prioritize the ini- mable bag provide a barrier mechanism and could fur- tiation of CPR in the case of a single rescuer41. If there ther combat hypoxia by connecting to an external oxy- are several, CPR should be initiated by one rescuer whi- gen supply. Therefore, the use of the self-inflating bag le another rescuer dries the victim’s chest and uses the seems reasonable when two rescuers may be in charge defibrillator. of the airway, and its use by a single rescuer is conside- Due to the effect of submersion, hypothermia is red inappropriate45,46. As for supraglottic devices, they very likely to be present. In a study in which 43 cases may not be entirely appropriate for drowned victims of drowning were analysed, it was concluded that pro- due to decreased pulmonary distensibility and increased longed submergence in water > 6 ˚C has a negative airway resistance, reasons why some case studies dis- effect on survival and neurological damage. Considering courage their use in this patient profile47. In short, there this temperature as a prognostic threshold, the authors is no consensus on the most appropriate ventilatory established a decision scheme when rescuing a submer- method for a drowned victim, although there is eviden- ged victim based on submersion time (Figure 4)56. ce of the safety and effectiveness of rescue breathing However, establishing a decision scheme based solely without intubation in the pre-hospital setting48. Oxygen on water temperature and submersion time has its limi- therapy is recommended to be administered at 100% tations, since environmental factors, relative to the vic- as soon as possible42. tim or the treatment itself, can influence prognosis57. In Although oxygenation and breaths are a priority in another study with pediatric victims, the prognosis of drowning, the overall quality of CPR must be optimal. drowned persons in winter (0-8 ˚C water temperature) Studies with rescuers have shown that the quality of was better, but the duration of the longest CPR that compressions drops significantly after a water rescue, achieved good recovery of neurological activity was falling below 70% after the first minute of CPR49. It only 25 minutes. Thus, a decision scheme was propo- would be advisable that another rescuer other than the sed for children in CRA derived from drowning based one performing the rescue initiate CPR to ensure its on recovery or non-recovery of pulse after 30 minutes quality, or that it be relieved after the first minute. of advanced life support (Figure 5)51. Under simulated conditions, following an aquatic res- Knowing the patient’s temperature in the pre-hospi- cue, the use of automatic compression mechanisms has tal setting requires the use of thermometers capable of been shown to be useful for increasing the quality of recording low temperatures. Tympanic measurement compressions, since the lifeguard has high fatigue in- due to the presence of water in the acoustic cavities dexes50, although their impact on survival has not been should be avoided41. The hypothermic patient in CRA confirmed. should receive continuous CPR. The use of automatic Regarding the defibrillator, numerous studies repor- compression mechanisms is recommended in cases of ted a majority of non-defibrillable heart rhythms in severe hypothermia (< 28 ˚C) due to chest stiffness. choked samples35,51-55, while ventricular fibrillation and CPR should not be stopped unless there is clear eviden-

275 Abelairas-Gómez C, et al. Emergencias 2019;31:270-280

Is WATER TEMPERATURE < 6º c? submersion time, there are other aspects that could play a determining role. A better prognosis has been associated with young victims than with adults53,54. Yes No Another study carried out in 2013 obtained similar results, but events involving people under 18 were more Very unlikely survival/ Very unlikely survival/ frequently seen and assisted by witnesses before the resuscitation after > 90 min resuscitation after > 30 min arrival of the emergency services than in the adult of submersion of submersion group. In addition, the number of CPRs combining compressions and rescue breaths was also higher in the Figure 4. Scheme for decision making based on water tempe- case of minors55. These variations in initial handling rature proposed by Tipton MJ, Golden FS (adapted from may have accentuated prognostic differences attributed Tipton and Golden et al.56. to age39,53,55. On the other hand, a recent meta-analysis found no differences in the prognosis of drowned vic- ce that its application would be futile (putrefaction, tims regarding age, water temperature and the presen- massive presence of severe trauma, etc.)41. Although di- ce of eyewitness, associated with a better prognosis fferent publications consider the possibility of stopping only the short period of submersion, short latency to CPR in hypothermic patients with prolonged asphyxia, medical attention and drowning in salt water59. The the difficulty of determining the submersion time, the possible impact on heart rhythm survival has also been origin of the stop and the asphyxia time complicates studied. The studies conducted in this regard have the establishment of a decision protocol to stop CPR. shown contradictory results: in favour of the association Therefore, it is recommended to follow the premise between survival and initial defibrillable rhythm in that “no one is dead until they are hot and dead”. some53,55, and neutral results in other cases54. Therefore, although there are many variables that Prognosis seem to influence prognosis of the drowned victim, the time of submersion has a higher consensus. Since drowning is a multifactorial event and subject to multiple elements of confusion, it is difficult to defi- nitively establish those independent variables that are Hospital treatment key in the prognosis. As previously stated, different studies have considered water temperature51,56 and sub- Medical complications from drowning will usually mersion time9,51,52,56 as key exogenous factors in survival require monitoring and treatment in an intensive care and neurological damage. However, in the case of wa- unit (ICU). Acute lung injury is the predominant picture ter temperature, a recent study has not found an asso- and may require different therapeutic measures to en- ciation between this variable and the prognosis58. sure adequate oxygenation. In addition, hypoxia can In addition to the temperature of the water and result in different degrees of neurological affectation

CRA AND HYPOTHERMIA AFTER DROWNING 30 minutes of ALS

Recovery of pulse?

Yes No

Transfer to P-ICU Special circumstances? Motor vehicle or boat accident with air inside Immersion before submersion Winter Fast water flow Ventricular bradycardia or fibrillation at the beginning of ALS Ventricular bradycardia or fibrillation after 30 min of ALS

Yes No

Continue CPR, preferably ECMO Stop resuscitation Figure 5. Decision scheme for paediatric CRA after 30 min of advanced life support (adapted from Kieboom et al.51). ECMO: extracorporeal membrane oxygenation; CPR: cardiopulmonary resuscitation; ALS: advanced life support; P-ICU: pediatric intensive care unit.

276 Abelairas-Gómez C, et al. Emergencias 2019;31:270-280

and cause cardiocirculatory, haematological, renal and Table 2. Main complications derived from drowning electrolytic problems, which are generally transient Pulmonary complications (Table 2). Acute Lung Injury/Acute Respiratory Distress Syndrome Lung infection Acute lung injury and acute respiratory distress Neurological complications syndrome Various levels and duration of neurologic impairment Mild local damage Cardiocirculatory problems By definition, drowning is a respiratory problem by Disseminated intravascular coagulopathy 28 aspiration of water , which can lead to further com- Acute renal failure plications (Table 3). Respiratory distress is typically Electrolyte disorders manifested as dyspnea, tachypnea, cough, cyanosis Hypothermia and humid crackles at auscultation, as well as expul- sion of foam through the mouth in the most severe 39 cases of pulmonary edema. Initially, arterial blood ga- further . ses will show hypoxemia and metabolic acidosis (lactic In addition to the above, initial respiratory deterio- acid) and may evolve into mixed acidosis. Chest radio- ration may be aggravated by primary infections caused graphy at admission may vary from normal to locali- by a wide variety of microorganisms (Table 5) or asso- sed consolidations, perihilars or diffuse pulmonary ciated with ventilation. edema60. The clinical picture bears great similarities to acute Neurological complications lung injury (ALI) or acute respiratory distress syndrome (ARDS), with the main difference that, initially, drow- Neurological damage can range from mild tempo- ning affects only the lungs. ALI/ARDS following a rary cognitive dysfunction to a permanent vegetative drowning event may occur immediately after rescue or state. In comatose patients it is not possible to predict within 6-24 hours. In case of development of ALI/ the neurological prognosis until at least three days later, ARDS, adequate oxygenation of the patient must be using a combination of clinical examination (Glasgow ensured, with target oxygen saturation above 94%, Coma Scale), continuous electroencephalogram, neuroi- and normocapnia, especially if brain injury is suspec- maging (brain magnetic resonance) and neurophysiolo- ted. If there is an adequate level of consciousness, hi- gical tests (somatosensory evoked potentials), as well as gh-flow oxygen therapy using a mask or non-invasive biochemical markers such as neuronal specific enolase39. mechanical rescue breaths with continuous positive Regarding treatment, the level of evidence of neuro- pressure or bi-level if this is not sufficient can be used. protective measures is for the time being low or absent, Indications for endotracheal intubation and connection so the recommendations have been established by con- to invasive mechanical breaths are shown in Table 4. sensus. These include optimization of oxygenation and Although there are no specific randomized clinical trials maintenance of homeostasis, with close monitoring of in this subtype of patients, these individuals should be capnography, blood pressure, blood volume, osmosis treated, as in other ARDS cases, with positive pressure and patient temperature. In particular, chills and con- at the end of expiration and protective pulmonary vulsions, as well as non-convulsant status epilepticus, breaths (standard volume of 6 ml/kg ideal body weight should be prevented and treated39. and plateau pressure < 30 cmH2O)61. The use of extracorporeal membrane oxygenation Cardiocirculatory problems (ECMO) appears to be a good therapeutic option39, especially in victims who have not had CRA62. An inter- Low blood pressure is common immediately after national multicenter retrospective study documented resuscitation as a result of low cardiac output or vaso- 71% survival in victims of drowning without CRA, 57% plegia. Hypovolemia by extravasation of fluid to the al- in the case of CRA with spontaneous recovery of circu- veoli may also contribute in the context of drowning in lation and 23% in case of ECMO application during salt water, although this will depend on the amount of resuscitation62. The fact that the cohort of patients in water aspirated30. Since most victims are young and whom ECMO was applied during CPR had significantly healthy, transient hypotension will usually be corrected more hypothermic patients is a limitation to be taken spontaneously. into account when interpreting the results, as it could Diuresis control, organic perfusion (lactic acid) and have implied a longer submergence time and duration of asphyxia and, consequently, a worse prognosis. Table 3. Main causes of respiratory complications from However, in the absence of detailed prehospital data drowning such an association cannot be concluded. Similarly, the Water aspiration low prevalence of hypothermic patients in the other Aspiration of microorganisms and development of respiratory infection two cohorts suggests relatively short periods of sub- Aspiration of chemicals mersion, which may have favoured the results. Suction of solid material with airway obstruction Although positive results have been shown, the use of Swim-induced pulmonary edema ECMO in the drowned patient still needs to be studied Pulmonary edema and laryngospasm

277 Abelairas-Gómez C, et al. Emergencias 2019;31:270-280

Table 4. Indications for endotracheal intubation Table 5. Microorganisms frequently causing infections in Signs of neurological impairment or inability to protect drowning victims the airway. Aerobic Gram-positive Gram-negative aerobics Inability to maintain PaO2 > 60 mmHg or SpO2 > 90% despite high Streptococcus Pseudomonas flow supplemental oxygen therapy. Anaerobic Gram-positive Haemophilus

A PaCO2 >50 mmHg. Staphylococcus aureus Branhamella

PaCO2: carbon dioxide pressure; PaO2: oxygen pressure; SpO2: oxygen Clostridium Citrobacter saturation. Peptostreptococcus Burkholderia psudomallei Propionibacterium Francisella philomiragia Fungi Legionella hemodynamic monitoring are essential to guide fluid Aspergillus Anaerobic Gram-negative replenishment. There is no evidence on the use of spe- Pseudoallescheria boydii Escherichia coli cific fluid therapy, diuretics or water restriction. If hae- Scedosporium apiospernum Aeromonas modynamics is not restored with crystalloid infusion, Candida Klebsiella echocardiography may help decide on the use of ino- Bacteroides tropic or vasopressor agents29. However, there is also Enterobacter no specific evidence on the use of these drugs in this Chromobacterium violaceum context; the general premises for critical patients should be followed, carefully monitoring their use in case of hypothermia. Management of the patient’s temperature is a criti- Rhythm disorders, especially supraventricular arr- cal aspect that can determine prognosis39. Body tem- hythmias, are common in drowning victims and usua- perature should be measured as soon as possible, as lly resolve by correcting hypoxia and acidosis. In addi- spontaneous hypothermia at the time of admission to tion, in hypothermic victims, electrocardiographic ICU is a major predictor of unfavourable prognosis. alterations (lengthening of the PR, widening of the Overheating of the drowned victim should be progres- QRS, descent of the ST or elevation of the J point), ge- sive, and aggressive measures should be avoided39. nerally non-specific and transitory, may occur. Regarding therapeutic hypothermia, the recommendations are extrapolated from studies of asphyxia and 39 Disseminated intravascular coagulation CRA , since due to the scarce published literature on this procedure in the drowned patient, specific recommendations cannot be made65. A practical recommen- Although this is a common complication in the dation is to maintain a core temperature of 32 to 34 drowned patient, it has not been studied in depth. It is ˚C and allow the body temperature to stabilize after a believed to be induced by hypoxia, which promotes period of 12-72 hours of intensive care. Overheating the release of tissue plasminogen activator. This disor- should be progressive to a maximum of 0.5 ˚C/h39. der manifests itself with high concentrations of Both chills and hyperthermia should be avoided du- D-dimer and anti-plasmin antibodies, low concentra- ring all care (> 37 ˚C). tion of fibrinogen and lengthening of coagulation ti- mes63. For monitoring purposes, there is no characteris- tic thromboelastometric pattern. Conclusions

Acute renal failure Drowning is a public health problem and institu- tions should assume greater responsibility by allocating Analytical abnormalities in plasma and urine as well resources and funds, ensuring greater rigour in recor- as low glomerular filtrate rates may occur during the ding and producing statistics. More accurate reporting first 72 hours. Acute renal failure is relatively rare, more will encourage the implementation of effective preventi- common in severe drowning and in men. Its origin is ve measures in each context, as well as studies to assess multifactorial, due to acute tubular injury due to their effectiveness in terms of mortality. Currently, the hypoxia, abrupt osmotic overload in the distal tubule, installation of barriers restricting access to water, tea- renal vasoconstriction, rhabdomyolysis and hypother- ching in the school of skills in the aquatic environment mia. It is usually reversible and rarely requires renal re- and lifesaving, training in lifesaving and CPR to the en- placement therapy64. tire population and the establishment of safety regulations for navigation are considered effective. The key Electrolyte disorders prognostic factor in drowning is submersion time. Acute lung injury and hypoxia are the predominant and objective picture of therapeutic management. However, Electrolyte variation by aspiration/ingestion of both more research is needed to provide the best treatment fresh and salt water have been studied in animal mo- for these patients. dels. However, its real clinical importance is limited, since the redistribution of liquids in the body quickly Conflicting interests: The authors declare no conflicts of interest in re- restores electrolyte balance30. lation to this article. Hypothermia Contribution of authors: All authors have confirmed their authorship

278 Abelairas-Gómez C, et al. Emergencias 2019;31:270-280

in the author’s responsibilities document, publication agreement and Saf Promot. 2012;19:63-7. transfer of rights to EMERGENCIAS. 23 Zhu Y, Jiang X, Li H, Li F, Chen J. Mortality among drowning rescuers in China, 2013: a review of 225 rescue incidents from the Financing: The authors declare the non-existence of funding in relation press. BMC Public Health. 2015;15:631. to this article. 24 Venema AM, Groothoff JW, Bierens JJ. The role of bystanders during Article not commissioned by the Editorial Board and peer-reviewed rescue and resuscitation of drowning victims. Resuscitation. externally 2010;81:434-9. 25 Matthews BL, Franklin RC. Examination of a pilot intervention pro- Acknowledgements: We would like to thank Dr. Rodríguez-Núñez A, gram to change parent supervision behaviour at Australian public Dr. Rodríguez-Ruiz E and Dr. González-Gómez LM for their contribu- swimming pools. Health Promot J Aust. 2018;29:153-9. tions and critical reviews. Also to Dr. Varela-Casal C for her help in the 26 Pajunen T, Vuori E, Vincenzi FF, Lillsunde P, Smith G, Lunetta P. redesign of the figures. Unintentional drowning: Role of medicinal drugs and alcohol. BMC Public Health. 2017;17:388. 27 Stempski S, Schiff M, Bennett E, Quan L. A case-control study of References boat-related injuries and fatalities in Washington State. Inj Prev. 2014;20:232-7. 1 World Health Organization. Global report on drowning. Ginebra: 28 Van Beeck EF, Branche CM, Szpilman D, Model JH, Bierens JJLM. A World Health Organization: 2014. new definition of drowning: towards documentation and prevention 2 Stark DE, Shah NH. Funding and publication of research on gun vio- of a global public health problem. Bull World Health Organ. lence and other leading causes of death. JAMA. 2017;317:84-6. 2005;83:853-6. 3 Szpilman D, Webber J, Quan L, Bierens J, Morizot-Leite L, 29 Szpilman D, Bierens JJLM, Handley AJ, Orlowski JP. Drowning. N Engl Langendorfer SJ, et al. Creating a drowning chain of survival. J Med. 2012;366:2102-10. Resuscitation. 2014;85:1149-52. 30 Bierens JJLM, Lunetta P, Tipton M, Warner DS. Physiology of drow- 4 Suárez-García I, Sethi D, Hutchings A. Mortality due to injuries by ning: a review. Physiology. 2016;31:147-66. place of occurrence in the European region: analysis of data quality 31 Lunetta P, Modell JH, Sajantila A. What is the incidence and signifi- in the WHO mortality database. Inj Prev. 2009;15:275-7. cance of “dry-lungs” in bodies found in water? Am J Forensic Med 5 Lu TH, Lunetta P, Walker S. Quality of cause-of-death reporting using Pathol. 2004;25:291-301. ICD-10 drowning codes: a descriptive study of 69 countries. BMC 32 Liu Z, Zhang B, Wang XB, Li Y, Xi RG, Han F, et al. Hypertonicity Med Res Methodol. 2010;10:30. contributes to seawater aspiration-induced lung injury: Role of 6 Puigdefàbregas Serra A, Freitas Ramírez A, Gispert Magarolas R, hypoxia-inducible factor 1α. Exp Lung Res. 2015;41:301-15. Castellà Garcia J, Vidal Gutiérrez C, Medallo Muñiz J, et al. Las muer- 33 Jin F, Li C. Seawater-drowning-induced acute lung injury: From mo- tes con intervención judicial y medicolegal y su impacto en la esta- lecular mechanisms to potential treatments. Exp Ther Med. dística de causas de muerte en Cataluña. Rev Esp Med Legal. 2017;13:2591-8. 2017;43:13-9. 34 Modell J. Pre-hospital treatment: Aspiration. En: Bierens JJLM, editor. 7 Escuela Segoviana de Socorrismo, Asociación Española de Técnicos Drowning. Prevention, rescue, treatment. Heidelberg: Springer; en Salvamento Acuático y Socorrismo. Ahogamiento en España. 2014. p. 561-4. Informe provisional año 2018 (datos al 30/12/2018). (Consultado 35 Grmec S, Strnad M, Podgorsek D. Comparison of the characteristics 11-01-2019) Disponible en: https://goo.gl/wcYcZz and outcome among patients suffering from out-of-hospital primary 8 Fundación MAPFRE y Equipo multidisciplinar de investigadores y cardiac arrest and drowning victims in cardiac arrest. Int J Emerg profesores de Universidad de A Coruña, Universidad de Santiago de Med. 2009;2:7-12. Compostela, Universidad de Vigo y Asociación Española de Técnicos 36 Shattock MJ, Tipton MJ. ‘Autonomic conflict’: a different way to die en Salvamento Acuático y Socorrismo. Estudio sobre los ahogamien- during cold water immersion? J Physiol. 2012;590:3219-30. (http:// tos y otros eventos de riesgo vital en el entorno acuático-marino. doi.org/ 10.1113/jphysiol.2012.229864). (Consultado 20-12-2018) Disponible en: https://goo.gl/3yfq2o. 37 Tipton M. Cold water immersion. En: Tipton M, Wooler A, editores. 9 Panzino F, Quintillá JM, Luaces C, Pou J. Ahogamientos por inmer- The science of beach lifeguarding. Boca Raton, FL: Taylor & Francis sion no intencional. Analisis de las circunstancias y perfil epidemiolo- Group; 2016. p. 87-98. gico de las victimas atendidas en 21 servicios de urgencias españo- 38 Kenny D, Martin R. Drowning and sudden cardiac death. Arch Dis les. An Pediatr. 2013;78:178-84. Child. 2011;96:5-8. 10 Irish Water Safety. Irish Water Safety data report on drowning in the 39 Topjian AA, Berg RA, Bierens JJLM, Branche CM, Clarke RS, Friberg Republic of Ireland 1988-2012. Galway: Irish Water Safety, 2013. H, et al. Brain resuscitation in the drowning victim. Neurocrit Care. 11 Clemens T, Tamim H, Rotondi M, Macpherson AK. A population ba- 2012;17:441-67. sed study of drowning in Canada. BMC Public Health. 2016;16:559. 40 Golden F. Mechanisms of body cooling in submersed victims. 12 Lunetta P, Smith GS, Penttilä A, Sajantila A. Unintentional drowning Resuscitation. 1997;35:107-9. in Finland 1970-2000: a population-based study. Int J Epidemiol. 41 Truhlárˇ A, Deakin CD, Soar J, Khalifa GE, Alfonzo A, Bierens JJLM, et 2004;33:1053-63. al. European Resuscitation Council Guidelines for Resuscitation 2015: 13 Mahony AJ, Peden AE, Franklin RC, Pearn JH, Scarr J. Fatal, uninten- Section 4. Cardiac arrest in special circumstances. Resuscitation. tional drowning in older people: an assessment of the role of pre- 2015;95:148-201. (http://doi.org/10.1016/j.resuscitation.2015.07.017). existing medical conditions. Healthy Aging Res. 2017;6:7. 42 Schmidt AC, Sempsrott JR, Hawkins SC, Arastu AS, Cushing TA, 14 Bain E, Keller AE, Jordan H, Robyn W, Pollanen MS, Williams AS, et Auerbach PS. Wilderness medical society practice guidelines for the al. Drowning in epilepsy: A population-based case series. Epilepsy prevention and treatment of drowning. Wilderness Environ Med Res. 2018;145:123-6. 2016;27:236-51. 15 Vignac E, Lebihain P, Soulé B. Tracking fatal drownings in public 43 Winkler BE, Eff AM, Eff S, Ehrmann U, Koch A, Kähler W, et al. swimming pools: A retrospective multiscale investigation within Efficacy of ventilation and ventilation adjuncts during in-water-resus- France. Int J Aquat Res Educ. 2015;9:184-200. citation--A randomized cross-over trial. Resuscitation. 16 Idris AH, Bierens JJLM, Perkins GD, Wenzel V, Nadkarni V, Morley P, 2013;84:1137-42. et al. 2015 revised Utstein-style recommended guidelines for uni- 44 Barcala-Furelos R, Abelairas-Gomez C, Palacios-Aguilar J, Rey E, form reporting of data from drowning-related resuscitation: An Costas-Veiga J, Lopez-Garcia S, et al. Can surf-lifeguards perform a ILCOR advisory statement. Resuscitation. 2017;118:147-58. quality cardiopulmonary resuscitation sailing on a lifeboat? A qua- 17 World Health Organization. Preventing drowning. An implementa- si-experimental study. Emerg Med J. 2017;34:370-5. tion guide. Ginebra: World Health Organization; 2017. 45 Adelborg K, Dalgas C, Grove EL, Jørgensen C, Al-Mashhadi RH, 18 Brenner RA, Saluja G, Smith GS. Swimming lessons, swimming abili- Løfgren B. Mouth-to-mouth ventilation is superior to mouth-to-poc- ty and the risk of drowning. Inj Control Saf Promot. 2003;10:211-6. ket mask and bag-valve-mask ventilation during lifeguard CPR: a 19 Abächerli R. “Water Safety at School”. How water safety became randomized study. Resuscitation. 2011;82:618-22. part of switzerland’s national syllabus and how it is being taught. 46 Hood N, Webber J. Pre-hospital treatment: airway management skills World Conference on Drowning Prevention. Libro de resúmenes. and equipment for aquatic first responders. En: Bierens JJLM, editor. Vancouver, 2017. Drowning. Prevention, rescue, treatment. Heidelberg: Springer; 20 Rahman F, Bose S, Linnan M, Rahman A, Mashreky S, Haaland B, et 2014. p. 613-9. al. Cost-effectiveness of an injury and drowning prevention program 47 Baker PA, Webber JB. Failure to ventilate with supraglottic airways in Bangladesh. Pediatrics. 2012;130:1621-8. after drowning. Anaesth Intensive Care. 2011;39:675-7. 21 Franklin RC, Pearn JH. Drowning for love: the aquatic victim-ins- 48 Michelet P, Bouzana F, Charmensat O, Tiger F, Durand-Gasselin J, tead-of-rescuer syndrome: drowning fatalities involving those at- Hraiech S, et al. Acute respiratory failure after drowning: a retrospec- tempting to rescue a child. J Paediatr Child Health. 2011;47:44-7. tive multicenter survey. Eur J Emerg Med. 2017;24:295-300. 22 Turgut A. A study on multiple drowning syndromes. Int J Inj Contr 49 Abelairas-Gómez C, Romo-Pérez V, Barcala-Furelos R, Palacios-Aguilar

279 Abelairas-Gómez C, et al. Emergencias 2019;31:270-280

J. Efecto de la fatiga física del socorrista en los primeros cuatro mi- mas of search and rescue efforts in drowning incidents. Resuscitation. nutos de la reanimación cardiopulmonar posrescate acuático. 2011;82:799-800. Emergencias. 2013;25:184-90. 58 Quan L, Mack CD, Schiff MA. Association of water temperature and 50 Barcala-Furelos R, Abelairas-Gómez C, Romo-Pérez V, Palacios- submersion duration and drowning outcome. Resuscitation. Aguilar. Influence of automatic compression device and water rescue 2014;85:790-4. equipment in quality lifesaving and cardiopulmonary resuscitation. 59 Quan L, Bierens JJ, Lis R, Rowhani-Rahbar A, Morley P, Perkins GD. Hong Kong J Emerg Med. 2014;21:291-9. Predicting outcome of drowning at the scene: A systematic review 51 Kieboom JK,Verkade HJ, Burgerhof JG, Bierens JJLM, van Rheenen PF, and meta-analyses. Resuscitation. 2016;104:63-75. Kneyber MC, et al. Outcome after resuscitation beyond 30 minutes 60 Forler J, Carsin A, Arlaud K, Bosdure E, Viard L, Paut O, et al. in drowned children with cardiac arrest and hypothermia: Dutch na- Respiratory complications of accidental drownings in children. Arch tionwide retrospective cohort study. BMJ. 2015;350:418. (http://doi. Pediatr. 2010;17:14-8. org/10.1136/bmj.h418). 61 Tomicic V, Fuentealba A, Martínez E, Graf J, Batista Bores, J. 52 Ballesteros MA, Gutiérrez-Cuadra M, Muñoz P, Miñambres E. Fundamentos de la ventilación mecánica en el síndrome de distress Prognostic factors and outcome after drowning in an adult popula- respiratorio agudo. Med Intensiva. 2010;34:418-27. tion. Acta Anaesthesiol Scand. 2009;53:935-40. 62 Burke CR, Chan T, Brogan TV, Lequier L, Thiagarajan RR, Rycus PT, et 53 Claesson A, Lindqvist J, Herlitz J. Cardiac arrest due to drow- al. Extracorporeal life support for victims of drowning. Resuscitation. ning--Changes over time and factors of importance for survival. 2016;104:19-23. Resuscitation. 2014;85:644-8. 63 Schwameis M, Schober A, Schörgenhofer C, Sperr WR, Schöchl H, 54 Tobin JM, Ramos WD, Pu Y, Wernicki PG, Quan L, Rossano JW. Bystander Janata-Schwatczek K. Asphyxia by drowning induces massive blee- CPR is associated with improved neurologically favourable survival in car- ding due to hyperfibrinolytic disseminated intravascular coagulation. diac arrest following drowning. Resuscitation. 2017;115:39-43. Crit Care Med. 2015;43:2394-402. 55 Nitta M, Kitamura T, Iwami T, Nadkarni VM, Berg RA, Topjian AA, et al. 64 Gorelik Y, Darawshi S, Yaseen H, Abassi Z, Heyman SN, Khamaisi M. Out-of-hospital cardiac arrest due to drowning among children and Acute renal failure following near-drowning. Kidney Int Rep. adults from the Utstein Osaka Project. Resuscitation. 2013;84:1568-73. 2018;3:833-40. 56 Tipton MJ, Golden FS. A proposed decision-making guide for the 65 Suen KF, Leung R, Leung LP. Therapeutic Hypothermia for asphyxial search, rescue and resuscitation of submersion (head under) victims out-of-hospital cardiac arrest due to drowning: a systematic review based on expert opinion. Resuscitation. 2011;82:819-24. (http://doi. of case series and case reports. Ther Hypothermia Temp Manag. org/10.1016/j.resuscitation.2011.02.021). 2017;7:210-21. 57 Perkins GD. Rescue and resuscitation or body retrieval—The dilem-

280