[Drowning-induced hyperfibrinolytic disseminated intravascular coagulation].

This article summarizes the current knowledge of drowning-induced hyperfibrinolytic disseminated intravascular coagulation. Drowning induces respiratory failure with ensuing cardiac arrest, hypoxaemia and ischaemia. A coagulopathy is induced by ischaemia, acidosis and hypothermia, and clinically the patient develops uncontrolled bleeding due to hyperfibrinolysis. A rapid diagnostic approach is required to recognize this hyperfibrinolytic state, since initiation of treatment with antifibrinolytics and fibrinogen concentrate may bring this life-threatening condition to cessation.

Brain injury after moderate drowning: subtle alterations detected by functional magnetic resonance imaging.

To describe cerebral (structural and functional MRI) and neuropsychological long term changes in moderate drowning victim's compared to healthy volunteers in working memory and motor domains. We studied 15 adult drowning victim's in chronic stage (DV - out of 157 eligible cases of sea water rescues with moderate drowning classification) paired to 18 healthy controls (HC). All participants were investigated using intelligence, memory, and attention neuropsychological standard tests and underwent functional (motor and working memory tasks) and structural magnetic resonance imaging (MRI) in a 3 T system. All images were preprocessed for head movement correction and quantitative analysis was performed using FSL and freesurfer software packages. We found no between group differences in neuropsychological assessments. No MRI brain lesion was observed in patients, neither difference on morphometric parameters in any cortical or subcortical brain structure. In constrast, functional MRI revealed that patients showed increased brain response in the motor (left putamen and insula) and memory (left cuneus and lingual gyrus - not the classical memory network) tasks. Functional brain changes in motor and visual brain regions in victims of moderate drowning may indicate reduced brain reserve, despite the lack of structural and behavior alterations. More attention should be given to investigate ageing effects in this nonfatal drowning group.

Drowning In The Adult Population: Emergency Department Resuscitation And Treatment.

Drowning is a global problem that affects all populations. The events leading up to and the sequelae from a drowning incident vary greatly based on numerous factors, but the primary physiologic insult is always hypoxia. This is the starting point for all morbidity and mortality, and it must remain the focus of treatment. This issue discusses the initial resuscitation and treatment of adult drowning patients in the emergency department. Primary focus is placed on the key components of pathophysiology that require immediate attention. From there, evidence is presented to help guide the management of associated clinical concerns such as hypothermia, mechanical ventilation, and traumatic injuries, and to help form safe and reasonable disposition plans.

Hypertonicity contributes to seawater aspiration-induced lung injury: Role of hypoxia-inducible factor 1α.

Drowning is an important public health problem, but the mechanism of acute lung injury induced by near-drowning is rarely reported. The aim of this study is to investigate the role of hypertonicity and HIF-1α in seawater aspiration-induced lung injury. Diverse solutions were used to study the effect of hypertonicity on hypoxia, inflammation, vascular leakage, edema, and HIF-1α expression in lungs of rats. The relationship between hypertonicity and hypoxia, when they induced HIF-1α, was studied and the roles of ATM, PI3K, and p38 in the course of hypertonicity inducing HIF-1α were investigated. At last, our conclusion was verified with HIF-1α inhibitor and inducer in seawater aspiration rats. The results showed that hypertonicity, but not isotonicity and hypotonicity, promoted hypoxia, inflammation, vascular leakage, edema, and HIF-1α expression in lungs. Hypertonicity not only induced HIF-1α in a time- and dose-dependent manner but also could increase HIF-1α synergistically with hypoxia in AEC. Furthermore, hypertonicity increased HIF-1α by promoting its mRNA expression through both ATM and PI3K activation and by suppressing its protein degradation through p38 activation. During hyperosmotic stress, the increased HIF-1α promoted the production of the inflammatory cytokines in NR8383 and elevated monolayer permeability through increasing VEGF in RLMVEC. In conclusion, hypertonicity induced by aspirated seawater aggravated lung injury through increasing HIF-1α which promoted inflammation and edema in lung tissues in rats.

Pediatric submersion injuries: emergency care and resuscitation.

Drowning and submersion injuries are highly prevalent, yet preventable, causes of childhood mortality and morbidity. Although much of the resuscitation of the drowning pediatric victim is basic to all respiratory and cardiac arrest situations, there are some caveats for treatment of this type of injury. Risk factors for drowning victims include epilepsy, underlying cardiac dysrhythmias, hyperventilation, hypoglycemia, hypothermia, and alcohol and illicit drug use. Prehospital care should focus on restoring normal ventilation and circulation as quickly as possible to limit the extent of hypoxic insult. Diagnostic testing for symptomatic patients may include blood glucose level, arterial blood gas level, complete blood count, electrolytes levels, chest radiography, and cardiorespiratory monitoring with pulse oximetry and a rhythm strip. In this review, passive external, active external, and active internal rewarming techniques for treatment of hypothermic patients are discussed. A systematic approach to treatment and disposition or admission of pediatric drowning victims is also included, with extensive clinical pathways for quick reference.

Pediatric near-drowning and drowning.

Childhood water submersion remains a major public health problem. The aim of this article is to present an updated overview of the topic with data from our region and special attention to prevention strategies. Children less than 5 years and males are particularly at risk. Infants are at higher risk of drowning in bathtubs, toilets, or washing machines, while most drowning in older children occurs in swimming pools. Poor supervision by inexperienced caregivers is a common factor and contributes to most deaths. Adolescents drown more often during outdoor water activity. Acute management should start as soon as possible in order to prevent unfavorable neurological outcome. Cardio-pulmonary resuscitation should be started at the scene. Most children who were rescued quickly will recover neurologically intact. Restricting access to water and close adult supervision are paramount in preventing near-drowning and drowning. High-risk groups, such as new or young parents, and lower socioeconomic families, should be targeted by such prevention programs.

"Not waving, drowning". Asphyxia and torture: the myth of simulated drowning and other forms of torture.

The article will give a brief introduction to what we understand by the term Asphyxiation. The main focus will then turn to how Asphyxiation is used as a method of torture, (often euphemistically called a "method of interrogation") with an overview of wet methods such as immersion in water or the pouring of water over the mouth and nose, and dry methods such as the use of bags/sacks/masks and how exacerbating factors such as the use of contaminants or irritants are used. The recently published International Forensic Expert Group Statement on Hooding will be introduced and the notion will be explored that during socalled 'enhanced interrogation' asphyxiation or drowning can be "simulated."

Drowning.

Approximately 500,000 deaths due to drowning are reported annually, 30,000 of which are reported in Europe. Because of the relatively low incidence of drowning victims at emergency departments, most emergency physicians do not routinely handle drowning victims. Although confusion regarding the classification and pathophysiology of drowning could be reduced by following the Utstein style consensus, the application of therapeutic modalities and, most important, the estimation of probable prognostic outcomes remain difficult for emergency physicians. This article presents an overview of the classification, pathophysiology, emergency-department treatment and prognostic outcomes of drowning accidents.

Sea drowning: a case report and review of the literature.

400,000 incidents of sea drowning take place every year. We report the case of a woman, 34 years old, attended on the beach by external hospital emergency services after suffering immersion in seawater resulting in drowning due to acute respiratory failure. She was admitted to the critical care unit and an emergency fiberoptic bronchoscopy was performed, extracting a large quantity of sand and algae. The respiratory function improved and FiO2 requirements were gradually reduced following the procedure. After 8 days of mechanical ventilation the patient was extubated, with good clinical tolerance and was transferred to a ward.

Failure to ventilate with supraglottic airways after drowning.

We report the failure of an i-gel and an Ambu AuraOnce supraglottic airway to ventilate a drowning victim. Failure was attributed to changes in lung physiology following submersion and inhalation of water that may have required ventilation pressures up to 40 cmH2O to treat the victim's hypoxaemia. The ease of use and rapid insertion of supraglottic airways without interrupting cardiac compression has prompted recommendations for their use during resuscitation. The relatively low leak pressures attainable from many supraglottic airways, however may cause inadequate lung ventilation and entrainment of air into the stomach when these devices are used in drowning victims.

Feasibility of pulse oximetry in the initial prehospital management of victims of drowning: a preliminary study.

AIM: Immediate delivery of oxygen is the most important treatment for victims of drowning at the rescue site. Monitoring oxygen saturation with pulse oximetry is potentially useful, but its use may be limited by poor peripheral perfusion due to hypothermia. This preliminary study explores the feasibility of pulse oximetry in simulated minor drowning scenarios. MATERIALS AND METHODS: Six different pulse oximeters were tested on ten healthy volunteers after brief submersion, after ten minutes of swimming in a swimming pool (warm water, temperature 21°C), and in the sea (cold water, temperature 16°C). A measured oxygen saturation reading ≤ 94% was assumed to be incorrect. RESULTS: There was considerable variability between each pulse oximeter. In warm water, 5.8% of measurements were outside the predicted range (8.3% after submersion, 3.3% after swimming), compared to 34% in cold water (20% after submersion, 48% after swimming). The spurious measurements came from two pulse oximeters in warm water, but from all six in cold water. The best and worst performing pulse oximeters showed 5% and 33% measurements respectively outside the predicted range. CONCLUSION: The performance of pulse oximeters varies considerably in healthy volunteers submersed or immersed in warm or cold water. Further studies are needed to understand these differences.

[Out-of-hospital treatment in case of drowning].

INTRODUCTION: Drowning is a leading preventable cause of unintentional morbidity and mortality. The dominant pathophysiological mechanism of drowning includes the development of acute hypoxia. FIRST AID: The rescue procedure of a drowning person includes careful pulling the victim out of the water, examination, maintenance of the airways passable and urgent transfer to hospital. BASIC LIFE SUPPORT: The first and most important treatment option of a drowning victim is the provision of ventilation which increases the chances of survival. As soon as the unresponsive victim is removed from the water, the lay rescuer should immediately begin chest compressions and provide cycles of ventilations and compressions. Some recent investigations have revealed that exterior compression of the chest is a necessary measure even in a situation when bystanders cannot provide airway. It is recommended to train bystanders to provide basic life support and apply automated external defibrillator in a drowning person whenever indicated and as early as possible. ADVANCED LIFE SUPPORT: In drowning, the victim with cardiac arrest requires advanced life support, including an early intubation. Extended medical measures, which are primarily provided by medical professionals, include cervical spine immobilization in case a spinal injury is suspected, or, establishment of the ventilation with oxygen, emergency transport, application of reanimation and advanced vital support measures.

A proposed decision-making guide for the search, rescue and resuscitation of submersion (head under) victims based on expert opinion.

There is some confusion, and consequent variation in policy, between the agencies responsible for the search, rescue and resuscitation of submersion victims regarding the likelihood of survival following a period of submersion. The aim of this work was to recommend a decision-making guide for such victims. This guidance was arrived at by a review of the relevant literature and specific case studies, and a "consensus" meeting on the topic. The factors found to be important for determining the possibility of prolonged survival underwater were: water temperature; salinity of water; duration of submersion; and age of the victim. Of these, only water temperature and duration are sufficiently clear to form the basis of guidance in this area. It is concluded that if water temperature is warmer than 6°C, survival/resuscitation is extremely unlikely if submerged longer than 30 min. If water temperature is 6°C or below, survival/resuscitation is extremely unlikely if submerged longer than 90 min.

Extracorporeal circulation for rewarming in drowning and near-drowning pediatric patients.

Drowning and near-drowning is often associated with severe hypothermia requiring active core rewarming.We performed rewarming by cardiopulmonary bypass(CPB). Between 1987 and 2007, 13 children (9 boys and 4 girls) with accidental hypothermia were rewarmed by extracorporeal circulation (ECC) in our institution. The average age of the patients was 3.2 years. Resuscitation was started immediately upon the arrival of the rescue team and was continuously performed during the transportation.All patients were intubated and ventilated. Core temperature at admission ranged from 20 to 29°C (mean 25.3°C). Connection to the CPB was performed by thoracic (9 patients) or femoral/iliac means (4 patients). Restoration of circulation was achieved in 11 patients (84.6%). After CPB termination two patients needed an extracorporeal membrane oxygenation system due to severe pulmonary edema.Five patients were discharged from hospital after prolonged hospital stay. During follow-up, two patients died(10 and 15 months, respectively) of pulmonary complications and one patient was lost to follow-up. The two remaining survivors were without neurological deficit.Modes of rewarming, age, sex, rectal temperature, and serum electrolytes did not influence mortality. In conclusion,drowning and near-drowning with severe hypothermia remains a challenging emergency. Rewarming by ECC provides efficient rewarming and full circulatory support.Although nearly half of the children may survive after rewarming by ECC, long-term outcome is limited by pulmonary and neurological complications.

Imaging the human microcirculation during cardiopulmonary resuscitation in a hypothermic victim of submersion trauma.

The microcirculation is essential for delivery of oxygen and nutrients to tissue. However, the human microvascular response to cardiopulmonary resuscitation (CPR) is unknown. We report on the first use of sidestream dark field imaging to assess the human microcirculation during CPR with a mechanical chest compression/decompression device (mCPR). mCPR was able to provide microvascular perfusion. Capillary flow persisted even during brief mCPR interruption. However, indices of microvascular perfusion were low and improved vastly after return of spontaneous circulation. Microvascular perfusion was relatively independent from blood pressure. The microcirculation may be a useful monitor for determining the adequacy of CPR.

Management of water incidents: drowning and hypothermia.

Dangers exist wherever water is present, and death resulting from submersion in water is likely to occur rapidly. This article discusses the management of drowning and hypothermia. Information on water hazards and preventive measures, the risks associated with rescuing people from water, and the pathophysiology of drowning and hypothermia is provided, enabling practitioners to translate theory into practice. The emphasis of first aid in this setting is on quick, effective action, including alerting the emergency services and maintaining the safety of all potential rescuers.