Drowning.

Drowning is responsible for considerable morbidity and mortality worldwide, and it is estimated that 90% of drownings are preventable. Drowning is defined as "the process of experiencing respiratory impairment from submersion/immersion in liquid." Emergency providers should focus on airway management and rapid delivery of oxygen to interrupt the drowning process and improve patient outcomes. Patients with minimal or no symptoms do not require any specific diagnostic workup, aside from physical examination and 4 to 6 hours of observation prior to discharge. Patients with more severe symptoms may present with rales and foamy secretions, and should be managed with high-concentration oxygen and positive airway pressure.

In-water resuscitation during a surf rescue: Time lost or breaths gained? A pilot study.

BACKGROUND: A technique called in-water resuscitation (IWR) was devised on a surfboard to ventilate persons who seemingly did not breathe upon a water rescue. Despite IWR still raises uncertainties regarding its applicability, this technique is recommended by the International Liaison Committee for Resuscitation (ILCOR). Thus, this study aimed to evaluate the feasibility of IWR with a rescue board before and during towing and, to compare rescue times and rescue-associated fatigue levels between rescues with rescue breath attempts and without (SR). METHODS: A randomized crossover pilot test was conducted: 1) IWR test with pocket mask and, 2) Conventional SR test. IWR tests were conducted using a Laerdal ResusciAnne manikin (Stavanger, Norway). Three groups of variables were recorded: a) rescue time (in s), b) effective ventilations during rescue, and c) rating of perceived effort (RPE). RESULTS: Focusing on the rescue time, the performance SR was significantly faster than IWR rescue which took 61 s longer to complete the rescue (Z = -2.805; p = 0.005). No significant differences were found between techniques for the RPE (T = -1.890; p = 0.095). In the IWR analysis, lifeguards performed an average of 27 ± 12 rescue breaths. CONCLUSION: The application of IWR on a rescue board is feasible both at the time of rescue and during towing. It shortens the reoxygenation time but delays the arrival time to shore. Both IWR and SR result in similar levels of perceived fatigue.

A quest for an integrated management system of children following a drowning incident: A review of the literature.

PURPOSE: Management of children following a drowning incident is based on specific interventions which are used in the prehospital environment, the emergency department (ED) and the Paediatric Intensive Care Unit (PICU). This paper presents a review of the literature to map and describe the management and interventions used by healthcare professionals when managing a child following a drowning incident. Of specific interest was to map, synthesise and describe the management and interventions according to the different clinical domains or practice areas of healthcare professionals. DESIGN AND METHODS: A traditional review of the literature was performed to appraise, map and describe information from 32 relevant articles. Four electronic databases were searched using search strings and the Boolean operators AND as well as OR. The included articles were all published in English between 2010 and 2022, as it comprised a timeline including current guidelines and practices necessary to describe management and interventions. RESULTS: Concepts and phrases from the literature were used as headings to form a picture or overview of the interventions used for managing a child following a drowning incident. Information extracted from the literature was mapped under management and interventions for prehospital, the ED and the PICU and a figure was constructed to display the findings. It was evident from the literature that management and interventions are well researched, evidence-informed and discussed, but no clear arguments or examples could be found to link the interventions for integrated management from the scene of drowning through to the PICU. Cooling and/or rewarming techniques and approaches and termination of resuscitation were found to be discussed as interventions, but no evidence of integration from prehospital to the ED and beyond was found. The review also highlighted the absence of parental involvement in the management of children following a drowning incident. PRACTICE IMPLICATIONS: Mapping the literature enables visualisation of management and interventions used for children following a drowning incident. Integration of these interventions can collaboratively be done by involving the healthcare practitioners to form a link or chain for integrated management from the scene of drowning through to the PICU.

Invasive pulmonary aspergillosis in a 4-year-old male following submersion in a manure pond.

Invasive pulmonary aspergillosis (IPA) is uncommon in immunocompetent patients, but rare cases have been described after nonfatal drowning, particularly in contaminated water sources. Given subacute disease manifestations, diagnostic difficulties and the rapidly progressive nature of this organism, its mortality rate approaches 50%. Clinicians must rely on nonculture-based biomarkers and imaging to inform early diagnosis. There are currently no recommendations regarding diagnostics or empiric therapy for mold infections in near-drowning patients. We report a fatal case of IPA in a 4-year-old male following submersion in a manure pond. Early serum biomarkers and empiric voriconazole should be strongly considered in all patients after near-drowning in contaminated water sources.

Children that survive drowning can suffer lung infections after inhaling water. The cause is usually bacteria (germs) that live in our nose, as well as the bacteria in the water itself. In dirty water, many different bacteria are present. Strong antibiotic medicines are usually given to treat or stop infections from happening after drowning. Molds (fungus germs) can also cause lung infections, but usually in people with weak infection-fighting ability. We report a case of a mold infection that spread from the lungs to the blood and brain which led to the death of a previously healthy boy after drowning in a pond of animal waste. These mold infections can be slow and then spread quickly, so testing and treating for it with antifungal medicine in addition to antibacterial medicine needs to be done as early as possible.

Drowning in Children and Predictive Parameters: A 15-Year Multicenter Retrospective Analysis.

BACKGROUND: Drowning is a serious and underestimated public health problem, with the highest morbidity and mortality reported among children. Data regarding pediatric outcomes of drowning are often inadequate, and data collection is poorly standardized among centers. This study aims to provide an overview of a drowning pediatric population in pediatric emergency department, focusing on its main characteristics and management and evaluating prognostic factors. METHODS: This is a retrospective multicenter study involving eight Italian Pediatric Emergency Departments. Data about patients between 0 to 16 years of age who drowned between 2006 and 2021 were collected and analyzed according to the Utstein-style guidelines for drowning. RESULTS: One hundred thirty-five patients (60.9% males, median age at the event 5; interquartile range, 3-10) were recruited and only those with known outcome were retained for the analysis (133). Nearly 10% had a preexisting medical conditions with epilepsy being the most common comorbidity. One third were hospitalized in the intensive care unit (ICU) and younger males had a higher rate of ICU admission than female peers. Thirty-five patients (26.3%) were hospitalized in a medical ward while 19 (14.3%) were discharged from the emergency department and 11 (8.3%) were discharged after a brief medical observation less than 24 hours. Six patients died (4.5%). Medium stay in the ED was approximately 40 hours. No difference in terms of ICU admission was found between cardiopulmonary resuscitation performed by bystanders or trained medical personnel ( P = 0.388 vs 0.390). CONCLUSIONS: This study offers several perspectives on ED victims who drowned. One of the major finding is that no difference in outcomes was seen in patients who received cardiopulmonary resuscitation performed by bystanders or medical services, highlighting the importance of a prompt intervention.

Drowning Accidents in a Spanish Pediatric Intensive Care Unit: An Observational Study for 29 Years.

INTRODUCTION: Drowning is one of the most frequent accidents in children. We aimed to describe demographic and epidemiological characteristics of drowned children who required admission to a pediatric intensive care unit (PICU) to identify risk factors to guide possible preventive measures to avoid severe drowning. METHODS: We conducted an observational study for 29 years (retrospective between 1991 and 2004; prospective between 2005 and 2019) that included all children (0-15 years old) requiring PICU admission after drowning. Data regarding patient characteristics, accident circumstances, and neurological outcomes at PICU discharge were analyzed. RESULTS: A total of 160 patients were included, with no significant decrease over the study period. There was a predominance of males (75%), young age (60%; 1-5 years), summer months (91.1%; May-September), tourists (14.12 [95% confidence interval, 9.2-21.7] times higher risk of drowning than residents), swimming pool accidents (88.8%), and inadequate supervision (77.9%). The mortality was 18.7%, and 7.5% of admitted children had severe neurological sequelae. The initial resuscitation maneuvers by accident witnesses were incorrect in nearly half of the patients in whom these could be analyzed. CONCLUSIONS: Emphasis should be placed on implementing preventive measures, focused on the described risk groups, and insisting on adequate supervision, swimming training programs, and training of the general population in safe rescue and cardiopulmonary resuscitation.

Pediatric submersion injuries: emergency care and resuscitation.

Drowning and submersion injuries are highly prevalent, yet preventable, causes of pediatric mortality and morbidity. 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, electrolyte 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 of pediatric drowning victims is provided, and risk factors, caveats in pediatric care, and factors affecting prognosis are also discussed.

Safe On-Boat Resuscitation by Lifeguards in COVID-19 Era: A Pilot Study Comparing Three Sets of Personal Protective Equipment.

INTRODUCTION: On-boat resuscitation can be applied by lifeguards in an inflatable rescue boat (IRB). Due to Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-COV-2) and recommendations for the use of personal protective equipment (PPE), prehospital care procedures need to be re-evaluated. The objective of this study was to determine how the use of PPE influences the amount of preparation time needed before beginning actual resuscitation and the quality of cardiopulmonary resuscitation (CPR; QCPR) on an IRB. METHODS: Three CPR tests were performed by 14 lifeguards, in teams of two, wearing different PPE: (1) Basic PPE (B-PPE): gloves, a mask, and protective glasses; (2) Full PPE (F-PPE): B-PPE + a waterproof apron; and (3) Basic PPE + plastic blanket (B+PPE). On-boat resuscitation using a bag-valve-mask (BVM) and high efficiency particulate air (HEPA) filter was performed sailing at 20km/hour. RESULTS: Using B-PPE takes less time and is significantly faster than F-PPE (B-PPE 17 [SD = 2] seconds versus F-PPE 69 [SD = 17] seconds; P = .001), and the use of B+PPE is slightly higher (B-PPE 17 [SD = 2] seconds versus B+PPE 34 [SD = 6] seconds; P = .002). The QCPR remained similar in all three scenarios (P >.05), reaching values over 79%. CONCLUSION: The use of PPE during on-board resuscitation is feasible and does not interfere with quality when performed by trained lifeguards. The use of a plastic blanket could be a quick and easy alternative to offer extra protection to lifeguards during CPR on an IRB.

A reappraisal of childhood drowning in a pediatric emergency department.

BACKGROUND: In the present study, we aimed to investigate the demographic and clinical features, laboratory and radiologic characteristics, management, and outcomes of pediatric drowning patients in order to identify predictors of hospital admission, and to evaluate the need for respiratory support, and prognosis. METHODS: In this retrospective chart review, children aged 0 to 18 years who presented to the pediatric emergency department due to drowning between July 2009 and September 2019 were included. Demographics, initial vital signs, clinical findings, laboratory and radiologic results, and the need for respiratory support or cardiopulmonary resuscitation in the emergency department were recorded. Subjects were divided into 6 groups using the Szpilman classification system. RESULTS: A total of 89 patients were enrolled. Among the children who were admitted to the hospital, initial Szpilman score, crepitations on lung auscultation, and pathologic chest X-ray (CXR) findings were higher and Glasgow Coma Score and oxygen saturation (SpO 2) levels were lower than those of children who were discharged from the emergency department. A Szpilman score of ≥4, a lactate level of >2 mmol/L, and pathologic CXR findings were identified as predictors of hospital admission. Of the 89 patients, 22 (24.7%) underwent non-invasive ventilation (NIV) treatment and were classified as grade 3 or 4 according to the Szpilman score. Length of stay in the pediatric intensive care unit (PICU) and in the hospital was lower in patients who underwent NIV. As the Szpilman score increased as of grade 3, a positive correlation was observed with lactate levels (p <0.001, r: 0.552) and the total length of stay in the hospital (p: 0.001, r : 0.491), both of which gradually increased. CONCLUSION: The Szpilman score was associated with the duration of hospital stay and the degree of hypoxia, so it could help the physician make rapid decisions on ventilation strategy. Application of NIV in the emergency department shortened the length of stay in the PICU and in the hospital, suggesting that it can be used more often in pediatric emergency settings.

Management for the Drowning Patient.

Drowning is "the process of experiencing respiratory impairment from submersion or immersion in liquid." According to the World Health Organization, drowning claims the lives of > 40 people every hour of every day. Drowning involves some physiological principles and medical interventions that are unique. It occurs in a deceptively hostile environment that involves an underestimation of the dangers or an overestimation of water competency. It has been estimated that > 90% of drownings are preventable. When water is aspirated into the airways, coughing is the initial reflex response. The acute lung injury alters the exchange of oxygen in different proportions. The combined effects of fluid in the lungs, loss of surfactant, and increased capillary-alveolar permeability result in decreased lung compliance, increased right-to-left shunting in the lungs, atelectasis, and alveolitis, a noncardiogenic pulmonary edema. Salt and fresh water aspirations cause similar pathology. If the person is not rescued, aspiration continues, and hypoxemia leads to loss of consciousness and apnea in seconds to minutes. As a consequence, hypoxic cardiac arrest occurs. The decision to admit to an ICU should consider the patient's drowning severity and comorbid or premorbid conditions. Ventilation therapy should achieve an intrapulmonary shunt ≤ 20% or Pao2:Fio2 ≥ 250. Premature ventilatory weaning may cause the return of pulmonary edema with the need for re-intubation and an anticipation of prolonged hospital stays and further morbidity. This review includes all the essential steps from the first call to action until the best practice at the prehospital, ED, and hospitalization.

Studying outcome predictors of drowning at the scene: Why do we have so few answers?

BACKGROUND: Identification of predictors of outcome at the scene of drowning events could guide prevention, care and resource utilization. This review aimed to describe where, what and how scene predictive factors have been evaluated in drowning outcome studies. METHODS: We reviewed studies reporting scene drowning predictors published between 2003 and 2019. Data extraction included study populations, data sources, predictor factors (victim, incident, rescue, resuscitation and hospital-related), outcome measures and type of analyses. RESULTS: Of 49 studies, 87.6% were from high-income countries, 57.1% used data from only one source (92.9% of these from either hospital or EMS), 73.5% included cases who received medical care and 53.1% defined outcomes as survival or death. A total of 78 different factors were studied; the most commonly studied group of factors described victim demographics, included in 42 studies (85.7%), followed by resuscitation factors, included in 30 studies (61.2%). Few studies described rescue (6.1%). The most frequent statistically significant single predictors of outcome known at the scene were submersion duration (evaluated in 19, predictor in 14) and age (evaluated in 31, predictor in 16). Only 38.7% of studies employed multivariable methods. CONCLUSIONS: Gaps to be addressed in drowning outcomes research include data from low- and middle-income countries, standardized definition of factors to allow evaluation across studies, inclusive study populations that can be generalized beyond those receiving medical care, study rescue and resuscitation factors, use of more meaningful outcomes (survival with good neurologic status) and advanced analyses to identify which factors are true predictors versus confounding variables.

Fifteen-minute consultation: Drowning in children.

Drowning is a significant cause of childhood morbidity and mortality globally. The underlying mechanisms vary with child development and most are modifiable to public health promotion strategies. This article serves to highlight some of the specific considerations for the clinical management of drowning in children, both prehospital and by the in-hospital paediatric resuscitation team. This includes changes to standard advanced paediatric life support in the presence of hypothermia.

Plastic blanket drowning kit: A protection barrier to immediate resuscitation at the beach in the Covid-19 era. A pilot study.

OBJECTIVE: Introducing a new, simple and inexpensive portable equipment for lifeguards, consisting of a pre-assembled full-size plastic blanket with a mask and HEPA filter, which could offer significant time-saving advantages to reduce COVID-19 risk transmission in the first few minutes of CPR after water rescue, avoiding the negative impact of delayed ventilation. METHOD: A pilot study was carried out to determine the feasibility of the pre-assembled kit of face-mask and HEPA filter adapted on a pre-set plastic-blanket. The first step consisted of washing hands, putting on safety glasses and gloves as the first personal protection equipment (PPE) and then covering the victim with an assembled plastic blanket. The second step consisted of 10 min of cardiopulmonary resuscitation (CPR) with PPE and plastic blanket, following the technical recommendations for ventilation during COVID-19. RESULTS: Ten rescuers took part in the pilot study. The average time to wear PPE and place the pre-assembly kit on the victim was 82 s [IC 58-105]. After 10 min the quality of the resuscitation (QCPR) was 91% [87-94]. Quality chest compressions (CC) were 22% better than ventilations (V). Most of the rescuers (60%) thought that placing the plastic blanket on the victim on the beach was somewhat simple or very simple. CONCLUSIONS: Resuscitation techniques in COVID-19 era at the beach have added complexities for the correct use of PPE. Plastic blanket plus basic ventilations equipment resource could be a new alternative to be considered for lifeguards to keep ventilation on use while reducing risk transmission.

Assessing the quality of CPR performed by a single lifeguard, two lifeguards and a lifeguard with a bystander after water rescue: a quasi-experimental trial.

BACKGROUND: High-quality cardiopulmonary resuscitation (CPR) could improve survival of drowning victims. The purpose of the study is to assess the impact of fatigue caused by water rescue on subsequent CPR quality and the influence of a bystander's participation on CPR quality in a lifeguard rescue. METHODS: This was a simulated quasi-experimental study with a sample of 14 lifeguards and 13 laypersons. Each lifeguard performed 2 min single-rescuer CPR as baseline measurement. In three separate trials, a single lifeguard swam 50 m to perform a water rescue in a pool and returned with the manikin another 50 m. After each rescue, 10 min of CPR was performed by a single lifeguard, two lifeguards or a lifeguard with a layperson with no CPR training. Paired t-test and repeated analysis of variance were used to analyse CPR quality variables. RESULTS: Baseline CPR quality was adequate for most measures except compression depth and re-expansion. After water rescue, the single lifeguard trial showed no significant differences compared with baseline. CPR score and ventilation score of the single-lifeguard trial was higher than that of the lifeguard-bystander trial (p=0.027, p<0.001). Both the two-lifeguard trial (p=0.025), and lifeguard-bystander trial (p=0.010) had a lower percentage of breaths with correct ventilation volume and higher percentage of breaths with excessive ventilation volume (p=0.007, p=0.011, respectively) than the single-lifeguard trial. No-flow time of the lifeguard-bystander trial was longer than other trials (p<0.001). CONCLUSIONS: Although CPR given by the lifeguard was not optimal, fatigue generated by a water rescue has no impact on the quality of subsequent CPR performed by a trained lifeguard for 10 min. Untrained bystanders assisting in CPR in a drowning event is unlikely to be helpful.

Drowning Classification: A Reappraisal of Clinical Presentation and Prognosis for Severe Cases.

BACKGROUND: Drowning is still a major cause of accidental death worldwide. In 1997, Szpilman proposed a classification of drowning that has become the reference. As considerable efforts have been made to improve prevention and care, it seemed appropriate to reassess the prognosis and clinical presentation of drowning patients more than 20 years after this first publication. The aim of this study is to provide a reappraisal of patients who need advanced health care and a precise description of their respective neurologic, respiratory, and hemodynamic profiles. METHODS: This retrospective study was conducted over four consecutive summer periods between 2014 and 2017 in ICUs located in France, French Polynesia, and the French Antilles. Patients were classified according to the drowning classification system proposed by Szpilman. RESULTS: During the study period, 312 drowning patients were admitted with severe clinical presentation (grades 2-6). All patients benefited from rapid extraction from the water (< 10 min for all) and specialized care (emergency medical services), starting from the prehospital period. Although the global hospital mortality was similar to that previously reported (18.5%), great differences existed among the severity grades. Respective grade mortalities were low for grades 2 through 5 (grade 2, 0%; grade 3, 3%; grade 4, 0%; grade 5, 2%), and the mortality for grade 6 remained similar to that previously reported (54%). These results confirmed that the occurrence of cardiac arrest after drowning is still bad prognosis. Conversely, for other grades, this study strengthens the importance of specialized intervention to interrupt the drowning process. CONCLUSIONS: On the basis of these results, drowning-related cardiac arrest is still the prognosis cornerstone. For other victims, the prognosis was better than previously expected, which strengthens the importance of specialized intervention to interrupt the drowning process.

Is it feasible "scoop and run while playing" resuscitation on a rescue water craft? A randomized simulation study with lifeguards.

OBJECTIVE: Response time is a predictive factor for survival of drowning victims and lifesaving. Rescue Water Craft (RWC) are lifeboats very common in lifeguards operations. The aim of this study was to analyze the feasibility of providing effective mouth-to-mouth ventilations and/or cardiopulmonary resuscitation (CPR) on the RWC while sailing at different speeds. METHOD: A quasi-experimental cross-over block design was used to test during one minute efforts the effectiveness of Mouth to Mouth ventilation (MM-only) and CRP, at the beach and sailing at two diferents speeds 5 knots(kn) and 10 kn with calm sea. Quality CPR reference were 2015 ERC guidelines. RESULTS: The data obtained from 13 lifeguards were included, that means that 78 resuscitation test were completed. The MM-only performance skills reached 69.7% ± 40.4 for 5 kn and 60.0% ± 41.8 for 10 kn (p = .59). For full CPR, performance was 74.4% ± 24.2 and 68.5% ± 23.9 respectively. Quality of MM and CPR decreased, not significantly, while sailing at 5 kn and 10 kn [(Q-MM; 5 kn: 59.9% ± 37.8 vs. 10 kn: 43.2% ± 41.4, p = .42)(Q-CPR; 5 kn: 64.8% ± 21.2 and 10 kn: 60.6% ± 21.0, p = .44)]. MM-only and CC variables were significantly worse on RJS when compared with resuscitation at the beach (p < .05). A trend for better results by lifeguards previously training on RJS was observed. CONCLUSIONS: Resuscitation techniques on board of a RWC are feasible and therefore they could be an option for lifeguards when their training, sea conditions, distance and the victim's characteristics allow it. CPR maneuvers may be highly effective at 10 kn, both for MM-only and CPR, however, the quality of the ventilations dramatically worsen with increasing speed.

Childhood Drowning: Review of Patients Presenting to the Emergency Departments of 2 Large Tertiary Care Pediatric Hospitals Near and Distant From the Sea Coast.

OBJECTIVE: Drowning is a leading cause of death among infants and toddlers. Unique physiological and behavioral factors contribute to high mortality rates. Drowning incidents predominantly occur during warmer months and holidays. The aim of this study was to describe the characteristics of pediatric drowning victims who attended 2 different emergency departments (EDs), 1 near and 1 distant from the sea coast, to recognize risk factors, complications, causes of death, and the educational needs of families and caregivers. METHODS: Retrospective cohort analysis of incident history, clinical presentation, treatments, and outcomes of drowning victims was performed. Data were analyzed both by age group and proximity of institution to the sea coast. RESULTS: From 2005 to 2015, 70 drowning patients presented to the 2 institutions; there was no difference in incident history or outcomes based on proximity to the sea coast. Fifty-six percent of patients were younger than 6 years, the majority drowning in pools. More of the older children drowned in the sea (48% vs 23%). Half of all patients were treated and followed in the ED or ward, and the other half were treated in the pediatric intensive care unit; 12 suffered severe complications, including 5 diagnosed with brain death. Cardiopulmonary resuscitation was performed in 80% of the fatal group and 23% of the nonfatal group (P = 0.006). Seven children who experienced a cardiac arrest with hypothermia were treated before arrival in the ED, and 5 had ongoing cardiac arrest upon arrival in the ED (these were the 5 suffering brain death). DISCUSSION: Most of patients younger than 6 years drowned in swimming pools, suggesting that parents are perhaps less vigilant in these circumstances, even though they may remain in close proximity. Active adult supervision entails attention, proximity, and continuity. Educational efforts should be aimed at reminding parents of this, especially in the summer months.

Pediatric Drowning: A Standard Operating Procedure to Aid the Prehospital Management of Pediatric Cardiac Arrest Resulting From Submersion.

OBJECTIVES: Drowning is one of the leading causes of death in children. Resuscitating a child following submersion is a high-pressure situation, and standard operating procedures can reduce error. Currently, the Resuscitation Council UK guidance does not include a standard operating procedure on pediatric drowning. The objective of this project was to design a standard operating procedure to improve outcomes of drowned children. METHODS: A literature review on the management of pediatric drowning was conducted. Relevant publications were used to develop a standard operating procedure for management of pediatric drowning. RESULTS: A concise standard operating procedure was developed for resuscitation following pediatric submersion. Specific recommendations include the following: the Heimlich maneuver should not be used in this context; however, prolonged resuscitation and therapeutic hypothermia are recommended. CONCLUSIONS: This standard operating procedure is a potentially useful adjunct to the Resuscitation Council UK guidance and should be considered for incorporation into its next iteration.