Impact of climate change on water-related physical events, consequent human migration, and burden of drowning in India: An evidence synthesis.

Introduction: Disrupted weather patterns are associated with climate change. Between 2001 and 2018, nearly 74% of disasters were water-related, including floods and cyclones. Such water-related cataclysmic events increase the risk of drowning. We aimed to map evidence on the impact of climate change on water-related physical events, associated human migration, and drowning burden in India. Materials and Methods: We searched electronic databases, government reports, and relevant websites to map evidence on water-related physical events (including but not limited to sea-level rise, glacier bursts, lake bursts, floods, rainfall, cyclones, and droughts) and consequent human migration using narrative review approach, while drowning burden through scoping review approach. We summarized the results narratively. Results: Evidence from 48 studies and seven reports suggest that India will witness the greatest sea-level rise, significantly impacting poor coastal communities. An increase in droughts, cyclonic rainfall, storms, and floods, with increasing surface rainwater and streamflow water, due to melting glaciers is expected. Climate change-triggered migration is expected notably in northeast and south India, making farmers, drivers, street vendors, women, and youth most vulnerable. No direct evidence was identified on the impact of climate change, water-related disasters, meteorological events, or seasonal variations on drowning from India. Conclusion: Our study highlights a significant gap in the availability of context-specific and localized data to improve disaster response and strengthen public health systems, especially for areas most vulnerable to climate change. There is an urgent need to generate new knowledge and understanding of climate change, water-related or meteorological events, and seasonal variations' impact on drowning burden as the level of risk remains unknown.

Challenges of the minimum postmortem interval (PMImin) estimation in forensic scenarios: Is dental histology an alternative?

Postmortem interval (PMI) estimates the time since death. Teeth are perennial elements capable of remaining intact in taphonomic environmental circumstances. The objective was to evaluate the feasibility of estimating the minimum postmortem interval (PMImin) through histological analyses of dental tissues exposed to burial and drowning conditions, simulating common scenarios in forensic practice. A total of n = 99 teeth were analyzed and divided into four groups: control (T0), one month (T1), three months (T2), and six months (T3). The control sample comprised 10 teeth, while T1, T2 e T3 were divided into three different subgroups: controlled environment, buried, and drowned. For each subgroup, ten samples were used. Following exposure to taphonomic conditions, the specimens were processed, and histological sections were obtained. The two-way ANOVA test and the Tukey's post-hoc test were employed for the quantitative analysis of dentin collagen fibrils, revealing statistically significant differences (α = 5 %). This allowed for the estimation of the PMImin at three months by observing pixel counts exceeding 13e+05 in drowned teeth and greater than 8e+05 in buried teeth. Qualitative analysis revealed that the PMImin of drowned teeth was estimated at one month due to the absence of the periodontal ligament (PDL) and at six months due to the absence of predentin and partial degradation of the cementum. For buried teeth, the three-month PMImin was indicated by the absence of PDL and partial cementum degradation. The absence of pulp and remnants of predentin characterized the six-month PMImin. Qualitative and quantitative histological characteristics and parameters are potential to estimate PMImin in forensic scenarios spanning up to six months.

The epidemiology and outcomes of hospitalized drowning in Thai children: a national data analysis 2015-2019.

BACKGROUND: Drowning remains a common cause of death among children. However, the epidemiology and impact of drowning in Thailand was underexplored. This study aimed to analyze the epidemiology and clinical outcomes of pediatric drowning in Thailand and to determine the factors associated with the need for intubation and mortality. METHODS: Data derived from the Thai healthcare delivery system for the period between 2015 and 2019 were used to examine the monthly admissions, mortality rates, length of hospital stay, and the number of patients who received endotracheal intubation. Multivariate logistic regression analysis was employed to identify the risk factors associated with the need for intubation and mortality. RESULTS: Of the 4,911, 58.8% were under six years old, 63.5% were male, and 31.2% were from the Northeastern region. The majority drowned during April, which is the summer season in Thailand. Among these patients, 28.8% required intubation, with the highest proportion found in the 6-<12 years age group (35.9%). The independent risk factors for intubation were metabolic acidosis (adjusted odd ratio [aOR] 9.74; 95% confidence interval [CI] 7.14-13.29; p < 0.001) and pulmonary edema (aOR 5.82; 95%CI 3.92-8.65; p < 0.001). The overall mortality rate due to drowning was 12.6%. Factors significantly associated with mortality included in-hospital cardiac arrest (aOR 4.43; 95%CI 2.78-7.06; p < 0.001), and the presence of drowning-related complications, particularly renal failure (aOR 7.13; 95%CI 3.93-12.94; p < 0.001). CONCLUSION: Drowning admissions and mortality were highest among male children under six years old, occurring mainly during the summer season. Significant factors associated with intubation requirement included metabolic acidosis and pulmonary edema. The mortality was significantly associated with in-hospital cardiac arrest and drowning-related complications, particularly renal failure. TRIAL REGISTRATION: This is an observational study, does not include any intervention, and has therefore not been registered.

Using syndromic surveillance for unintentional and undetermined intent drowning surveillance in a large metropolitan area.

INTRODUCTION: A drowning definition is available for use with National Syndromic Surveillance Program (NSSP) data. However, its accuracy in capturing drowning emergency department and urgent care visits at the regional level is unknown. We tested the ability of the syndromic surveillance (SS) definition in capturing unintentional and undetermined intent drowning (UUID) and describe UUID SS visit trends in a large metropolitan area. METHODS: We applied the drowning definition to NSSP data from 2016 to 2022 for the 8-county metropolitan Houston region. We queried the dataset for UUID ICD-10-CM codes and manually reviewed the chief complaint (CC) and discharge diagnosis (DD) for SS visits. True-positives were calculated by dividing the number of UUID cases identified by UUID ICD-10-CM codes and CC/DD review by the total visits captured by the SS definition. Demographics and trends of UUID visits were calculated from 2018 to 2022 due to limited data from 2016 to 2017 in NSSP. RESULTS: 2,759 visits were captured by the SS definition. After case review, 2,019 (73.2%) had ICD-10-CM drowning codes of any intent; and 2,015 of those (99.8%) were classified as UUID. Of the remaining 740 cases with no ICD-10-CM codes that were pulled by the SS definition, 690 (93.2%) had a CC/DD diagnosis of drowning/submersion/underwater related to aquatic exposure. Taken together, 2,705 (98.0%) were true-positive UUID visits based on the SS drowning definition.. Children (aged < 18 years) constituted 79% of UUID visits. Black, White and Asian/Pacific Islander persons comprised 17%, 60% and 4% of UUID visits respectively. Rates of UUID visits were lowest in 2020. CONCLUSION: Syndromic surveillance is a novel and accurate method to conduct real-time drowning surveillance in a large metropolitan region.

Auditing learner driver information about floodwaters: An environmental scan of government issued resources in Australia.

INTRODUCTION: Vehicles driving, or being swept, into floodwaters is a leading cause of flood-related death. Establishing safe behaviors among learner drivers may reduce risk throughout their driving lifetime. METHODS: An environmental scan of publicly available government issued learner and driver handbooks across the eight Australian jurisdictions was conducted to identify information provided regarding floodwaters. Search terms included 'flood,' 'rain,' 'water,' and 'wet.' A visual audit of flood-related signage was also conducted. RESULTS: Twelve documents, across eight jurisdictions, were analyzed. Four jurisdictions' documents provided no information on flooding. Of the four jurisdictions that provided information, content varied. This included highlighting risks and discouraging entering floodwaters in a vehicle, including penalties associated with travel on closed roads, to advising depth and current checks if crossing a flooded roadway, with recommendations based on vehicle size (preference given to bigger vehicles, i.e., 4wds). Information on flood-related signage was found in one jurisdiction. DISCUSSION: Learner and driver handbooks represent a missed opportunity to provide flood safety information. Currently, information is not provided in all jurisdictions, despite flood-related vehicle drowning deaths of drivers and passengers being a national issue. Where information is presented, it is limited, often lacks practical guidance on how to assess water depth, current, and road base stability, and could better use evidence regarding the psychological factors underpinning, and behavioral prompts for performing, or avoiding, risky driving behavior during floods. CONCLUSIONS: The provision and content of information in learner driver and driver handbooks must be improved, particularly within the context of increasing flooding and extreme weather associated with the effects of climate change. PRACTICAL APPLICATIONS: We encourage all jurisdictions to provide practical information that draws on evidence-based risk factors and empirically established psychological factors for behavioral change to help establish safe driver behaviors around floods in the formative years of learning to drive.

Characteristics of drug-related deaths where individuals are found submerged in a bath or hot tub in the United Kingdom, 1997-2023.

INTRODUCTION: Recent media reports highlight that drug-related fatalities can occur while individuals are immersed in water in domestic settings. We aimed to determine the case characteristics, circumstances of death and type of implicated drugs among individuals dying due to unintentional drug-related causes found immersed in a bath or hot tub. METHODS: Retrospective cohort study in the United Kingdom using coronial records from the National Programme on Substance Abuse Deaths, 1997-2023. Information was available on decedent socio-demographics, characteristics of death and drugs implicated in death. RESULTS: One hundred fifty-six decedents were found immersed in the bath and six in a hot tub, a mean of 6.4 deaths per year (SD 3.7; range 1-13). Overall decedents were predominantly male (n = 94, 58.0%), of White ethnicity (n = 98, 60.5%) with a mean age of 40 years (SD 13; range 19-74). Only 12 decedents had any physical contributory factor to death other than poisoning or drowning. The median number of drugs detected at post-mortem was 3 (interquartile range 2, 5) with multiple drug toxicity implicated in the majority of cases (n = 90, 55.6%). The most common implicated drugs were heroin (n = 53, 32.7%), alcohol (n = 46, 28.4%) and cocaine (n = 33, 20.4%). DISCUSSION AND CONCLUSIONS: Over the last two decades in the United Kingdom there have been consistent numbers of unintentional drug-related deaths each year where individuals were found in a bath or hot tub. Polysubstance, opioid and alcohol use are overrepresented. Targeted advice to avoid bathing while intoxicated would appear to be an appropriate harm reduction message.

Child drowning in Indonesia: insights from parental and community perspectives and practices.

Child drowning is a significant public health issue in Indonesia, however, there is insufficient understanding of the issue and its associated risk factors within communities. This qualitative study aimed to explore parental and community perceptions and practices related to child drowning in Indonesian communities, and the perceived causes and risk factors. Seven focus group discussions (n = 62) were conducted with parents of children aged under-5 years and village community leaders in seven villages across all districts of Lombok Island, West Nusa Tenggara Province of Indonesia. Participants were recruited using purposive and snowball sampling. The thematic analysis, guided by Braun and Clarke's framework, used both deductive approaches, utilizing the Health Belief Model's constructs and inductive approaches. Most participants were unaware of the susceptibility of their children and others in their community to drowning and of the potential severe outcomes of drowning such as injury, disability and death. Participants generally associated drowning with beaches or open seas. Unprotected wells, tubs and buckets were identified as notable risk factors for child drowning in and around the home, shaped by some experience of child drowning incidents in the community. Supervision was identified as protective factor, however, mothers were often unavailable to supervise children, and supervision responsibility was often delegated to other family and community members. This study highlights the urgent need to enhance public awareness regarding children's susceptibility to drowning. Further exploration of local contexts and social determinants of drowning in Indonesian communities is crucial for ensuring effective water safety and drowning prevention strategies.

Drowning incidents precipitated by unusual causes (DIPUCs): A narrative review of their diagnoses, evaluation and management.

Drowning is a cause of significant morbidity and mortality worldwide. In most circumstances, the proximate cause is attributable to human factors, such as inexperience, fatigue, intoxication, or hazardous water conditions. The phenomenon of drowning incidents precipitated by unusual circumstances (DIPUCs) - either fatal or nonfatal - involving otherwise healthy individuals under generally safe conditions has not been comprehensively addressed in the medical and drowning literature to date. In this review, we discuss etiologies of DIPUCs, diagnostic clues, suggested workup, suggested postmortem testing, and implications for surviving patients and families. Identifying the cause of a drowning incident can be extremely challenging for the initially treating physician, relying perforce on historical context, environmental clues, physical exam, medical history, eyewitness accounts or video recordings. If no clear explanation for a drowning incident emerges despite a thorough investigation, clinicians should consider some of the less common diagnoses we describe in this paper, and, when appropriate, refer for an autopsy with postmortem molecular genetic testing. While time-consuming, these efforts can prove life-saving for some non-fatal drowning victims and the families of all victims of DIPUCs.

Next-Generation swimming pool drowning prevention strategy integrating AI and IoT technologies.

Drowning, as a leading cause of unintentional injury-related deaths worldwide, is a major public health concern. Swimming pool drowning is the main cause of most drowning incidents, and even with preventive measures such as surveillance cameras and lifeguards, tens of thousands of lives are lost to drowning every year. To address this issue, technology is being utilized to prevent drowning accidents and provide timely alerts for rescue. This paper explores the use of drowning prevention technology in embedded systems within enclosed environments, artificial intelligence (AI), and the Internet of Things (IoT) to decrease the likelihood of drowning incidents. Embedded systems play a critical role in such technology, enabling real-time monitoring, identification of dangerous situations, and prompt alerting. Due to their ease of installation and technical implementation, embedded devices are especially effective as drowning prevention devices. The image recognition capabilities of drowning prevention systems are enhanced through computer vision. Swimming pool drowning situations can be identified with the help of cameras and deep learning technologies, thereby increasing rescue efficiency. Finally, the IoT endows drowning prevention systems with comprehensive intelligence by connecting various devices and communication tools. Real-time alert transmission and analysis have become possible, enabling the early prediction of dangerous situations and the implementation of preventive measures, significantly reducing drowning incidents. In summary, the integration of these three types of drowning prevention technologies represents significant progress. The flexibility, accuracy, and intelligence of drowning prevention systems are enhanced through the incorporation of these technologies, providing robust support for safeguarding human lives and thus potentially saving tens of thousands of lives each year.

Turn Around, Don't Drown: A Systematic Review of Risk Factors for Motor Vehicle-Related Drowning in Floods and its Preventive Strategies.

OBJECTIVE: Exposure to flood, one of the most widespread disasters caused by natural hazards, increases the risk of drowning. Driving through flooded waterways is a cause of death due to flood-related drowning, especially in flood-prone areas. This study aimed at identifying the risk factors for motor vehicle-related drowning in floods and its prevention strategies. METHODS: International and national databases (WOS, PubMed, Scopus, Google Scholar, Magiran, and SID) were searched in the time span from 2000 to 2022. The studies investigating the risk factors relevant to land motor vehicle-related drowning in floods and its prevention strategies were included and analyzed using thematic content analysis. RESULTS: In 14 eligible studies, risk factors for land motor vehicle-related drowning in floods were identified and categorized in 3 subthemes: driver (3 categories: socio-demographic characteristics, knowledge and attitude, and beliefs); technology (1 category: land motor vehicles); and environment (2 categories: physical and socio-economic environment). Physical and structural measures (1 category: road safety improvement) and nonstructural measures (4 categories: research and education and raising awareness, risk management, promoting social-cognitive beliefs, and reconstruction and improvement of legal infrastructure) were proposed as drowning prevention strategies. CONCLUSIONS: The knowledge, attitude, and belief of the driver; the vehicle; and the environment were the most important risk factors of driving through flooded waterways. These factors should be considered when designing programs and physical and structural strategies for future interventions to curb this dangerous and potentially fatal driving behavior.

National trends in pediatric drowning - insights from the Israeli Ministry of Health registry-based cohort.

This study analyzes the epidemiology of pediatric drowning in Israel from 2010 to 2022, focusing on differences across age groups, sex, and regions. We conducted a retrospective cohort study using data from the Ministry of Health's administrative databases, covering all children aged 0-17 years who were seen in the emergency department, discharged after hospitalization, or died at the scene due to drowning, excluding cases of intentional harm or suicide. The primary outcome was the annual drowning rate per 100,000 children, categorized by age, sex, and region, along with hospitalization duration, intensive care unit admissions, and mortality rates. A total of 2101 drowning incidents were identified, with 9% resulting in death. Higher drowning rates were found in younger children (1-4 years) and teenagers (15-17 years), with notable differences by sex. Drowning rates were higher in coastal regions and more frequent during winter and spring. An increase in drowning rates was observed over the last 3 years of the study (2020-2022). Children hospitalized for more than 3 days had significantly higher mortality rates, both in general wards and intensive care units. CONCLUSIONS: Pediatric drowning is a persistent public health concern in Israel, with distinct seasonal, regional, age-specific, and sex-specific patterns in incidence and mortality. This study underscores the need for a comprehensive prevention strategy that includes year-round public education, environmental safety measures, and targeted interventions for high-risk groups to reduce drowning incidents and fatalities among children effectively. WHAT IS KNOWN: • Pediatric drowning represents a significant public health challenge globally, with varying rates. • In Israel, pediatric drowning is the second leading cause of death from all injury-related deaths. Thus far, the measures and interventions to reduce fatalities were not proven effective enough. WHAT IS NEW: • Pediatric drowning in Israel, with a 9% mortality rate, revealed a biphasic rate varied by sex and is higher in coastal regions and during winter and spring. • There was a notable increase in drowning incidents during the last 3 years of the study period (2020-2022), coinciding with the COVID-19 pandemic.

A critical assessment of the diatom test of rib bone marrow as a supporting procedure in the case of drowning.

Diatoms (Bacillariophyta), being single-celled photosynthetic organisms, are widely distributed in aquatic ecosystems around the globe. Their exoskeletons are resistant to most environmental factors as well as chemical reagents in laboratory settings. Moreover, the ornamentation featured on exoskeletons can be used to identify individual diatomaceous species. As a result, the detection of diatoms in the internal organs, and especially rib marrow, of corpses found in water can serve as an important tool for diagnosing drowning as the cause of death as long as passive postmortem penetration of diatoms into those organs is excluded. In the environmental experiments described in this paper, diatoms were detected in rib marrow only when contamination resulted from a mechanical breach of bone integrity and structure, irrespective of the residence time of bone material in the aquatic environment. Our research suggests that the presence of diatom in the rib marrow may be the gold standard in the diagnosis of drowning in the future. Our animal model research dispels one of the doubts, such as the possibility of passive penetration of diatoms into the bone marrow, which is still under discussion in the forensic medicine community.

Negative prior aquatic experiences and children's aquatic competency: Do parent perceptions differ from reality?

ISSUE ADDRESSED: Achieving aquatic competence is recommended for preventing childhood drownings, yet many children in Victoria, Australia do not meet aquatic benchmarks despite participating in swimming and water safety programs. While few studies have explored factors influencing aquatic competency development, negative prior aquatic experiences (NPAE) have surfaced as a potential influence. Research on children's NPAE has primarily focused on parental perceptions rather than the child's actual experiences. METHODS: Parents and children (aged 10-12 years) completed reliable surveys for background information and NPAE-related data. Children also completed aquatic competency assessments against benchmark standards. Chi-square tests determined relationships between NPAE and aquatic competency, and thematic analysis categorised themes related to perceptions of the child's NPAE. RESULTS: Most parents (82.9%) indicated their child had not had NPAE, while only half (51.0%) of children did not report NPAE. Children reporting NPAE often perceived incidents as nearly drowning (41%), encompassing swimming pool environments and underwater submersion. Similarly, parents reported varied situations, noting NPAE involving open water and the child's loss of control. Parent-reported NPAE was associated with children less likely to achieve knowledge, continuous swimming, and survival competency benchmarks (p < .05). Children reporting NPAE were less likely to achieve underwater competencies (p < .05). CONCLUSIONS: The disparity between parent and child perspectives of NPAE demonstrates the importance of considering both perspectives. This should assist in providing appropriate support for children to develop aquatic competencies. SO WHAT?: Using NPAE data, practitioners can customise swim teaching approaches to address and prevent NPAE, particularly as many children associate their NPAE with pools, the common setting for aquatic education.

Gaps in Education: A Cross-Sectional Survey Study of Knowledge of Advanced Lifesaving Interventions among Canadian Lifeguards.

Objective: The aim of this study was to assess lifeguards' knowledge retention of airway management, oxygen administration, and ventilation interventions following certification and employer-provided training. Methods: This cross-sectional study was conducted using an online survey administered between February and May 2024. A total of 1322 responses from Canadian lifeguards certified in airway management and oxygen administration were deemed eligible for analysis. The survey included 15 knowledge assessment questions, with data analyzed based on lifeguard experience and the date of last certification or in-service training. Results: The mean knowledge assessment score was 10.4 ± 2.2 (69.3 ± 14.6%), with the highest scores in the airway management category and the lowest in the oxygen administration category. Lifeguard experience significantly increased knowledge retention, whereas recertification showed no significant impact, and employer-provided training significantly decreased knowledge retention. Conclusions: The findings underscore the importance of lifeguarding experience in knowledge retention among lifeguards. Optional airway management and oxygen administration recertification, coupled with inconsistent in-service training, have created significant gaps in lifeguard education. This study identifies the need for regular, competency-based training delivered by qualified facilitators. Addressing these gaps is crucial for enhancing the effectiveness of lifeguards in emergency response and ensuring high-quality care for drowning victims.

Burden of unintentional drowning in Indonesia: insights from the Global Burden of Disease Study 2019.

INTRODUCTION: A high burden of unintentional fatal drowning has been reported in low- and middle-income countries. However, little is known about unintentional drowning in Indonesia. METHODS: This population-based retrospective cohort study analysed unintentional drowning data for Indonesia sourced from The Global Burden of Disease Study 2019. Estimates of trends, mortality rates, incidence rates, years lived with disability (YLDs) and disability adjusted life years were generated. RESULTS: A decline in unintentional drowning mortality rates was observed, with an average annual mortality rate of 2.58/100 000. Males were 1.81 (95% CI 1.79 to 1.84) times more likely than females to unintentionally drown. Average annual mortality rates were highest among the under-5 age group (9.67/100 000) and 70 and over (5.71/100 000 for males; 5.14/100 000 for females). Distributions of drowning deaths vary depending on region, with mortality rates higher in Papua, Kalimantan, Sulawesi, Maluku, Sumatra and Nusa Tenggara regions. DISCUSSION: While a decline in drowning mortality rates in Indonesia was identified between 2005 and 2019, mortality rates for unintentional drowning remained high among children under 5 years, the elderly population and those residing in Papua, Kalimantan, Sulawesi, Maluku, Sumatra and Nusa Tenggara, warranting further focused attention. CONCLUSION: A downward trend in the rate of unintentional drowning deaths in Indonesia is observed from 2005 onwards, with risk variation based on age, gender and region. The findings highlight the importance of addressing drowning as a cause of premature mortality and health system burden in Indonesia, including through enhancing drowning data collection systems and identifying drowning risk factors.

Homicide by drowning: a literature review and analysis of three cases.

Background: Homicide by drowning in adults is rare. Usually, marks of violence are found on both the victim and the perpetrator, unless the victim was under the influence of alcohol, drugs, or was unexpectedly forced or dragged into the water. Indeed, many cases of drowning in adults are believed to be accidental, but they may be the result of drunken fights or attempts to make the death appear ac-cidental. In order to define the manner of death, cooperation between the forensic pathologist and the investigators is mandatory. Indeed, the autopsy is important to distinguish homicide by drowning from other kinds of drowning. The purpose of this study is to highlight the features of homicide by drowning. Materials and Methods: Literature search was conducted using PubMed databases, using the following keywords: "(homicide) and (drowning)". 3 articles were included in the systematic review, in addition to 3 cases observed in our institute. Conclusions: Both external examination and autopsy findings and the results of the investigation are essential to differentiate a homicide by drowning from accidental ones. The low specificity and variability of external and internal findings, the possibility of atypical asphyctic and nonasphyctic pathophysiological mechanisms, whose nature is not detectable at postmortem examinations, makes the diagnosis of cause of death difficult and often based on exclusion criteria only. In complex cases only using a strict forensic method allows to use the essential tools to identify the real manner of death.

[Forensic characteristic of drowning cases in the Russian Federation for the period from 2013 to 2022]. / Sudebno-meditsinskaya kharakteristika sluchaev utopleniya v Rossiiskoi Federatsii s 2013 po 2022 god.

OBJECTIVE: To study forensic characteristic of drowning mortality cases in the Russian Federation for the period from 2013 to 2022. MATERIAL AND METHODS: Dynamics and territorial specificity of drowning (in absolute values and in terms of 100 thous. population), proportion of histological examinations, cases of ethanol detection in the blood upon the occurrence of death by drowning and the proportion of children under 14 years among deceased from drowning. RESULTS AND CONCLUSION: The evidence suggests the necessity for intersectoral approaches of preventive measures creation. The results of the study could be used to establish a monitoring system as part of a national water safety strategy.

Prehospital guidelines on in-water traumatic spinal injuries for lifeguards and prehospital emergency medical services: an international Delphi consensus study.

BACKGROUND: Trauma guidelines on spinal motion restriction (SMR) have changed drastically in recent years. An international group of experts explored whether consensus could be reached and if guidelines on SMR performed by trained lifeguards and prehospital EMS following in-water traumatic spinal cord injury (TSCI) should also be changed. METHODS: An international three-round Delphi process was conducted from October 2022 to November 2023. In Delphi round one, brainstorming resulted in an exhaustive list of recommendations for handling patients with suspected in-water TSCI. The list was also used to construct a preliminary flowchart for in-water SMR. In Delphi round two, three levels of agreement for each recommendation and the flowchart were established. Recommendations with strong consensus (≥ 85% agreement) underwent minor revisions and entered round three; recommendations with moderate consensus (75-85% agreement) underwent major revisions in two consecutive phases; and recommendations with weak consensus (< 75% agreement) were excluded. In Delphi round 3, the level of consensus for each of the final recommendations and each of the routes in the flowchart was tested using the same procedure as in Delphi round 2. RESULTS: Twenty-four experts participated in Delphi round one. The response rates for Delphi rounds two and three were 92% and 88%, respectively. The study resulted in 25 recommendations and one flowchart with four flowchart paths; 24 recommendations received strong consensus (≥ 85%), and one recommendation received moderate consensus (81%). Each of the four paths in the flowchart received strong consensus (90-95%). The integral flowchart received strong consensus (93%). CONCLUSIONS: This study produced expert consensus on 25 recommendations and a flowchart on handling patients with suspected in-water TSCI by trained lifeguards and prehospital EMS. These results provide clear and simple guidelines on SMR, which can standardise training and guidelines on SMR performed by trained lifeguards or prehospital EMS.

Population-based study of factors associated with severe paediatric drowning events in Maryland.

INTRODUCTION: Paediatric drowning is an injury associated with significant morbidity and mortality. OBJECTIVE: The objective is to describe drowning trends, including associations with inpatient hospitalisation or fatality, in a state-wide paediatric cohort to inform prevention strategies. METHODS: In this retrospective cohort study using the Health Services Cost Review Commission database, we used International Classification of Diseases, Tenth Revision (ICD-10) codes to identify patients aged 0-19 years with an outpatient (including emergency department) or inpatient medical encounter following a non-fatal or fatal drowning event between 2016 and 2019. Descriptive statistics and logistic regression were used to summarise the data and evaluate associations with inpatient hospitalisation or fatality. RESULTS: There were 541 medical encounters for drowning events, including 483 non-fatal outpatient encounters, 42 non-fatal inpatient encounters and 16 fatal cases. Overall, most patients were boys, 0-4 years, white and lived in urban settings. White children accounted for 66% of encounters among those aged 0-4 years, whereas non-white children accounted for 62% of visits among those aged 10-19 years. Non-white children were more likely than white children to experience a fatal drowning (OR 3.6, 95% CI: 1.2 to 11.5). Adolescents were more likely than younger children to be hospitalised (OR 3.1, 95% CI: 1.6 to 6.5) and had higher charges in outpatient (p=0.002) and inpatient settings (p=0.003). DISCUSSION: Our study revealed high fatality rates among non-white children and high admission rates among adolescents.