Multi-organ involvement caused by Scedosporium apiospermum infection after near drowning: a case report and literature review.

BACKGROUND: Scedosporium apiospermum (S. apiospermum) is a rare fungal pathogen that causes disseminated infections. It rarely affects immunocompetent individuals and has a poor prognosis. CASE PRESENTATION: A 37-year-old woman presented with multiple lesions in the lungs, brain, and eyes, shortly after near drowning in a car accident. The primary symptoms were chest tightness, limb weakness, headache, and poor vision in the left eye. S. apiospermum infection was confirmed by metagenomic next-generation sequencing (mNGS) of intracranial abscess drainage fluid, although intracranial metastases were initially considered. After systemic treatment with voriconazole, her symptoms improved significantly; however, she lost vision in her left eye due to delayed diagnosis. CONCLUSION: While S. apiospermum infection is rare, it should be considered even in immunocompetent patients. Prompt diagnosis and treatment are essential. Voriconazole may be an effective treatment option.

Transient changes in the ST-T waveform mimicking myocardial infarction in a child with near-drowning: a case report.

Drowning is a common cause of childhood morbidity and mortality worldwide. Anoxia, hypothermia, and metabolic acidosis are mainly responsible for this morbidity. Drowning may lead to multiple organ damage, especially cardiac damage, in cases in which severe hypothermia and hypoxemia occur. We report a case of a 4-year-old girl who was admitted to our hospital's Emergency Department because of drowning. She had elevated troponin I concentrations and ST-segment elevation with T wave inversion. However, cardiovascular computed tomography showed no obvious abnormalities in the coronary arteries. We suggest that cardiac damage in this situation is caused by coronary artery spasms. To the best of our knowledge, this is the first case of cardiac damage with electrocardiographic changes after drowning in a preschool child.

Perforating Calcinosis Cutis as a Complication of Intraosseous Fluid Infusion in the Setting of a Near-Drowning Event.

Iatrogenic calcinosis cutis represents a subset of calcinosis cutis resulting secondary to treatments or procedures. We present the first report of calcinosis cutis resulting from the intraosseous infusion and one of a few cases with associated transepidermal elimination. A previously healthy 2-year-old female presented with a new-onset unilateral shin rash 1 week following hospitalization for a near-drowning event. A dermatologic exam revealed multiple small, tender, firm, chalky-white papules with surrounding erythema, in addition to two erythematous macules superior and medial to the papular lesions, corresponding to prior intraosseous access sites. The rash persisted despite trials of topical mupirocin and acyclovir cream, prompting a referral to a dermatologist. An excisional biopsy was performed, revealing circumscribed dermal deposits of acellular basophilic material connected to the overlying epidermis through an invaginated keratin plug. A von Kossa silver stain highlighted the deposits, confirming the diagnosis of perforating calcinosis cutis. The lesions did not recur following the excisional biopsy. Iatrogenic calcinosis cutis may be seen as a complication of the infusion of calcium-containing fluids via intraosseous access, in addition to the more commonly observed peripheral intravenous access. Awareness of this disorder is important in order to distinguish it from an infectious mimic and guide the selection of therapy.

BET 1: cervical spine immobilisation in the management of drowning victims.

A short cut review was carried out to establish whether patients presenting to the emergency department after a near drowning should have cervical spine immobilisation. A search of the literature found only three studies directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that cervical spine injuries are rare in drowning and near drowning unless there is a history of diving or a fall or signs of trauma. Cervical spine immobilisation should be reserved for cases where there is a reasonable suspicion of a spinal injury.

BET 2: CT head in investigation of near drowning.

A short cut review was carried out to establish whether patients presenting to the emergency department after a near drowning should have a CT head scan as part of their initial assessment. A search of the literature found only three studies directly relevant to the question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that anyone with GCS≤4 should have a CT head as an abnormal scan at this stage heralds a very poor prognosis.

Impact of trauma designation levels on survival of drowning victims: An observational study from trauma centers in the United States.

Drowning causes significant morbidity and mortality. Healthcare regionalization aims at improving patient outcomes. This study examines the impact of trauma center level designation on survival of drowning victims.Retrospective cohort study utilizing the National Trauma Data Bank (NTDB) 2015. Descriptive, bivariate and multivariate analyses were conducted.The 212 patients were included. Mean age was 33.58 (±20.02) years with 69.3% (n = 147) males. Patients were mostly taken to Level I (n = 107, 50.5%) and II (n = 81, 32.8%) centers, requiring admission (43.5% (n = 96), 23.1% (n = 49) and 8.5% (n = 18) to Intensive Care, floor, and Operating Room, respectively). Overall hospital discharge survival was 83.5% (n = 177). After adjusting for confounders, there was no significant difference in survival of patients taken to Level I compared to Level II and III centers.This study did not identify a survival benefit for patients with drowning related injuries when taken to Level I compared to Level II or III Trauma centers. Further outcome studies are needed in organized trauma systems to improve field triage criteria for specific injury mechanisms.

Predictors for hospital admission of asymptomatic to moderately symptomatic children after drowning.

Drowning is a leading cause of injury-related death worldwide, but there are limited data on the management and disposition of asymptomatic and mildly symptomatic adults and children following a drowning event. Some authors have recommended admission for all drowning victims due to the possibility of respiratory and clinical deterioration in a seemingly well patient. In order to identify predictors for admission and to establish a unified approach for management, we retrospectively collected all children ≤ 16 years old presented following a drowning event to the pediatric ED over a period of 12 years. The children were divided into two groups, those who were discharged home from the ED and those who were admitted. Seventy-one surviving and non-intubated children were asymptomatic to moderately symptomatic, and they comprised the study group. Crepitations on lung auscultation, oxygen desaturation, and respiratory distress were significantly higher in the admitted group (n = 26) compared with the discharged group (n = 45) (P < 0.05). Respiratory distress and lung crepitations were independent predictors for admission. Eventually, 30% of the hospitalized patients required oxygen therapy, but there were no cases that deteriorated and required invasive ventilation. No readmissions occurred in the group of children who were discharged from the ED.Conclusion: Children who after six hours show no respiratory distress and have normal oxygen saturation and normal auscultation can be safely discharged home. Respiratory distress and lung crepitations should both warrant the physician to consider admission of asymptomatic to moderately symptomatic children following a drowning event. An algorithm to assist patient management is proposed. What is Known: •There are few data in the literature regarding the management and disposition of asymptomatic to moderately symptomatic children after drowning. What is New: •We found that respiratory distress and lung crepitations are independent predictors for admission. An algorithm to assist patient management is proposed.

Association of bystander cardiopulmonary resuscitation and neurological outcome after out-of-hospital cardiac arrest due to drowning in Japan, 2013-2016.

BACKGROUND: Early initiation of cardiopulmonary resuscitation (CPR) performed by bystanders is essential in patients with out-of-hospital cardiac arrest (OHCA) due to primary cardiac cause. However, evidence about the effect of bystander CPR on neurologically favorable survival after OHCA due to drowning is scarce and controversial. METHODS: This nationwide population-based observational study using prospectively collected government-led registry data included patients with OHCA due to drowning who were transported to an emergency hospital between 2013 and 2016. The primary outcome was one-month neurologically favorable survival defined as Glasgow-Pittsburgh Cerebral Performance Category score of 1-2. The secondary outcomes were one-month survival and prehospital return of spontaneous circulation (ROSC). RESULTS: The full cohort (n = 12,139) comprised 6291 (51.8%) male patients, and the mean age was 73.7 (standard deviation [SD], 18.8). Of these, 5157 (42.5%) received bystander CPR, and 6982 (57.5%) did not. 4345 patients receiving bystander CPR were propensity-matched with 4345 patients not receiving bystander CPR. In the propensity score-matched cohort, bystander CPR was associated with increased chance of one-month neurologically favorable survival (0.4% vs. 0.8%; risk ratio [RR], 2.19; 95%confidence interval [CI], 1.21-3.95; P = 0.0076), one-month survival (1.1% vs. 1.7%; RR, 1.55; 95%CI, 1.09-2.22; P = 0.0150), and prehospital ROSC (2.7% vs. 3.5%; RR, 1.30; 95%CI, 1.03-1.65; P = 0.0296). Similar association was observed across a variety of sensitivity analyses. In subgroup analysis, statistically significant difference was not observed in pediatric OHCA due to drowning, although the sample size was too small (n = 218). CONCLUSIONS: Among patients with OHCA due to drowning, bystander CPR was associated with increased chance of neurologically favorable survival.

Quantitative EEG predicts outcomes in children after cardiac arrest.

OBJECTIVE: To determine whether quantitative EEG (QEEG) features predict neurologic outcomes in children after cardiac arrest. METHODS: We performed a single-center prospective observational study of 87 consecutive children resuscitated and admitted to the pediatric intensive care unit after cardiac arrest. Full-array conventional EEG data were obtained as part of clinical management. We computed 8 QEEG features from 5-minute epochs every hour after return of circulation. We developed predictive models utilizing random forest classifiers trained on patient age and 8 QEEG features to predict outcome. The features included SD of each EEG channel, normalized band power in alpha, beta, theta, delta, and gamma wave frequencies, line length, and regularity function scores. We measured outcomes using Pediatric Cerebral Performance Category (PCPC) scores. We evaluated the models using 5-fold cross-validation and 1,000 bootstrap samples. RESULTS: The best performing model had a 5-fold cross-validation accuracy of 0.8 (0.88 area under the receiver operating characteristic curve). It had a positive predictive value of 0.79 and a sensitivity of 0.84 in predicting patients with favorable outcomes (PCPC score of 1-3). It had a negative predictive value of 0.8 and a specificity of 0.75 in predicting patients with unfavorable outcomes (PCPC score of 4-6). The model also identified the relative importance of each feature. Analyses using only frontal electrodes did not differ in prediction performance compared to analyses using all electrodes. CONCLUSIONS: QEEG features can standardize EEG interpretation and predict neurologic outcomes in children after cardiac arrest.

[Near-drowning associated Aeromonas pneumonia]. / Pneumopathie à Aeromonas liée aux noyades.

INTRODUCTION: Aeromonas pneumonia associated with near-drowning, though uncommon, is serious and a major morbidity factor for patients. CLINICAL CASE: A healthy 30-year-old man nearly drowned in a pound. He was admitted to the medical intensive care unit and required intubation and mechanical ventilation. He was given antibiotic therapy in the form of amoxicillin/clavulanic acid. After a brief stable period post immersion, he rapidly developed fever and respiratory failure. The thoracic scan revealed bilateral alveolar infiltrates and led to a fibreoptic bronchoscopy. Aeromonas veroniiandPseudomonas aeruginosa were found on culture of the bronchial aspirate. A change of antibiotic therapy appropriate to these bacteria led to clinical improvement and allowed complete withdrawal of ventilation. CONCLUSION: Rapid respiratory deterioration following near-drowning should raise the suspicion of pulmonary infection with the bacteria usually found in the respiratory tract during ventilation but without overlooking the possibility of unusual organisms, particularly Aeromonas.It is usuallysensitive to third generation cephalosporins and fluoroquinolones. Ideally, Aeromonas should be sought in pulmonary aspirates and samples of the water where immersion occurred.

Neurocognitive outcomes in children following immersion: a long-term study.

OBJECTIVE: To investigate long-term neurocognitive outcomes after a near-drowning incident in children who were deemed neurologically intact on discharge from hospital. DESIGN: A prospective cohort study of near-drowning children. SETTING: 95 drowning and near-drowning admissions, 0-16 years of age, from January 2009 to December 2013, to The Children's Hospital at Westmead, Sydney, NSW, Australia. PARTICIPANTS: 23 children both met the criteria and had parental consent for the study. MAIN OUTCOME MEASURES: Identification of the long-term deficits in behaviour, executive function, motor skills, communicative skills and well-being over a 5-year period. Assessment was undertaken at 3-6 months, 1 year, 3 years and 5 years after near-drowning at clinic visits. Physical developmental screening and executive function screening were done using Behavior Rating Inventory of Executive Function-Preschool version (BRIEF-P) and BRIEF. RESULT: 95 drowning and near-drowning episodes occurred during the study period. 10 (11%) children died, 28 were admitted to the paediatric intensive care unit and 64 directly to a ward. 3 children died in emergency department, 7 children had severe neurological deficit on discharge from the hospital. 23 were subsequently recruited into the study; 5 (22%) of these children had abnormalities in behaviour and/or executive function at some during their follow-up. CONCLUSION: Children admitted to hospital following a near-drowning event warrant long-term follow-up to identify any subtle sequelae which might be amenable to intervention to ensure optimal patient outcome.

Incidence and Consequences of Near-Drowning-Related Pneumonia-A Descriptive Series from Martinique, French West Indies.

Drowning represents one major cause of accidental death. Near-drowning patients are exposed to aspiration that may result in pneumonia with life-threatening consequences. We designed this descriptive study to investigate the frequency, nature, and consequences of post-drowning pneumonia. One hundred and forty-four near-drowning patients (33 children and 111 adults) admitted during four years to the University Hospital of Martinique, French Indies, were included. Patients presented pre-hospital cardiac arrest (41%) and exhibited acute respiratory failure (54%), cardiovascular failure (27%), and lactic acidosis (75%) on admission. Empirical antibiotics, as decided by the physicians in charge, were administered in 85 patients (59%). Post-drowning early onset bacterial pneumonia was diagnosed as "possible" in 13 patients (9%) and "confirmed" in 22 patients (15%). Tracheal aspiration revealed the presence of polymorphous pharyngeal flora (59%) or one predominant bacteria species (41%) including Enterobacter aerogenes, Enterobacter cloacae, Staphylococcus aureus, Pseudomonas aeruginosa, Aeromonas hydrophilia, and Morganella morgani. Despite adequate supportive care, drowning resulted in 45 fatalities (31%). Early onset bacterial aspiration pneumonia (either possible or confirmed) did not significantly influence the risk of death. In conclusion, near-drowning-related bacterial aspiration pneumonia seems rare and does not influence the mortality rate. There is still a need for practice standardization to improve diagnosis of post-drowning pneumonia and near-drowning patient management.

[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.

Can Apparent Diffusion Coefficient Predict the Clinical Outcome in Drowned Children?

INTRODUCTION: Pediatric cerebral hypoxic-ischemic injury frequently results in severe neurological outcome. Imaging with diffusion-weighted magnetic resonance imaging (DWi) demonstrates that the acute cerebral injury and apparent diffusion coefficient (ADC) allow the assessment of the severity of brain damage. The main objective was to examine if spatial distribution of reductions in ADC values is associated with clinical outcome in drowned children. METHODS: This is a retrospective study of 7 children (7 examinations) suffering from a hypoxic-ischemic event who underwent DWi. Seven subjects with normal DWi served as controls. The mean patient age was 4.88 ± 2.93 years and the male-to-female ratio was 5:2. The neurological outcome was divided into 2 categories: 4 children with Apallic syndrome and 3 deaths. We analysed the differences between the drowned children and the control group regarding clinical data, DWi abnormalities, and ADC values. RESULTS: The ADC values in the occipital and parietal grey matter were significantly different between the drowned children (765.14 ± 65.47 vs 920.95 ± 69.62; P = .003) and the control group (670.82 ± 233.99 vs 900.66 ± 92.72; P = .005). The ADC showed low values in the precentral area also (P = .044). CONCLUSION: The ADC reduction may be useful to predict the poor outcome in drowned children and can be a valuable tool for clinical assessment.

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.

Near-drowning-associated pneumonia with bacteremia caused by coinfection with methicillin-susceptible Staphylococcus aureus and Edwardsiella tarda in a healthy white man: a case report.

BACKGROUND: Edwardsiella tarda is an Enterobacteriaceae found in aquatic environments. Extraintestinal infections caused by Edwardsiella tarda in humans are rare and occur in the presence of some risk factors. As far as we know, this is the first case of near-drowning-associated pneumonia with bacteremia caused by coinfection with methicillin-susceptible Staphylococcus aureus and Edwardsiella tarda in a healthy patient. CASE PRESENTATION: A 27-year-old previously healthy white man had an episode of fresh water drowning after acute alcohol consumption. Edwardsiella tarda and methicillin-sensitive Staphylococcus aureus were isolated in both tracheal aspirate cultures and blood cultures. CONCLUSION: This case shows that Edwardsiella tarda is an important pathogen in near drowning even in healthy individuals, and not only in the presence of risk factors, as previously known.