Monday, October 1, 2018

Prognostic Factors of Children Admitted to a Pediatric Intensive Care Unit After an Episode of Drowning

Title: Prognostic Factors of Children Admitted to a Pediatric Intensive Care Unit After an Episode of Drowning
Authors: Ballestin, A, et al.
Journal: Pediatric Emergency Care, July 2018

This articles adds to a group of studies over the past year which have greatly added to the understanding of what initial clinical factors may help predict clinical outcome in pediatric drowning patients.

Study Aim
Evaluate prognostic factors through analyzing the characteristics and clinical course of patients admitted in a pediatric intensive care unit (PICU) after an episode of drowning over the past 24 years.

Study Design
  • Observational study
  • patients admitted to PICU in Spain
  • 131 patients
    • 73% male
    • Mean age 5 years
  • Outcomes
    • Poor outcome (death or severe disability) in 25%
      • 17% mortality
      • 8% significant neuro injury
    • Witnessed status
      • 96% witnessed drowning had good outcome
      • 69% of unwitnessed had good outcome
    • Pupils
      • 90% of patients with non-dilated and reactive pupils had good outcome
      • 87% of patients with dilated/non-reactive pupils had bad outcome
    • pH
      • 91% of patients with pH > 7.1 on admission had good outcome
    • CPR
      • All patients who did not require CPR or had basic CPR (no intubation or meds) had good neuro outcome
      • All but one patient with CPR, endotracheal intubation, and meds had death or poor neuro outcome
Bottom Line

In this study of PICU patients, the most important factor predicting poor outcome was the need for advanced CPR on scene (endotracheal intubation, IV meds).  All patients in the group who needed no CPR or basic CPR survived with good neuro outcome. These results are in line with previous studies.

Salas Ballestín A, de Carlos Vicente JC, Frontera Juan G, Sharluyan Petrosyan 
A, Reina Ferragut CM, González Calvar A, Clavero Rubio MDC, Fernández de la
Ballina A. Prognostic Factors of Children Admitted to a Pediatric Intensive Care 

Unit After an Episode of Drowning. Pediatr Emerg Care. 2018 Jul 16.

Wednesday, June 27, 2018

Is drowning a mere matter of resuscitation?

Title: Is drowning a mere matter of resuscitation?
Authors: Szpilman D, de Barros Oliveira R, Mocellin O, Webber J
Journal: Resuscitation, June 2018

While much of the focus of media and research is on drowning cases which require resuscitation or hospitalization, the reality of lifeguarding is that the vast majority of interventions performed by lifeguards don't involve such severe cases. To highlight the need for better surveillance of what lifeguards do most, these authors analyzed 6 summers worth of data from a Brazilian lifesaving agency and categorized interventions based on 3 broad categories from the Drowning Chain of Survival (prevention, rescue, first aid).

Study Findings
  • 1,565,699 reported lifeguard actions
    • 1,563,300 preventative (99.8%)
    • 2044 recognizing distress and rescuing (0.1%)
      • 1689 no evidence aspiration
      • 14 (0.7%) Grade 5 or 6 (needed respiratory or cardiac resus)
    • 355 needed medical assistance
      • Grade 1: 234 (66%)
      • Grade 2: 78 (22%)
      • Grade 3: 22 (6%)
      • Grade 4: 7 (2%)
      • Grade 5: 4 (1%)
      • Grade 6: 10 (3%)
  • For each rescue made, the were 765 preventative actions
  • Of all rescues made, 17% needed medical assistance, 0.7% needed resuscitation
  • Of all lifeguard interventions, 0.0009% needed resuscitation
This study highlights the fact that the vast majority of interventions performed by lifeguards are not associated with resuscitation or severe drowning injury. Better surveillance and data collection of non-fatal and Grade 1-4 drownings is needed to truly understand burden and properly target interventions.

Wednesday, April 18, 2018

Review of 14 drowning publications based on the Utstein style for drowning

Title: Review of 14 drowning publications based on the Utstein style for drowning
Author: Venema A, Absalom A, Idris A, Bieren J
Journal:  Scandinavian Journal of Trauma, Resuscitation, and Emergency Medicine, March 2018

In 2003, ILCOR recommended the use of a Utstein style for drowning (USFD) approach to drowning data collection. With these recommendations came the development of a template with 22 core parameters and 19 supplemental parameters. This study aimed to "generate an inventory of the use of the USFD parameters and compare the findings of the publications that have used the USFD."

Study Design

  • Systematic review of drowning literature from 10/1/2003 to 3/22/2015
Summary of Results
  • 37 publications included from initial search
  • After exclusion for not explicitly using USFD, 8 articles remained
  • Additional search yielded 6 more articles, for a total of 14
  • None of the USFD articles included all paramters
  • 14 USFD parameters related to outcome
    • Core
      • Age
      • Date
      • Witnessed/Unwitnessed
      • Resuscitation before EMS
      • Time of first EMS Resuscitation
      • ED Vital Signs
      • ABG analysis
      • Initial neuro status
      • Airway/vent requirements
    • Supplemental
      • Approx water time
      • Time of submersion
      • Scene oxygen sat, temp, BP, pupil reaction
      • ED Pupillary reaction
      • Hospital serial neuro function
  • Non-USFD parameters associated with outcome
    • Initial cardiac rhtyhtm
    • Time points/intervals during resus
    • Intubation at scene
    • First hospital core temp
    • Serum glucose/potassium
    • Use of pressors
    • Pediatric Index of Mortality 2-score
The Bottom Line is that while the USFD is in use in peer-reviewed literature, it isn't common and there is large heterogenicity. This leads to a lack of comparatibility and to weak pooled data sets when analysis is performed to determine prognostic indicators.

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

TitleA Standard Operating Procedure to Aid the Prehospital Management of Pediatric Cardiac Arrest Resulting From Submersion
Authors: Best R, Harris B, Walsh J, Manfield T
Journal: Pediatric Emergency Care, May 2017

This is a simple, straight-forward article focused on developing a "Standard Operating Procedure" (SOP) for the resuscitation of a pediatric drowning patient. The authors do a stellar job of sticking with the evidence and focusing on the goal of reversing systemic hypoxemia. Included in the article is a a treatment pathway that can be easily adopted in to pre-hospital and emergency department treatment protocols.

The main points of the SOP include:

  • Utilizing a "pit-crew" approach top the resuscitation with pre-defined roles and prioritied
  • An organized approached based primarily on the respiratory status
  • Exclude unnecessary treatments like abdominal thrusts that take focus away from reversing hypoxemia

Best RR, Harris BHL, Walsh JL, Manfield T. Pediatric Drowning: A Standard
Operating Procedure to Aid the Prehospital Management of Pediatric Cardiac Arrest Resulting From Submersion. Pediatr Emerg Care. 2017 May 8.

Saturday, February 24, 2018

The Pediatric Submersion Score Predicts Children at Low Risk for Injury Following Submersions

Title: The Pediatric Submersion Score Predicts Children at Low Risk for Injury Following Submersions
Authors: Shenoi RP, Allahabadi S, Rubalcava DM, Camp EA
Journal: Academic Emergency Medicine, December 2017

This is the 3rd paper in a few months concerning improving prognostication of pediatric drowning patients in the emergency department (ED). The aim of this is to better understand who can be safely discharged and who needs to be admitted. This group of authors did some very nice work to derive and validate a clinical score to be used in the ED. They based the derivation on previous work by Dr David Szpilman, found which factors correlated best with "safe discharge" within 8 hours, and then re-applied this criteria to earlier data to validate the score.

This paper has a lot of advanced study design and statistics, but here is the bottom line:


  • Derivation
    • Retrospective review of pediatric drowning cases 2010-2015
    • Evaluated predictor variables based on previous literature
    • Correlated to outcome of safe discharge at 8 hours post-submersion
      • Absence of respiratory distress/need for O2
      • Normal mentation (GCS 14-15)
      • Normal lung exam
      • Normal vital signs
  • Validation
    • Retrospective review of pediatric drowning cases 2008-2009
    • Applied factors found in validation to these cases
      • Correlated with "safe discharge" and outcome, found by reviewing medical records and fatality records
  • Risk score derivation
    • Based on 278 patients
    • Predictors chosen for score
      • Normal ED mentation
      • Normal ED respiratory rate
      • Absence of ED dyspnea
      • Absence of need for airway support
      • Absence of ED hypotension
  • Risk score validation
    • Based on 80 patients
    • 1 point for each criteria named above
      • Discriminative ability peaked at 75% with score ≥ 3.5
      • Score of ≥ 4 in ED suggests a safe discharge at 8 hours
  • Outcome analysis
    • Based on medical records of all derivation and validation patients
      • No patients who were judged to be safe for discharge at 8 hours__
      • 2 patients returned to ED in derivation group, both at 4 days, one with pneumonia and one with fever
      • No return visits by those in validation group
      • No deaths in those children deemed safe for discharge 

These authors derived and validation a clinical score to assist in determining pediatric patients who are safe for discharged after 8 hours of ED observation. The following factors predict safe discharge:

  • Normal ED mentation
  • Normal ED respiratory rate
  • Absence of ED dyspnea
  • Absence of need for airway support
  • Absence of ED hypotension
Presence of 4 or more of the above predicts safe discharge. While there are some inherent weaknesses to the design and the single-center nature restricts its generalizability, this study will hopefully set a foundation for further validation throughout other health systems.


Sunday, February 4, 2018

Predictors of safe discharge for pediatric drowning patients in the emergency department

Title: Predictors of safe discharge for pediatric drowning patients in the emergency department
Authors: Courtney E. Brennan, Travis K.F. Hong, Vincent J. Wang
Journal: The American Journal of Emergency Medicine, Jan 2018

This is the second article on this topic within the past 6 months. This is great to see as the evidence concerning this important topic is scant.

Study Aim

"determine if pediatric drowning patients who are well-appearing with normal age-adjusted vital signs and pulse oximetry at presentation to the emergency department can be safely discharged without admission or a prolonged observation period."

  • Retrospective chart review of all pediatric patients with discharge diagnosis of drowning, near drowning, or submersion injury, 1995-2014
  • Excluded patients transferred in, with significant comorbids, distracting injuries, or GCS < 14
  • 180 patient included
    • Mean age 2.94 years
    • 64% males
    • Majority of drownings in pools
    • Submersion time known 66%, all less than 5 minutes
  • Findings
    • No correlation between age, submersion time, apneic time, resus time, and disposition
    • 34% had normal age-adjusted initial vital signs and pulse oximetry on arrival
      • One of these patients had clinical decline and had grunting respirations within 1 hour of presentation.
    • 52% of patients in the study admitted to the hospital
      • 8 of these patients had clinical decline
        • All experienced decline within 1 hour of presentation
        • None of these patients required more than supplement oxygen
        • All returned to baseline before discharge
        • 2 of these patients had normal vital signs on presentation
          • Both developed grunting within 1 hour
        • Abnormal vital signs on presentation not associated with decline
        • Those with decline more likely to have abnormal pulse ox on arrival
    • 48% discharged from emergency department
      • 2 had return visits within 3 days, both discharged from department same day
Bottom Line

While small in nature, this study adds much needed evidence to an important and not well-studied topic. The most important result of this study is that it helps confirm what we have found in similar studies: patients presenting to the emergency department following drowning who are initially stable and mentating well tend to do well, and if they decline they do so within first 4-8 hours.


Saturday, October 28, 2017

Predictors of emergency department discharge following pediatric drowning

Title: Predictors of emergency department discharge following pediatric drowning
Authors: Cantu R, Pruitt C, Samuy N, Wu C
Journal: American Journal of Emergency Medicine (Aug 2017)

When it comes to treating pediatric drowning patients in the Emergency Department, one of the toughest (and scariest) decisions is whether to send the well-appearing patient home or not. The evidence supporting these decisions is fairly weak, with 3 small retrospective studies providing most of the data. This article adds a small but significant piece to the puzzle.

Study Aim:
" ...our study aims to identify predictors of discharge in children presenting to the ED after accidental drowning. "


  • Single Pediatric Emergency Department (ED), all drowning patients over 4 years
  • Retrospective review to determine disposition (discharge, admission, death)
  • Secondary review to determine any follow-up at 7 or 30 days
  • 90 total patients included (48% age 1-5)
    • 37% of patients discharged from ED
    • 1 patient died in ED
    • 63% of patients admitted (26% to ICU)
  • 3 patients re-admitted within 7 days
    • none related to drowning incident
  • 2 patients re-admitted within 30 days
    • 1 feeding tube dislodged, one femur fracture unrelated to drowning
  • Radiography
    • 25% of patients had abnormal chest imaging
    • 4% of patients had abnormal initial head CTs

  • Independent predictors of safe discharge
    • Lack of hypoxia in ED
    • Lack of field intervention
    • Normal Chest X-ray
    • No blood gas testing
While not the strongest study, owing to it's single-center, retrospective nature and small population, it does add to the small field of evidence to help support ED disposition of drowning patients. Only a minority of the patients studied were actually discharged from the ED, but those who were did not return for worsening morbidity associated with the event.