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.


Sunday, October 1, 2017

Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning

Title: Bystander CPR is associated with improved neurologically favourable survival in cardiac arrest following drowning

Authors: Joshua M. Tobin, William D. Ramos, Yongjia Pu, Peter G. Wernicki,
Linda Quan, Joseph W. Rossano

Journal: Resuscitation, June 2017

Long term prognosis following a drowning cardiac arrest is always difficult, multiple studies have found little consistent correlation with scene and clinical findings and outcome. One factor that is often studied with any type of cardiac arrest is bystander CPR, as the earlier CPR is started the better the patient should do. This study is aimed at determining factors associated with good neurologic outcome following drowning cardiac arrest.

Study details

Method: Retrospective analysis of CARES database

  • All patients who suffered drowning cardiac arrest
  • Stratified bystander CPR vs no bystander CPR
  • Multi-variate analysis: bystander CPR, AED use, location, gender, witnessed status, shockable rhythm, age
  • Survivors stratified by neurologic outcome

  • 908 patients included
  • Bystander CPR in 428 (47%)
  • Majority of cases no AED
  • Majority of the cases male, unwitnessed, in public place
  • First rhythm non-shockable in 93%
  • 123 patients survived to discharge (14%)
    • 97 (80%) favorable neuro outcome
    • Associated with favorable outcome: bystander CPR, witnessed, younger
    • Not associated with favorable outcome: Public, male, shockable rhythm

"Bystander CPR is associated with improved neurologic outcome following cardiac arrest from drowning. Shockable rhythms were uncommon and not associated with improved outcomes."


Friday, August 25, 2017

What Is the Effect of Fins and Rescue Tubes in Lifesaving and Cardiopulmonary Resuscitation After Rescue?

Authors: Abelairas-G√≥mez C, et al.
Journal: Wilderness and Environmental Medicine, July 2016 (online)

This article doesn't necessarily provide any groundbreaking discoveries, but I thought it is worth sharing if anyone needs evidence concerning the benefit of using fins in water rescue. In this article, the authors describe the performance of 20 lifeguards during 3 different rescue scenarios: baseline CPR, water rescue without equipment + CPR, water rescue with fins and tube + CPR.

To determine effect of tube and fins, study looked at the following:
  • CPR quality
  • Time to rescue
  • Distance covered (trajectory to patient based on GPS)
  • Physiologic parameters (blood lactate and heart rate)
Bottom Line
  • The use of fins and tube reduced the time for rescue and distance covered
  • No effect on quality of CPR

Friday, July 28, 2017

Recent publications and interviews

We have been very busy lately...

Original research on the use of non-uniform drowning terminology:

Co-authored article concerning the use of the term "dry drowning" for medical providers:

Consulted on a piece about misuse of term "dry drowning" for parents:

Consulted on piece about water safety for medical providers:

News interview about CPR and drowning:

Wednesday, July 26, 2017

Subacute normobaric oxygen and hyperbaric oxygen therapy in drowning, reversal of brain volume loss: a case report

Title: Subacute normobaric oxygen and hyperbaric oxygen therapy in drowning, reversal of brain volume loss: a case report
Author: Harch P, Fogarty E
Journal: Medical Gas Research, 2017(7)

This article may go over some folks' heads, but it was such an interesting case report I had to share it. This report outlines a case involving a 2 year old girl who was submerged for an estimated 15 minutes in 41F water and underwent 100 minutes of CPR. After 35 days in the hospital she was discharged with apparent severe anoxic brain injury (unresponsive, immobile with legs drawn to chest, constant head shaking). At 55 days post-drowning, Dr Harch (lead author) was consulted to facilitate normobaric and hyperbaric oxygen therapy.

The paper goes on to explain in detail the treatment protocols and subsequent studies done. Here is a summary:

  • Initial normobaric oxygen therapy (2L nasal cannula, 45 min twice a day)
    • Behavioral changes noted within hours
    • Neurologic improvement over next 23 days
      • laughing
      • increased use of extremities
      • oral feeding
      • short speech
  • Hyperbaric treatment started at post-drowning day 78
    • Changes noted within hours
      • decreased tone
      • increased motor activity
      • Increased vocabulary, alertness
    • After 10 sessions patient "near normal, except for gross motor function" per mother
    • After 39 sessions
      • assisted gait
      • speech better than pre-drowning
      • normal cognition
      • discontinued all meds
  • Repeat MRI at post-drowning day 162 showed mild residual injury and some near-complete reversal
Paper Conclusion
"Short duration normobaric oxygen and hyperbaric oxygen therapy in the subacute phase of drowning recovery resulted in video-documented near-complete resolution of severe neurological deficits and near-complete reversal of gray and white matter atrophy on MRI"

This is a fascinating case that sheds light on a therapy that has been described very little with the treatment of drowning patients but had a drastic effect on the outcome of this patient. There is still a long way to go in terms of collecting more cases and usable data, but promising and interesting non the less. Congrats to Dr Harch on a very successful case.