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
Reference


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:

Design

  • 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
Results
  • 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 
Discussion

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.

Reference

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."

Methods
  • 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
Results
  • 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.


Reference


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. "

Methods

  • 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
Results
  • 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.

Reference


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

Results
  • 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
Conlusion

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


Reference





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
Link: