Tuesday, December 10, 2019

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

Title: BET 1: cervical spine immobilisation in the management of drowning victims
Authors: Jones T, Rennie A
Journal: Emerg Med J. 2019 Dec;36(12):766-767

This article describes the findings of a "short cut review" to analyze previous literature regarding the incidence of cervical spine injuries in drowning patients. This is an important topic because there are still agencies around the world that, despite the known rarity of this type of injury in drowning, still require their providers to facilitate spinal motion restriction for all drowning patients. Unfortunately, focusing on the spine in many of these patients can take the focus away from proper resuscitation and complicate an already complicated airway. This is in addition to the paucity of data to support the use of spinal motion restriction on any trauma patients.

This was a quick review as there are only 3 pertinent articles. As expected, the review found that cervical spine injury is extremely rare in drowning and the authors agree with current recommendations to not focus on this treatment modality in the rescue and resuscitation of all drowning patients. Patients known to have suffered a high risk injury pattern may benefit from inline stabilization during resuscitation, but focusing on prolonged efforts of full spinal motion restriction is unnecessary.

One final note about this article and a similar one reported in the same journal; the authors prominently use the out-dated term "near drowning" through out the manuscript. We know that this continues to be a very prevalent problem in peer-reviewed literature, and its use in high impact journals from British Medical Journal is upsetting.  I see a letter to the editor in my future...

Reference:
Jones T, Rennie A. BET 1: cervical spine immobilisation in the management of
drowning victims. Emerg Med J. 2019 Dec;36(12):766-767.

Monday, November 4, 2019

Bystander-initiated conventional vs compression-only cardiopulmonary resuscitation and outcomes after out-of-hospital cardiac arrest due to drowning.

Title: Bystander-initiated conventional vs compression-only cardiopulmonary resuscitation and outcomes after out-of-hospital cardiac arrest due to drowning.
Authors: Fukuda, et al.
Journal: Resuscitation, Article in press (Nov 2019)

This article sought to answer the question of whether compression only CPR or conventional CPR (with rescue breaths) is better for improving survival in cardiac arrest due to drowning. This is obviously a very difficult topic to study given the overall quality of this kind of data, but the authors of this study did their best using a large national registry.

This study is important for a few reasons:

  1. This is a very important question with big education and treatment implications
  2. Misinterpreting the data from this specific paper can easily lead to incorrect assumptions regarding the treatment of the average drowning patient
Study design
  • Retrospective analysis with propensity matching
  • Inclusion
    • Out of hospital cardiac arrest (OHCA) due to drowning 
    • Received bystander CPR (with or without breaths)
  • Cohort
    • 5121 patients with OHCA due to drowning and bystander CPR
      • 928 conventional CPR
      • 4153 compression only CPR
      • 48.5% male
      • Median age 79 years
    • Propensity matched 928 in to conventional and compression only CPR groups
Results

  • 90% unwitnessed and asystole
  • No differences in favorable outcome. one month survival, and pre-hospital ROSC
Discussion

On the surface, this article would seem to suggest that there is no difference in survival benefit between compression-only CPR and CPR with breaths. These results go against our knowledge and teachings that drowning is defined by hypoxemia and that the goal of treatment should be its reversal. For this reason, evidence-based guidelines call for the inclusion of breaths in the CPR algorithm for drowning, despite the constant push for bystander compression-only CPR for cardiac arrest of cardiac origin.

As with any study like this, it is very important to understand WHO you are studying before you apply the results generally. In most studies done on drowning, the majority of patients are 1-4 years of age, or around there. In this study, 81% of patients were above 65; this is a very unusual and skewed drowning cohort. In Japan, multiple studies have found a higher rate of elderly drownings, especially while bathing which may explain these results. This issue with this is the high probability that many of these deaths were actually cardiac in nature and just happened to occur in water. Also, given the fact that 90% were witnessed and were found to be in asystole, the outcome can be expected to be dismal no matter what.

Even when looking at the younger age groups (more common for drowning), the small numbers and wide confidence intervals (without significance) don't reveal any useful conclusions.

Conclusions

While the authors did meet their goals of the paper, the unusually old study cohort makes it so the results of this paper can't be generalized to the average drowning patient. Researchers, educators, and public health officials should use caution when applying these results to practice and education.


Reference:

Fukuda T, Ohashi-Fukuda N, Hayashida K, Kondo Y, Kukita I. Bystander-initiated conventional vs compression-only cardiopulmonary resuscitation and outcomes after out-of-hospital cardiac arrest due to drowning. Resuscitation. 2019 Aug 22.

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
Results
  • 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.


Reference
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%)
Summary
  • 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
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