Monday, December 22, 2014

ECMO and Drowning Cardiac Arrest

ECMO and Drowning Cardiac Arrest

While working on a review article recently I was forced to dive deeper into the murky waters of extra-corporeal membrane oxygenation (ECMO) [ Click here for an ECMO introduction ].  ECMO has classically been used in the pediatric ICU setting for severe pulmonary and cardiac disease, essentially taking those bodily systems out of the picture and allowing time to heal or time for intervention.  In the past decade we have seen increased use in the adult populations, specifically in the Emergency Department and even the pre-hospital setting.

While the literature on the use of ECMO specifically for refractory cardiac arrest following drowning is lacking, this month two articles were published in the literature which warrant review.

Extracorporeal membrane oxygenation in near-drowning patients with cardiac or pulmonary failure

  • Summary
    • Very small (9 patients)
    • All initially pulseless
      • 3 return of spontaneous circulation (ROSC) with initial EMS rests
      • 6 EMS CPR
        • 4 ROSC with EMS
        • 1 ROSC on arrival to ED
        • 1 prolonged cardiac arrest
    • Course
      • 8 intubated --> eventual ECMO due to ARDS, usually within 6 hours
      • 1 immediate ECMO
    • Outcomes
      • 7 patients discharged with intact near
      • 2 patients hypoxic brain injury
  • Findings
    • Significant decrease in mortality scores (SOFA, SAPS-II) with ECMO
    • 1 patient with fall into icy water survived near intact after > 20 min submersion
  • Weaknesses
    • Small size, no multi-variate analysis
    • No control
    • Inaccurate scene data (submersion time, bystander CPR, temp)
While this study doesn't reveal anything too ground-breaking, it does show the feasibility of such a treatment in the initial resuscitation and within the first 6 hours of treatment in those patients who begin to develop ARDS.  Would have liked to see a multi-variate analysis and the data in the paper was very hard to decipher and determine which patients died to compare initial findings.

Extracorporeal life support (ECLS) for refractory cardiac arrest after drowning: An 11-year experience.

  • Summary
    • Inclusion: Severe hypothermia (18-30 C), submersion < 60 min or shockable rhythm)
      • If initial Potassium (K) > 8, ECMO not started
    • 41 patients with attempted ECMO
      • 21 ECMO not started (7 failed cannulation, 13 K too high, 1 pump fail)
    • 20 total ECMO patients
      • 16 died in first 24 hours
      • 4 survived first 24 hours
        • 2 died in ICU
        • 2 discharged
          • 1 good neuro
          • 1 poor neuro
  • Interesting Findings
    • 37% suicidal
    • 19% initial shockable rhythm
      • ALL patients in asystole on arrival to hospital
    • Predictive variables for survival > 24 hours
      • Initial core temp (< 26 C)
      • Serum K 4.2-6 mM
Overall, this study showed a fairly poor outcome.  With the rhythm on arrival to hospital being asystole in all patients, the chances of survival were poor from the start.  It is unfortunate to see that even the ones with an initial shockable rhythm ended up in asystole, may reveal room for improvement in the EMS treatment.  Some other issues were a high rate of suicide, which may have been associated with ingestions (no autopsy data available).  The authors did attempt to provide some predictive factors, but they are essentially based on a single patient.

What I like about this paper is the detail they give on the standardized system which is in place for initial resuscitation and transport of drowning patients.  You can tell this is a disease that is taken very seriously.  They even have a system in place for prophylactic antibiotics specific to drowning; while the current data has not shown benefit to tis initial treatment, theirs is at least based on the known flora of the Seine and the protocol includes initial tracheal aspirates on these patients.  I also like the discussion section which provides a nice review of the other pertinent literature on this topic.


To date, most of the "promising" literature for the use of ECMO with drowning cardiac arrest is in single patients case studies.  Larger studies have not shown benefit, but also not shown harm.  Most of these studies are doomed from the beginning due to the already poor outcome of this patient population, but I like that is shows that these systems connecting EMS, ED, and ICU with one common goal are possible.  In the right patient population, ECMO will likely benefit, especially when used to bridge patients with good prognostic indicators through clinical deterioration like ARDS.  

Definitely a lot of work to be done.


1. Kim KI, Lee WY, Kim HS, Jeong JH, Ko HH. Extracorporeal membrane oxygenation
in near-drowning patients with cardiac or pulmonary failure. Scand J Trauma
Resusc Emerg Med. 2014 Dec 12;22(1):77.

2. Champigneulle B, Bellenfant-Zegdi F, Follin A, Lebard C, Guinvarch A, Thomas
F, Pirracchio R, Journois D. Extracorporeal life support (ECLS) for refractory
cardiac arrest after drowning: An 11-year experience. Resuscitation. 2014 Dec 5. [Epub]

Wednesday, November 26, 2014

WHO: Global Report on Drowning

This week, the World Health Organization released their Global Report on Drowning, their first ever report fully dedicated to the burden of drowning.  Definitely worth the read.  Highly focused on developing nations, a movement we have seen in the drowning prevention world over the last decade.   Here is what I like about the report:
  • Concise synopsis of the current data
  • Comments on the current quality of data 
  • Beautiful graphics that can be used to present some of the key findings
  • Inclusion of the "Ten Actions to Prevent Drowning"
In terms of visualizing the overall low quality of data collection that exists in the countries that are most impacted, see this map below; all of the countries that are not blue are not included in the data:

I think graphics like this make this report a very high impact one in terms of providing simplified evidence for organizations and countries to use when lobbying for funding and resources.  Take the time to go through this report from start to finish.  No matter your involvement with drowning prevention and treatment, you will get something out of it that will better your teachings, research, and global view on the burden of drowning.

Saturday, November 15, 2014

JEM Letter to The Editor

Here is our Letter to The Editor that will be published in The Journal of Emergency Medicine bringing attention to the misuse of the dated term "near-drowning".  (click link below to view)

More information on the definition of drowning and correct terminology can be found here:

Schmidt A, Sempsrott J. Near drowning and adult respiratory distress syndrome [Letter to Editor]. J Emerg Med. 2014. (Online)

Thursday, October 9, 2014

Helicopter-based in-water resuscitation with chest compressions: a pilot study

Article: Helicopter-based in-water resuscitation with chest compressions: a pilot study
Authors: Winkler, BL, et al.
Journal: Emergency Medicine Journal

I have covered some of Dr Winkler's articles in the past, primarily concerning mannequin-based in-water resuscitation studies.  This article reviews a recent pilot study he performed to evaluate a possible helicopter-based protocol for performing in-water resuscitation.  The protocol involves the following:

  • Dispatching rescue divers from a helicopter on scene
  • Deploying inflatable platform
  • Placing LMA airway and ventilating with Oxylator
  • Applying Lucas chest compression device
  • Inserting intraosseous needle
This rescue protocol was carried out in a wave pool from a simulated helicopter platform in calm and choppy water.  The idea of the study was to "investigate the feasibility and time requirement of the in-water resuscitation measures..."

I have always enjoyed reading the innovative study designs Dr Winkler comes up with, but what concerns me is that these studies may be missing the point and complicating things.  Many folks get caught up in fancy devices and techniques without focusing on basic airway techniques.  I understand where Dr Winkler is coming from and applaud his efforts to improve in-water resuscitation, but these articles need to be read with the understanding that any time used to insert devices and carried out complex protocols may be taking away from much needed ventilations and transport to advanced care.  In the case of helicopter rescue, it would be more beneficial, in my mind, to perfect protocols for getting a victim in to the helicopter and on the way to advanced care as fast as possible.  There is no reason to bring the resuscitation bay to the patient when you have a perfectly good one hovering right above you.  

Overall I am impressed that they were able to deploy and use all of this equipment in to the aquatic environment.  Definitely too many moving parts and too much room for error for my taste, but I enjoy the innovative science.


Saving of Children's Lives from Drowning in Bangladesh

Article: Saving of Children’s Lives from Drowning Project in Bangladesh
Authors: Hyder, AA et al
Journal: American Journal of Preventative Medicine, 2014 (Article in press)

The Johns Hopkins International Injury Research Unit and the Bloomberg Philanthropies have awarded a large grant to the International Center for Diarrhoeal Disease Research, Bangladesh and the Center for Injury Prevention and Research Bangladesh (CIPRB) to fund the Saving of Children’s Lives from Drowning Project in Bangladesh.  (More info here)

This article discusses the planned interventions for the project, which include providing playpens (seen above), access to a daycare, or both to around 80,0000 children.  The project will then compare pre and post-intervention community awareness and death rates.

Over the past decade, a larger focus has been placed on developing countries for drowning prevention  interventions.  We have seen a lot of impressive work from CIPRB in the past, including projects run by our friend Tom Mecrow, and I am excited to see the outcome of this project.  It represents a unique approach to large-scale drowning prevention, bypassing the usual interventions of swimming and water safety training.  These interventions are ideal but are a large resource and logistics burden, and restricted by the age of the children involved.  Hopefully success with this project will provide a proven means for improving the burden of drowning on a country-wide scale.

Article Abstract Link

Saturday, July 19, 2014

Unintentional drowning mortality, by age and body of water: an analysis of 60 countries

Title: Unintentional drowning mortality, by age and body of water: an analysis of 60 countries
Authors: Lin C,Y Wang YF, Lu TH, Kawach I.
Journal: Injury Prevention, June 18 2014

In an effort to compare the burden of drowning in multiple countries, these authors used WHO databases to calculate mortality rates for unintentional drownings, and, if available, determine rates for various bodies of water.  To improve data collection and results, they combined data from the past 3 years and only reported countries with > 150 deaths for all age groups during that time.

The following is a summary of the interesting results:

  • Highest mortality rates for all ages (per 100,000)
    • Guayana (9.2)
    • Belarus (8.6)
    • Lithuania (8.5)
  • Highest mortality rates for ages 0-4
    • Kyrgyzstan (12)
    • Thailand (12)
    • Guayana (8.2)
  • Highest mortality rates for ages 65+
    • Japan (19)
    • Guayana (17.7)
    • Greece (10.5)
  • United States Statistics
    • All ages: 1.3
    • 0-4: 2.4
    • 65+: 1.5
  • UK Statistics
    • All ages: 0.4
    • 0-4: 0.4
    • 65+: 0.5
  • Australia Statistics
    • All ages: 1.1
    • 0-4: 2.1
    • 65+: 1.7
  • Of countries reporting high quality data for body of water (14)
    • Natural water was main body in 13
    • Bath tub was main body in Japan (mostly older adults, likely cardiac arrests)
    • Swimming pool deaths highest in US (18%) and Australia (13%)
    • US swimming pools
      • Majority of black victims drowned in public pools
      • Majority of white victims drowned in residential pools
      • Majority of hispanic victims drowned in neighborhood pools

As with any study looking at data of this nature, the authors found large variations in data quality between countries.  Unfortunately, countries like India and Bangladesh, both of which are known to have devastating mortality rates, had no WHO data available.


Lin CY, Wang YF, Lu TH, Kawach I. Unintentional drowning mortality, by age and

body of water: an analysis of 60 countries. Inj Prev. 2014 Jun 18.

Wednesday, July 2, 2014

Drowning Chain of Survival

Article: Creating a drowning chain of survival
Author: Szpilman D, et al.
Journal: Resuscitation, July 2014

Many folks are familiar with the Cardiac Chain of Survival, a teaching tool used to simplify and visually depict the most important steps to take to improve survival in out-of-hospital cardiac arrest.  It makes sense then that drowning, its own disease entity with its own important steps in treatment, could use its own chain of survival.  Since 2002, when the Congress on Drowning called for a more standardized definition and reporting of drowning, the development of a drowning chain of survival has been evolving.

During the 2013 Conference on Drowning Prevention in Potsdam, Germany, we had the pleasure of participating in a workshop with the best and the brightest in international drowning prevention and treatment to create the final graphic image and descriptions for the chain.  This month, Dr David Szpilman was lead author on a paper in Resuscitation describing the Drowning Chain of Survival.

Summary of chain links

  • Prevent Drowning
    • Stay within arms reach of children
    • Swim in waters guarded by lifeguards
  • Recognize distress
    • Learn subtle signs of drowning
    • Call for help
  • Provide flotation
    • Avoid entering the water unless trained to do so
    • Throw floating object to victim
  • Remove from water
    • Attempt to instruct victim on returning to shore
    • Reach, throw, row to victim
  • Provide care as needed
    • If not breathing, start CPR including ventilations
    • Consider oxygen and AED if available
    • Seek medical attention if any symptoms present

It was very interesting to be a part of these discussions and I am excited to see them released in a major journal.  People from every different level of training and experience had different things they wanted to highlight, but in the end, I think this chain provides a sound foundation for public and basic lifeguard/medical training.  Keep this in mind, share it with others, and save a life.

Download open source version of article

Szpilman D, et al. Creating a drowning chain of survival. Resuscitation (2014), (Link to abstract)

Friday, May 2, 2014

Association of water temperature and submersion duration and drowning outcome

Association of water temperature and submersion duration and drowning outcome

Authors: Quan L, Mack CD, Schiff MA
Journal: Resuscitation, March 2014
  • Study Design
    • Database of drowning victims from 3 counties in Washington state, 1975-11996
    • Case Control study
      • Case: victims with good outcome (survived with no, mild, or moderate neuro sequelae)
      • Control: victims with bad outcome (died or with severe neuro sequelae)
    • Location correlated with water temperature
      • Pond, bath-tubs, pools excluded
    • Used best estimated submersion times
    • Goal: evaluate effects of submersion duration and water temperature on outcome
  • Results
    • 1377 victims identified
    • Correlations with good outcomes
      • younger (< 15)
      • female
      • submersion time < 6 min in water > 16 C
    • Majority of good outcomes submerged < 6 min
    • No significant correlation between water temp and survival
    • CPR
      • Bystander: 50% good outcomes vs 21% bad outcomes
      • EMS: 10% good outcomes vs 27% bas outcomes
  •  Take Home Points
    • Duration of submersion was the only factor that correlated well with outcome, a findings we have seen time and time again in various studies.  Drowning is a hypoxic injury, and time is brain.
Quan L, Mack CD, Schiff MA. Association of water temperature and submersionduration and drowning outcome. Resuscitation. 2014 Mar 4. pii:S0300-9572(14)00114-2.

Tuesday, April 1, 2014

Don't forget your ABCs

Over the last decade, we have seen multiple changes in how lay-persons are taught to treat cardiac arrests in the community.  The AHA now encourages the lay rescuer to perform compression only CPR on adults who suddenly collapse in the community, and multiple large-scale campaigns have attempted to spread this message, some better than others.  The idea behind this is two-fold: (1) it may increase the number of people willing to do CPR since there isn't a push for mouth-to-mouth, and (2) if an adult collapses out in the community, it is most likely a cardiac cause.

It is important to note that when it comes to the treatment of drowning, an injury defined by a lack of oxygen, compression only CPR does't cut it.  By performing only compressions, or by focusing primarily on compressions, the rescuer is leaving out the most important part of the treatment, restoration of oxygenation; for this reason, rescue breathing must continue to play a role in CPR for the drowning victim. 

Both the American Heart Association and the European Resuscitation Council advocate for CPR following the traditional ABC paradigm in the treatment of drowning, this information is unfortunately tucked way in the back of the guidelines:

2010 AHA Guidelines

2010 ERC Guidelines

Bottom Line:

In the treatment of drowning victims, airway takes priority.  Treat using traditional A-B-C paradigm.

Sunday, March 16, 2014

Cardiac arrest due to drowning - Changes over time and factors of importance for survival

Cardiac arrest due to drowning - Changes over time and factors of importance for survival
Author: Andreas Claesson, Jonny Lindqvist, Johan Herlitz
Journal: Resuscitation, ePub Feb 2014

The past 20 years have seen a shift in the treatment of drowning victims, primarily through a tighter focus on ventilations in the treatment algorithm.  Other factors like improved and more widespread EMS systems, public CPR campaigns, and improvements in ICU care have also occurred during this time, but there isn't a large amount of evidence to tell us what impact this is all having on survival and neurological outcome.  

Andreas Claesson, who has already provided a wealth of information to the drowning community, leads this investigation which looked specifically at the Swedish OHCA (Out of hospital cardiac arrest) database over a 20 year period.  His team compared different time frames over this 20 year period to see if there were any differences in patient demographics, EMS times, and survival.  This is a very limited study given its small size and limited geographic scale, but definitely a nice model for other agencies who want to investigate trends in drowning survival in their regions.

Study design
  • Retrospective
  • OHCA registry from 1990 to 2012
    • 66,476 patients experiencing OHCA in which CPR was initiated
    • 529 judged by EMS to be caused by drowning
Major Findings
  • No significant change
    • Witnessed status
    • Shockable rhythm
    • Survival to one month
  • Significant increase
    • Patients receiving bystander CPR
    • Survival to hospital admission
      • Highest if incident witnessed and bystander CPR initiated
  • Trend towards decrease
    • Delay between incident and EMS called
  • Trend towards increase
    • EMS called and EMS arrival

Compared to the US, the rates of bystander CPR were impressively high (74% during 2006-2012 period).  Despite this, there was still an overall disappointing rate of survival to one month.  This can be for many factors, including the initial injury just being too severe for recovery, but what needs continued investigation is whether the proper bystander treatments are being administered.  Bystander CPR is a great thing, but its use for drowning injury is very different than for cardiac disease since the patients with drowning injury need ventilations in addition to chest compressions.  This is especially important given the trend, in this study, towards increased EMS arrival time.  


Sunday, January 19, 2014

Drowning in swimming pools

Drowning in swimming pools
Author: Joost Bierens, Andrea Scapigliati
Journal: Microchemical Journal, March 2014

I haven't covered pool-related drownings too much on this blog, but (yet another) article by Dr. Joost Bierens deserves special attention.  It very nicely summarizes the issue with a global perspective, outlines topics unique to the pool environment, and provides basic prevention and treatment strategies.  Definitely a good read for any pool managers or any medical personnel needing additional information to share with patients and families for the upcoming summer months.

Bierens J, Scapigliati A. Drowning in swimming pools. Microchem J. 2014;113:53-58.