Tuesday, December 22, 2015

Acute respiratory failure after drowning: a retrospective multicenter survey

TitleAcute respiratory failure after drowning: a retrospective multicenter survey
Authors: Michelet P, et al.
Journal: European Journal of Emergency Medicine, December 2015

This article evaluates the pre-hospital and ICU care of non-fatal drowning patients experiencing acute respiratory failure (ARF).  Treatment modalities included supplemental oxygen, non-invasive ventilations (NIV) [BiPap, CPAP], and intubation with mechanical ventilation (MV).  The authors' aim was to analyze the course of these patients and to describe the efficacy of NIV when used.

Study design: Retrospective review of EMS and ICU over 3 summers, 7 ICUs
Inclusion: all adult patients with ARF after drowning in regional Mediterranean Sea

The Numbers: 88 patients

  • 37 started on supplemental oxygen
    • 23 switched to NIV in ICU (due to worsening mentation or respiratory status)
    • None intubated
    • All discharge without neurologic sequelae
  • 25 started on NIV
    • 4 switched to MV in ICU (3 for respiratory failure, 1 for neuro decline)
    • Average initial GCS 12 +/- 3
    • All discharged without neurologic sequelae
  • 26 intubated on scene
    • Average GCS 7 +/- 2
    • 3 vegetative state, 2 moderate disabilities
  • NIV was useful in this population.  More than 80% of NIV remained stable and avoided intubation
  • Initial poor GCS and respiratory status associated with need for MV and worse outcome

There are 3 things I really like about this article: (1) they stick to the Utstein style of reporting and utilize the Szpilman Classification for drowning, (2) they show the utility of high-quality, combined pre-hospital/ICU data collection, and (3) they provide the largest data set to date evaluating the use of NIV in drowning patients.  Before this study, there were only a few cases studies to guide our use of NIV in these patients.  These authors give us evidence on which to base our practice; evidence that tell us that even if the patient has a depressed mental status, if they are protecting their airway to the point that you don't need to immediately intubate, NIV may be tried and is associated with successful treatment and discharge from ICU without neurologic sequelae. 


Michelet P, Bouzana F, Charmensat O, Tiger F, Durand-Gasselin J, Hraiech S,Jaber S, Dellamonica J, Ichai C. Acute respiratory failure after drowning: aretrospective multicenter survey. Eur J Emerg Med. 2015 Dec 17.

Sunday, November 15, 2015

Article: Retrospective evaluation of prehospital triage, presentation, interventions and outcome in paediatric drowning managed by a physician staffed helicopter emergency medical service. 

(click here to access)

Authors: Garner AA, Barker CL, Weatherall AD
Journal: Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, Nov 2015

To start off, cheers to these authors for sticking to the Utstein reporting template for drowning, focusing on teasing out initial clinical factors and correlating them to neurologic outcome.  Studies like these make me jealous for the providers who work in systems where they can easily and seamlessly connect pre-hospital and hospital data to track a patient's course from injury to disposition.

In a nutshell, the authors conducted a retrospective cohort analysis of pediatric drowning patients treated and transported by a physician staffed helicopter emergency medical service (P-HEMS) in Australia.  Their aim was to "describe all paediatric drowning patients treated by a P-HEMS comparing the initial presentation on arrival of the service at the incident scene, interventions performed, and survival rates with neurological outcome."

Summary of findings:
  • 42 total patients
    • Median age 2.8 years
    • 29 patients had Injury Severity Score > 15 (they were critically ill)
  • Outcome
    • 10 patients died within 30 days (5 died in Emergency Dept, 5 died while inpatient)
      • All patients had GCS 3 on scene
    • All patients with GCS ≥ 8 on arrival of HEMS had survival with good neurologic
    • In patients with GCS < 8 
      • GCS 3 + Cardiac arrest @ Emergency Dept --> 100% died
      • GCS 3 + ROSC @ Emergency Dept
        • 7/8 died
        • 1/8 survived with good neuro (initially asystole on scene)
      • GCS 4 - 7: 7/8 survived with good neuro, one survived with bad neuro
  • All patients with GCS > 3 on arrival of HEMS survived
  • An initial GCS > 8 on arrival of HEMS associated with full recovery
  • No patient survived who did not have spontaneous circulation on arrival to Emergency Dept

While this study did not provide sufficient evidence to correlate HEMS interventions with outcome, it did add to the understanding of prognosis associated with initial patient condition.  An increased initial GCS was associated with improved outcome, which has been shown before in the literature. Very good adherence to the Utstein template, showing promise for future similar studies to help us better understand the burden of fatal and non-fatal drowning, and associated prognostic factors.


Wednesday, November 4, 2015

2015 ERC Guidelines: Cardiac Arrest in Special Situations

Article: European Resuscitation Council Guidelines for Resuscitation 2015 Section 4. Cardiac arrest in special circumstances (click for link)

Authors: Truhlar A, et al.

Journal: Resuscitation, October 2015

Drowning has traditionally received a back seat in cardiac arrest guidelines; the topic is tucked way in the back under "special circumstances", often leaving instructors and responders unaware of the differences in treatment when compared with primary cardiac events.  While the new ERC guidelines move the drowning content from Section 8 to Section 4 (moving on up!), the largest impact is in quality of the content and the focus on simplification of resuscitation with a primary focus on providing early and adequate ventilations.

Here are the important points from the 2015 ERC guidelines:
  • Includes discussion on the Drowning Chain of Survival (click for link)
  • Updates the evidence on prognostic indicators
    • Submersion duration of less than 10 minutes associated with good outcome
    • Submersion time of more than 25 minutes associated with bad outcome
    • Age, EMS time, water salinity, water temp, and witness status not useful in prognosis
  • Provides simplified approach to initial resuscitation
    • Prioritizes ventilations and leaves out pulse check

  • Discusses the high prevalence of foam in the airway, and that clearing this foam should not delay ventilations.  If ventilations are not possible, then the patient should be turned on side.
While "guidelines" can be looked down on at times for being out of date by the time they are published and often complicating what should be simple messages, the drowning sections in the 2015 ERC guidelines are a useful update to previous versions, developed by individuals currently on the forefront drowning resuscitation.  They should be used to help guide protocol development for front-line responders associated with water safety and drowning resuscitation.


Saturday, September 19, 2015

Excellent Outcome With Extracorporeal Membrane Oxygenation After Accidental Profound Hypothermia (13.8°C) and Drowning

Title: Excellent Outcome With Extracorporeal Membrane Oxygenation After Accidental Profound Hypothermia (13.8°C) and Drowning
Authors: Romlin BS, et al.
Journal: Critical Care Medicine, ePub, Aug 27, 2015.

This is a case report of a year girl who fell in to icy water in Sweden after wandering away from home.  The air temperature was -12 C (10 F), and it was estimated that the girl was submerged for at least 83 minutes.  A helicopter-based search and rescue team found the girl and started CPR on the way to the hospital.  On arrival, 26 minutes after CPR was started, she was in asystole with a core temperature of 13.8 C.(56 F).

The article outlines her hospital course, including:
  • Placement on ECMO 64 minutes after CPR started
  • Large need for blood transfusions
  • Compartment syndrome requiring leg fasciotomies on Day 3
  • Cardiac tamponade
  • Acute kidney injury requiring peritoneal dialysis
  • ECMO wean on Day 4
  • Evidence of traumatic brain injury
  • 26 days in the PICU
  • 67 days in the hospital
Ten months after the incident she had generalized seizures, and fifteen months after the incident the patient was back to her mental and physical baseline.

This case outlines an extraordinary recovery from prolonged submersion.  Despite dismal prognostic indicators indluing severe acidosis (prolonged submersion, asytole, pH 6.6, Hyperkalemia of 11), what she had on her side was a rapid submersion into icy water, aspiration of icy water leading to rapid central cooling, and a well-organized ECMO-based system of treatment.

The literature surrounding the used of ECMO for drowning patients has not shown much benefit.  This is likely due to the severe level of anoxic injury sustained by the study groups, since most of these patients are either PEA or aystole on arrival.  Case reports like these do show some promise, but they are few and far between, and often exclusive to the pediatric population.  What is does lend evidence to is the utility of a protocolized system of ECMO-based care in areas with a high potential for falls into icy water. Outcomes like this are only possible if every piece of the operational puzzle is planned ahead of time with buy in from multiple pre-hospital agencies and hospital departments.

Romlin BS, Winberg H, Janson M, Nilsson B, Björk K, Jeppsson A, Drake G,Claesson A. Excellent Outcome With Extracorporeal Membrane Oxygenation AfterAccidental Profound Hypothermia (13.8°C) and Drowning. Crit Care Med. 2015 Aug27. [Epub ahead of print] PubMed PMID: 26317568.

Sunday, July 19, 2015

Mortality among drowning rescuers in China, 2013: a review of 225 rescue incidents from the press

Title: Mortality among drowning rescuers in China, 2013: a review of 225 rescue incidents from the press
Authors: Zhu Y, Jiang X, Li H, Li F, Chen J.
Journal: BMC Public Health, July 2015

Multiple case studies in the past have confirmed the alarmingly high rate of rescuer deaths while attempting to save drowning victims, especially in untrained bystanders.  This study out of China analyzed online reports of drowning to determine the prevalence of and factors associated with rescuer deaths.

  • Findings
    • Total of 225 rescue incidents reported
    • 28 (12.4%) incidents resulted in at least one victim death
    • 40 (17.8%) incidents resulted in at least one rescuer death
    • 26 (11.6%) incidents with no victim deaths and more than one rescuer death
    • Factors associated with higher risk of rescuer death:
      • Rescuer was a child
      • Rescuer swam to victim
The fact that the mortality rate between rescuers and victims was "statistically indistinguishable" is scary.  There are few (if any) other diseases/injuries where the person trying to help the patient has a similar mortality rate.  Additional analysis found that those rescuers who chose to assist swimmers through direct contact in the water instead of reaching from a boat had a higher risk of mortality, further confirming the "Reach, Throw, Ro, Don't go!" mantra aimed at keeping rescuers safe.  The article did not go in to detail on the background training of the rescuers, but it can be assumed that little training and resources were available.

Evidence like this highlights the importance of broad public education in areas of high drowning prevalence, especially when trained rescue personnel are not within close proximity.  By taking simple steps to ensure rescuer safety (using a floating craft or another object to reach victim), the complex burden of drowning can be improved.

Zhu Y, Jiang X, Li H, Li F, Chen J. Mortality among drowning rescuers in
China, 2013: a review of 225 rescue incidents from the press. BMC Public Health. 
2015 Jul 10;15(1):631.

Tuesday, June 2, 2015

Drowning In The Adult Population: Emergency Department Resuscitation And Treatment

Our review article on the Emergency Department treatment of drowning was just published in one of my absolute favorite publications, Emergency Medicine Practice.  I was so honored to be able to write for this publication, and I think we did a really good critical review of the literature. You can also get CME credit for taking the test at the end:

Friday, February 20, 2015

Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia

Authors: J Kieboom, H Verkade,J Burgerhof, J Bierens, P van Rheenen, M Kneyber, M Albers
Journal: British Medical Journal,  Feb 2015

Hypothermia plays an important role in the pathophysiology and treatment of resuscitation... that is about as much as we know.  The degree to which it plays a role, and even whether its beneficial or detrimental, is not so clear.  What we are pretty sure of is that, in general, hypothermia is a poor prognostic factor; what complicates things are the multiple case reports of survival with good neurologic outcome following prolonged submersion and cardiac arrest in very cold water.  These are usually young patients with a rapid cooling due to fall in icy water, which differs greatly from some one who is hypothermic due to prolonged exposure in warmer water.

This article reports the findings from 20 years of retrospective analysis of pediatric patients in the Netherlands who were found to be hypothermic and in cardiac arrest due to drowning.  The authors sought to determine the outcome of those patients who undergo prolonged resuscitation.  Some current guidelines call for extending resuscitation in this patient population due to the possible neuroprotective properties of hypothermia and reports of survival after prolonged submersion.

Population: patients aged 16 and under, cardiac arrest due to drowning, hypothermic
Outcome measures: mortality, survival, neurologic outcome

  • 160 total patient
  • 86% survived to ICU
  • 44 survived to discharge (27%)
    •  17 survived with no, mild, or moderate neuro insult (10% of total, 3% of survivors)
  • Prolonged CPR (> 30 min)
    • 89% death
    • 11% severe neuro insult or vegetative state
    • 0% good outcome
    • Max CPR time with good neuro outcome was 25 min
    • ECMO did not change outcome with prolonged CPR
  • Effect of season  (used as marker for water temp)
    • More died from drowning in summer and spring
    • Better survival rates with good neuro outcome in winter
  • Submersion time
    • Not known in most cases (3% witnessed)
    • Longest submersion with good neuro outcome was 25 minutes
  • Initial Cardiac rhythm
    • 86% asystole
    • 13% bradycardia
    • 2% Vent fib
I really like this study, if for no other reason than that fact that they analysed relatively good data following Utstein reporting to focus not just on survival, but survival with good neurologic outcome.  Also, it was performed in an almost ideal medical environment, where these patients get a repsonse from an ambulance and physician-lead helicopter, and protocols are in place for direct/rapid transfer to PICUs and ECMO-capable centers.  When it comes to pediatric drowning, especially in cold water, there is often a push in the literature and in practice for prolonged resuscitation.  In this study, despite achieving survival after CPR > 30 min, the neurologic outcomes were terrible.  Additionally, while true water temperatures were not collected, there was a trend towards improved survival in the winter months, which would possibly indicate a protective effect of very cold water, although the authors note that this sub-population was too small to draw any real conclusions. We need to keep collecting and reporting data like this to be able to make evidence-based recommendations, so that we don't do more harm than good resuscitating a child who will live out the rest of his/her life in a vegetative state.

Link to PubMed abstract