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.