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:



Friday, July 28, 2017

Recent publications and interviews

We have been very busy lately...

Original research on the use of non-uniform drowning terminology:
https://sjtrem.biomedcentral.com/articles/10.1186/s13049-017-0405-x

Co-authored article concerning the use of the term "dry drowning" for medical providers:
http://journals.lww.com/em-news/blog/BreakingNews/Pages/post.aspx?PostID=377

Consulted on a piece about misuse of term "dry drowning" for parents:
https://www.babble.com/parenting/what-parents-should-know-about-drowning/

Consulted on piece about water safety for medical providers:
http://doctorsthatdo.org/water-safety-drowning-prevention-strategies-save-life

News interview about CPR and drowning:
https://youtu.be/JvQYpSNipdc

Wednesday, July 26, 2017

Subacute normobaric oxygen and hyperbaric oxygen therapy in drowning, reversal of brain volume loss: a case report

Title: Subacute normobaric oxygen and hyperbaric oxygen therapy in drowning, reversal of brain volume loss: a case report
Author: Harch P, Fogarty E
Journal: Medical Gas Research, 2017(7)

This article may go over some folks' heads, but it was such an interesting case report I had to share it. This report outlines a case involving a 2 year old girl who was submerged for an estimated 15 minutes in 41F water and underwent 100 minutes of CPR. After 35 days in the hospital she was discharged with apparent severe anoxic brain injury (unresponsive, immobile with legs drawn to chest, constant head shaking). At 55 days post-drowning, Dr Harch (lead author) was consulted to facilitate normobaric and hyperbaric oxygen therapy.

The paper goes on to explain in detail the treatment protocols and subsequent studies done. Here is a summary:


  • Initial normobaric oxygen therapy (2L nasal cannula, 45 min twice a day)
    • Behavioral changes noted within hours
    • Neurologic improvement over next 23 days
      • laughing
      • increased use of extremities
      • oral feeding
      • short speech
  • Hyperbaric treatment started at post-drowning day 78
    • Changes noted within hours
      • decreased tone
      • increased motor activity
      • Increased vocabulary, alertness
    • After 10 sessions patient "near normal, except for gross motor function" per mother
    • After 39 sessions
      • assisted gait
      • speech better than pre-drowning
      • normal cognition
      • discontinued all meds
  • Repeat MRI at post-drowning day 162 showed mild residual injury and some near-complete reversal
Paper Conclusion
"Short duration normobaric oxygen and hyperbaric oxygen therapy in the subacute phase of drowning recovery resulted in video-documented near-complete resolution of severe neurological deficits and near-complete reversal of gray and white matter atrophy on MRI"



This is a fascinating case that sheds light on a therapy that has been described very little with the treatment of drowning patients but had a drastic effect on the outcome of this patient. There is still a long way to go in terms of collecting more cases and usable data, but promising and interesting non the less. Congrats to Dr Harch on a very successful case.


Link:
http://www.medgasres.com/article.asp?issn=2045-9912;year=2017;volume=7;issue=2;spage=144;epage=149;aulast=Harch

Tuesday, June 13, 2017

On "Dry Drowning"

On June 3, 2017, a 4 year old child suddenly died. The initial treating physicians told the family this was due to a rare condition known as "dry drowning", since the child had swam a few days earlier and now had evidence of water in his lungs. Despite the fact that this term does not exist in medicine and that it goes against every current national and international guideline for drowning terminology, physicians and the media together have perpetuated its use to a dangerous level over the last week.

A quick history:
In 2002, the World Congress on Drowning created the following Uniform Definition for drowning:

The process of experiencing respiratory impairment due to submersion or immersion in a liquid.

From this definition, there can be 3 outcomes
  1. Fatal drowning
  2. Non-fatal drowning without morbidity (injury)
  3. Non-fatal drowning with morbidity
That's it... The primary definition has nothing to do with outcome (living vs dead), location, water type, water temperature, or time since submersion. Bottom line: if a person's airway drops below the water and they have breathing problems because of it, it is considered a drowning.

With this definition came recommendations to discontinue the use of the following modifiers to describe drowning: near, secondary, delayed, wet, dry, active passive.

This definition and these recommendations have been accepted by all of the following
  • Centers for Disease Control and Prevention
  • American Heart Association
  • European Resuscitation Council
  • American Red Cross
  • United States Lifesaving Association
  • International Surf Life Saving Federation
  • And many, many more...
Just as you can't have a near-stroke or a near gun shot, you can't have a near drowning. Drowning is a process that begins at the beginning and doesn't appear out of nowhere. That is why the term "dry drowning" is incorrect. It suggest the child had no injury and then suddenly drowned while in bed. 

What the heck happened?
Incorrect information was given to the family from the beginning. This is not surprising. Research we have conducted over the past 5 years tells us that even in the highest quality medical literature, incorrect terms are used 30-40% of the time. We still have work to do.

Next, the news quickly disseminated this incorrect information. Again, not too surprising. We like to rely on the media for correct information, but in a competitive market speed often trumps accuracy.

What followed was the sad part. The media turned to medical professionals for guidance, most of whom allowed the media to create the message and then gave blind stamps of approval. Even some of those interviewed stated that they knew this term was wrong, but then continued to use it and justify this with "it's what the public is used to". At very few points did anyone stop to check if what they were saying was true or accurate or yield to some one knowledgable in the field.

Why does this matter?
Ok, so nitty-gritty details about drowning were incorrect. So what? Well, drowning is a preventable injury, and prevention feeds off of data and communication. Knowing how big a problem is, where to target efforts, and what efforts work is essential.  This cannot happen if we are unable to speak to one another, and a major road block to that is using correct terms.

We also want an informed public. When a parent's decision on whether or not to have their child evaluated after a drowning event is based on their own experiences and knowledge (much of which comes from the headlines), we need that parent to understand the truth. We need them to know what drowning IS and what it ISN'T. Most of all, we need them to trust the physician who is telling them "it is ok for your child to go home". When everything they have heard over the past week from the media and uninformed medical "experts" is telling them otherwise, this trust is lost.

What about the child?
As of today, no autopsy report has been released. In the initial reports, there was talk of "fluid around the heart" which is not a common finding in drowning. There are a hundred other things which could have caused this child's death and many individuals in the drowning research community are doubting drowning as the actual cause of death.

What you need to know.
Anyone who experiences a drowning event needs to be evaluated carefully by a medical professional.  Obviously children love to jump in and choke on water, but this is usually resolved with a few coughs. The time to worry is when the child has a prolonged submersion, definitely has trouble breathing after, or continues to have coughing, foam from the mouth, vomiting, or altered behavior. Those without symptoms can safely be released after a period of observation. Symptoms may worsen over time, but they don't appear out of nowhere. 

For medical professionals, choose your words wisely, vet your message, and if you are not familiar with the information you are giving or haven't updated your own knowledge in a while, have patience and look it up.

Wednesday, April 12, 2017

Drones may be used to save lives in out of hospital cardiac arrest due to drowning


Title: Drones may be used to save lives in out of hospital cardiac arrest due to drowning
Authors: Claesson A, et al.
Journal: Resuscitation, Jan 2017

This is a first of its kind study evaluating the effectiveness of a human-operated drone to detect a submerged victim, as compared to a traditional line search party. The authors conducted 10 simulated recoveries for both the drone method and search line (control) method, comparing time to recognition and time to contact. For the purposes of contact, a rescue boat responded to the site identified by the drone.

Setting: 10000 square meter area, max depth 2 meters
Simulated victim: manikin submerged 1.5 meters at random locations, locations came for both groups

Median time to contact

  • Search party: 4:34 (Range 0:53-9:30)
  • Drone: 0:47 (Range 0:18-0:39)
Median area searched
  • Search party: 2600 sq meters
  • Drone: 5000 sq meters
Author Conclusions

A drone transmitting live video to a tablet is feasible, time saving in comparison to traditional search parties and may be used for providing earlier location of submerged victims at a beach. Drone search can possibly contribute to earlier onset of CPR in drowning v
ictims.

Discussion
The authors did a very good job answering a question that has not been answered before. Their methods were sound and conclusions correct based on their results.  This definitely has real-world implications concerning the search and rescue of drowning victims. It will be nice to see future studies in varying conditions and any case reports from actual use.

While the study itself is commendable, forces which have brought a study like this to be "needed" are worth discussion. If you have access to Resuscitation it is worth your time to read the Editorial by Dr Joost Bierens at the beginning of the issue. If not, I will try and summarize, but won't come close to matching his insight. Essentially, what this study does, and not at the fault of the authors, is bring to light not necessarily the giant steps forward we have taken in the prevention and treatment of drowning, but rather the steps we have taken over the basic principles of prevention and treatment. By focusing on technologies such as these, we continue miss the point that we have yet to optimize preventative strategies which WE KNOW work and we continue to build the divide between the haves (those countries who can afford devices like these and have low drowning rates) and the have nots (those countries who cannot afford them and have the highest burden of drowning).  Both very interesting reads authored by very smart and dedicated individuals.

Reference
Claesson A, Svensson L, Nordberg P, Ringh M, Rosenqvist M, Djarv T, Samuelsson
J, Hernborg O, Dahlbom P, Jansson A, Hollenberg J. Drones may be used to save
lives in out of hospital cardiac arrest due to drowning. Resuscitation. 2017 Jan 

18. pii: S0300-9572(17)30013-8.



Monday, March 13, 2017

Relationship between drowning location and outcome after drowning-associated out-of-hospital cardiac arrest: nationwide study


Title: Relationship between drowning location and outcome after drowning-associated out-of-hospital cardiac arrest: nationwide study
Authors: Jeong J, et al.
Journal: American Journal of Emergency Medicine, September 2016

Study Focus: This study examined the association between location and drowning-OHCA outcomes in South Korea

Study design

  • Cross-sectional study
  • Nationwide out-of-hospital cardiac arrest (OHCA) registry in South Korea
  • Analyzed drowning OHCA cases 2006-2013
  • Classified event locations
    1. Recreational public pools with lifeguards
    2. Recreational public beaches with lifeguards
    3. Natural freshwater locations without lifeguards
    4. Natural saltwater locations without lifeguards
  • Examined effects of the following on outcome:
    • age, sex
    • presence of witness, bystander CPR
    • EMS response time, EMS scene time, EMS transport time
    • Primary ECG at scene, prehospital defibrillation
    • Level of emergency department triage
  • The primary end point was survival-to-hospital discharge
  • Statistical models (2)
    1. Adjusted for confounding variables present before rescue (age, sex, witness)
    2. Adjusted for all potential confounders including prehospital variables and variables from Model 1
Results


Discussion
  • Model 1: Higher chance of survival for those who had drowning OHCA at supervised location
  • Model 2: No significant difference
  • Bystander CPR associated with location which likely accounts for difference in outcome of models
This study is nice for a couple of reasons: (1) it uses a nationwide database with fairly good drowning data and (2) it analyzes a country with national safety laws pertaining to lifeguards for all public bodies of water. This allows for a nice comparison given the lower variability of coverage than we would see in the US. The authors do mention, however, that they don't specifically evaluated the pools and beaches adherence to the national safety laws.

Bottom Line: In this single-nation study, drowning OHCA in bodies of water with lifeguards was found to have a higher survival to discharge than those without lifeguards.


Reference
Jeong J, Hong KJ, Shin SD, Ro YS, Song KJ, Lee EJ, Lee YJ, Ahn KO.
Relationship between drowning location and outcome after drowning-associated
out-of-hospital cardiac arrest: nationwide study. Am J Emerg Med. 2016

Sep;34(9):1799-803.