Literature Review

Neurologic long term outcome after drowning in children

Article· Literature Review (PDF Available)inScandinavian Journal of Trauma Resuscitation and Emergency Medicine 20(1):55 · August 2012with 814 Reads
DOI: 10.1186/1757-7241-20-55 · Source: PubMed
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Abstract
Drowning is a major source of mortality and morbidity in children worldwide. Neurocognitive outcome of children after drowning incidents cannot be accurately predicted in the early course of treatment. Therefore, aggressive out-of-hospital and in-hospital treatment is emphasized. There are "miracle" cases after long submersion times that have been reported in the medical literature, which mostly concern small children. However, many of the survivors will remain severely neurologically compromised after remarkably shorter submersion times and will consequently be a great burden to their family and society for the rest of their lives.The duration of submersion, the need of advanced life support at the site of the accident, the duration of cardiopulmonary resuscitation, whether spontaneous breathing and circulation are present on arrival at the emergency room are important factors related to survival with mild neurological deficits or intact function in drowned children. Data on long-term outcome are scarce. The used outcome measurement methods and the duration of follow-up have not been optimal in most of the existing studies. Proper neurological and neurophysiological examinations for drowned children are superior to outcome scales based chart reviews. There is evidence that gross neurological examination at the time of discharge from the hospital in young children does not reveal all the possible sequelae related to hypoxic brain injury and thus long-term follow-up of drowned resuscitated children is strongly recommended.
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R E V I E W Open Access
Neurologic long term outcome after drowning
in children
Pertti K Suominen
*
and Raisa Vähätalo
Abstract
Drowning is a major source of mortality and morbidity in children worldwide. Neurocognitive outcome of children
after drowning incidents cannot be accurately predicted in the early course of treatment. Therefore, aggressive
out-of-hospital and in-hospital treatment is emphasized. There are "miracle" cases after long submersion times that
have been reported in the medical literature, which mostly concern small children. However, many of the survivors
will remain severely neurologically compromised after remarkably shorter submersion times and will consequently
be a great burden to their family and society for the rest of their lives. The duration of submersion, the need of
advanced life support at the site of the accident, the duration of cardiopulmonary resuscitation, whether
spontaneous breathing and circulation are present on arrival at the emergency room are important factors related
to survival with mild neurological deficits or intact function in drowned children. Data on long-term outcome are
scarce. The used outcome measurement methods and the duration of follow-up have not been optimal in most of
the existing studies. Proper neurological and neurophysiological examinations for drowned children are superior to
outcome scales based chart reviews. There is evidence that gross neurological examination at the time of discharge
from the hospital in young children does not reveal all the possible sequelae related to hypoxic brain injury and
thus long-term follow-up of drowned resuscitated children is strongly recommended.
Keywords: Drowning, Cardiopulmonary resuscitation, Children, Outcomes, Health related quality of life
Introduction
It is increasingly recognized that the assessment of health
related quality of life (HRQoL) should become a standard
of care in children after trauma and cardiac arrest f1,2]. In
contrast, there have been numerous attempts to determine
different predictors of neurologic outcome at hospital dis-
charge after drowning accidents [3-12]. However, little is
known about long-term neurocognitive outcome after a
drowning incident. The neurological status of survivors is
often retrospectively evaluated using hospital records and
also the Pediatric Overall Performance Category Scale
(POPC) at discharge and at 1-year after the incident. These
evaluations are currently recommended by the Utstein
guidelines for research on drowning [13-16]. Pediatric
drowning victims may have grossly intact neurological
examinations at discharge from the hospital, but the long-
term cognitive sequelae may not manifest until the child
enters school [17,18].
The aims of this review are a) to report the main factors
related to the outcome of drowned children and b) to
present existing evidence of long-term neurologic out-
come. The latter findings were obtained from reviewed
studies that report the outcome of children after extended
follow-up periods.
Materials and methods
Bibliographic MEDLINE and PUBMED databases were
searched for English language literature using medical sub-
ject headings: 1) drowning or near drowning; 2) submer-
sion and immersion; 3) children; 4) outcome and 5) quality
of life. The search was done from inception until March
2012. We also searched previously published literature for
additional references. We included all the studies that re-
port the outcome of drowned children after extended
follow-up periods. We excluded studies without any
follow-up of drowned children after the hospital discharge.
* Correspondence: pertti.suominen@hus.fi
Department of Anaesthesia and Intensive Care, Childrens Hospital, Helsinki
University Central Hospital, Stenbäckinkatu 9, FIN-00029 HUS, Helsinki,
Finland
© 2012 Suominen and Vähätalo; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the
Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use,
distribution, and reproduction in any medium, provided the original work is properly cited.
Suominen and Vähätalo Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:55
http://www.sjtrem.com/content/20/1/55
One case report was included, because it was the only
study published with an adequate follow-up time [18].
Definition of drowning
A review by Papa et al. found a total of 35 different defini-
tions to describe drowning incident and 20 different out-
come measures [19]. The variability of these definitions
and outcomes makes it very difficult to assess and draw
conclusions from the existing literature. Therefore, in 2002
consensus experts agreed upon a definition that includes
both fatal and non-fatal drowning cases. The following def-
inition was adopted: Drowning is the process of expiring
respiratory impairment from submersion/immersion in li-
quid[20]. Implicit in this definition is that liquid/air inter-
ference occurs at the entrance of the airways of the victim,
which prevents the victim from breathing air [19,20]. A
victim can be rescued at any time during the drowning
process and may not require any intervention. On the
other hand, victims may receive appropriate resuscitative
measures, in which case the drowning process is inter-
rupted [13]. Drowning outcomes should be classified
according to the following categories: death, morbidity or
no morbidity [13,20].
Epidemiology
Drowning is the fifth leading cause of accidental deaths in
the United States. It is also the second leading cause of ac-
cidental deaths among children aged 114 years in the US
[21]. Although the incidence of drowning in children
younger than 15 years of age is 1.1/100 000, the incidence/
of drowning is highest among 04 year-old children
[21-23]. Drowning studies are based on national or state
statistics, national drowning rescue organizations databases
and ICD codes at hospital discharge [21,24,25]. Most of
these databases are not designed for research purposes and
so they may not include all the drowning cases that actu-
ally occurred. Furthermore, the outcomes of the victims in
particular are not very reliably reported nor are they very
robust as cases are categorized as either survive or die [24].
Some children with a witnessed short submersion time
will begin breathing and regain conscious after they have
been removed from the water and they may also have
received some rescue mouth-to-mouth breaths. Some of
these minor cases may not have received hospital treat-
ment and thus may not be recorded in the national statis-
tics. At the other end of the spectrum, are children
brought to the hospital who have had long submersion and
rescue times, who consequently suffer from severe anoxic
brain injury and who are subsequently discharged to an-
other institution. When some of these patients decease
months or years after the accident due to pneumonia or
some other causes, they are not necessary included in the
drowning statistics per se: instead they are often reported
in studies as survivors of drowning.
There are also differences in the quality of out-of-
hospital care and the decision making at the site of the ac-
cident. In many European countries, physician staffed
emergency units are able to pronounce a drowned patient
dead with or without cardiopulmonary resuscitation
(CPR). Such a procedure is in contrast to that used by
emergency medical services (EMS) units that are staffed by
emergency technicians or paramedics who usually trans-
port all the victims with ongoing CPR to the emergency
room (ER). Therefore, the outcome of drowned patients
treated in different hospitals and in different countries may
not be comparable.
The ratio between fatal and non-fatal cannot be reliably
determined because of the above-mentioned reasons in
reporting the incidences of drowning and because of the
inconsistencies in the terms used for drowning. Neverthe-
less, it has been estimated that the numbers of non-fatal
drownings are two to four times higher than the numbers
of fatal drownings [8,25-27].
Most of the drowning accidents in children occur in nat-
ural bodies of water [8,20,27,28]. However, drownings often
occur in bathtubs for infants and in private pools for tod-
dlers during brief lapses in adult supervision [26,27,29].
Proper safety barrier/childproof fencing of private pools
and garden ponds, and water safety training to children at
a young age are instrumental in reducing the risk for
drowning [26,28,29]. Continuous adult supervision in or
near water can prevent many of these deaths, especially
drownings in bathtubs and pools [26,27,29].
Hypoxic ischemic brain injury
Organs such as the brain, lungs and kidneys are mainly
affected by drowning accidents. Treatment of pulmonary
complications depend on the lung injury that was incurred
during aspiration and also the bacteria that was aspirated
[25]. Some patients may develop adult respiratory disease
syndrome (ARDS) and may even need ECMO to survive.
However, the long-term outcome of survived drowning
victims depend mainly on the severity of the initial ische-
mic brain insult, the effectiveness of immediate resuscita-
tion with subsequent transfer to the ER, and also on the
post-resuscitation management in the intensive care unit
[30,31]. The most susceptibility areas to ischemic injuryare
vascular end zones, hippocampus, insular cortex, and basal
ganglia. With greater severity of hypoxic-ischemia, more
extensive and global neocortical injury will occur [23].
Important predictors for survival itself either with mild
or severe neurological deficits include: the duration of sub-
mersion, the need of advanced life support at the site of
the accident, the duration of CPR, and the establishment
of spontaneous breathing and circulation on arrival to the
ER [3,5,8,10,16,27,32]. Submersion time mainly determines
the level of hypoxic-ischemic injury but it is at best an esti-
mate given in an extremely stressful situation. It has been
Suominen and Vähätalo Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:55 Page 2 of 7
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shown that a prolongation of submersion over 5 10 min
worsens the prognosis considerably [5,8]. Many other pre-
dictors of survival that have been reported in the literature
are mainly consequences of the duration of the primary in-
sult of CPR and the quality of the treatment the patient
has received before or after the arrival to the ER. Labora-
tory values such as severe acidotic pH-values, high blood
sugarandlactateareusuallysignsofalongsubmersion
and resuscitation time and therefore they are signs of poor
outcome except in hypothermic children drowned in icy
water [7,10,27,32-36]. There are insufficient data on bio-
chemical markers such as neuron-specific enolase (NSE)
or serum astroglial protein (S-100B) in children after car-
diac arrest to help outcome prediction [31].
There is no entirely reliable algorithm of clinical signs or
investigations that allow a definitive prognosis but the
combination of careful repeated observations and examina-
tions will give accurate information to advise on manage-
ment [30,31]. Clinical assessment in the PICU is also often
compromised by factors that include: sedation, neuromus-
cular blockade, ventilation, hypothermia and inotropic
management [30,31]. The presence of any motor activity
and pupillary reactivity noted on arrival to the ER could
significantly discriminate between survivors and fatalities,
but could not discriminate between intact and vegetative
survivors [6]. Successful control of intracranial pressure
(ICP) and cerebral perfusion pressure (CPP) did not ensure
intact survival and a sustained late intracranial hyperten-
sion was more likely to be a sign of irreversible brain
damage [6,35,37]. The duration of consciousness after
drowning when good recovery is still considered possible
seem to vary in the literature. In a study by Bratton
et al. all satisfactory survivors were sufficiently awake
and had spontaneous, purposeful movements and nor-
mal brain-stem function as early as 24 hours after the
drowning event [11]. In comparison, the findings of Bell
et al. show that all children who made good recoveries
regained consciousness within a two-week period [6].
Repeated or continuous electroencephalogram (EEG)
may provide useful information to assist the differentiation
between patients with good and poor neurological out-
come. Reactivity to auditory and painful stimulations is a
more important sign of good prognosis than the dominant
EEG frequency alone [30,31,38]. A bad outcome can be
associated with burst-suppression, generalized suppression,
status epilepticus, and nonreactivity [31,38]. Somatosen-
sory evoked potentials are valuable in assessing prognosis
and they are also less susceptible than EEG tosedation and
metabolic factors. However, the accuracy in predicting
neurological outcome is still not very good [30,31].
The increased use of neuroimaging techniques can add
valuable information, in particular brain magnetic reson-
ance imaging (MRI) shows characteristic patterns depend-
ing on the severity of the injury and also the timing of
imaging [30,31]. The degree of edema and brain swelling is
better seen by MRI than by computer tomography (CT)
scans, therefore CT scans are not widely used for early out-
come prediction [31]. In the European resuscitation coun-
cil guidelines for resuscitation, it is recommended to
consider induced hypothermia for 12 24 hours for chil-
dren who remain comatose following resuscitation, al-
though there is no strong scientific evidence in the
literature to support this treatment of children [39].
Studies on long-term outcome
A good functional outcome after a drowning accident is
vital because severe neurological injury will incur a great
burden to the victims family and to society as a whole. Data
on long-term outcome are scarce. We were able to find
only six articles that included neurologic follow-up data on
solely drowned pediatric patients from the existing litera-
ture. In addition, one case report and one case series were
included in the review (Table 1) [6,8,10,11,18,33,40,41].
Pern studied 56 children with freshwater immersion acci-
dents in the Brisbane area of Australia, in which conscious-
ness was lost in the water and which also necessitated a
subsequent admission to hospital [40]. The mean estimated
submersion time was 3.7 min (range 0.5 10 min). Fifty-
four children were re-examined medically and psychomet-
rically. Of these 54 children, 52 were completely normal.
The other two patients had severe neurologic sequelae. The
median IQ of the survivors was 110 (range 90137), which
is higher than that of the general population. There is a sug-
gestion that visualmotor (performance) skills are particu-
larly vulnerable to freshwater immersion hypoxia. In 20
percent of survivors subscale disparities between verbal and
performance skills exceeded 15 IQ-points. No long-term
emotional or personality disorders were encountered [40].
In an early study Kruus et al. reported on 30 children
patients who were treated in the Children's Hospital in
Helsinki, Finland, after a drowning accident. The submer-
sion time was not known 11 patients, but in other patients
it was estimated to be between less than 5 to 20 minutes.
All except two out of 30 patients needed CPR after the ac-
cident. Thirteen children (43%) died in the hospital. The
surviving 17 children underwent neurological, neuro-
physiological and psychological examination 6 58 months
after the accident. Four of the 17 surviving children were
tetraplegic, unable to speak and had convulsions. Thirteen
children (43%) had slight neurological or psychological
signs. Their median general IQ was 96 (range 88115),
except for two of these 13 children whose respective IQs
were 48 and 76 [10].
In another study 49 drowned children for whom CPR
had been initiated by EMS personnel and were admitted to
Childrens Hospital of Los Angeles, were investigated [6].
Submersion times were not reported. Of the 49 patients,
29 (59%) died in the hospital one day to three months after
Suominen and Vähätalo Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:55 Page 3 of 7
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Table 1 Studies on long term survival in children after drowning accident
Study Design
Patient
population
Patients (N) Age Patient selection Follow up period Assessment tool Conclusion
Pearn 1977 [40] Prospective
1971-75
54 Not reported Freshwater immersion
accidents in which
consciousness was lost
Median 23 months
(360 months)
Neurological and
neuropsychological
testing
95% of children survived
neurologically normal
Kruus et al. 1979 [10] Prospective
1971-76
30 Median 4 years Drowned children of whom
28/30 had been
resuscitated
Median 22 months
(658 months)
Neurological and
neuropsychological
testing of 17 survivors
13 children with slight
neurological deficit and 4
with severe deficit
Bell et al. 1984 [6] Prospective
1979-83
49 8-154 months Drowned children who had
been resuscitated
by EMS personnel
8-40 months Neurological and
neuropsychological
testing of 7 apparently
intact survivors
Long-term survivors had
nearly normal levels of
cognitive function
Bratton et al. 1994 [11] Retrospective
1986-91
44 Median 28 months
(8 mo-14 yrs)
Children admitted to PICU
after warm drowning,
43/44 received CPR at the scene
Minimum of 6 months A discussion with childs
physician or chart review
17/44 (39%) had normal
functioning or mild
neurological deficit
Suominen et al 1997 [8] Retrospective
1985-94
48 Median 3.7 years
(0.8-15.0 years)
Drowned children who had
received ALS at
the scene
1 year Chart review with POPC 29/48 (60%) had normal
functioning or mild
neurological deficit
Hughes et al. 2002 [18] Case report
1986
1 2.5 years Neuropsychological recovery
after 66 min
submersion, CPR and CPB
12 years Neuropsychological
testing,
neuroimaging
Cognitive difficulties and
global memory impairment
in follow-up
Suominen et al. 2010 [33] Retrospective
1994-2008
9 Median 3.7 years
(0.8-15.0 years)
Hypothermic drowning victims
treated with CPB
3 years Neurological and
neuropsychological
testing
One survived with mild
to moderate
neurological deficit
Suominen et al.2011 [41] Questionnaire 29 Median 3.0
(range 1.2-15.7) years
Drowned children who had
been resuscitated
either bystanders and/or
EMS personnel
Median 10.3 years
(1.8-21.8 years)
Mailed HRQoL
questionnare
Good HRQoL in most of
the long term survivors
Abbreviations: CPR, Cardiopulmonary resuscitation; ALS, advanced life support; POPC, Paediatric Overall Performance Category Scale; HRQoL, Health-related quality of life.
Suominen and Vähätalo Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine 2012, 20:55 Page 4 of 7
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admission, 13 (27%) were discharged in vegetative states,
and 7 (14%) made good recoveries [6]. Eleven of those 13
vegetative survivors were followed up. Four of the 11 had
died and the remaining seven had no significant improve-
ment after the hospital discharge. Extensive neuropsycho-
logical testing indicated that the seven children with
apparently intact recovery showed nearly normal levels of
cognitive functioning, except for one child who already
had significant development delays prior to the accident.
Four of the seven children had neurological examination.
Two of them were normal and two had ataxia and motor
and coordination deficits. No significant personality distur-
bances were detected in any of the seven children [6].
In the study by Bratton et al. 44 children were admitted
to PICU after drowning [11]. Of these patients 43 had
received CPR at the scene. Although it was not mentioned
in their study, some of the children most likely received
only bystander CPR because of the high survival rate. Sub-
mersion times were not reported. Of the 44 patients, 19
died in the hospital (43%), eight (18%) survived with severe
neurologic sequelae, and 17 children (39%) had satisfactory
outcome meaning mild or no deficits at discharge from the
hospital [11]. Children with ataxia and dysarthria were
included in patients with satisfactory outcome. The neuro-
logic status of the17 children with satisfactory outcome
were evaluated after a follow-up period of minimum of six
months by discussing with the respective childsprimary
physician or by medical chart review. Fifteen survivors
were classified as normal because they had returned to
their pre-accident level. One child with mental retardation
before the accident had some attenuation of verbal and
motor skills and another child had attention deficit dis-
order [11].
Forty-eight children for whom advanced life support was
initiated at the scene and who required admission to the
PICU in Southern Finland, were analyzed [8]. The submer-
sion times ranged from 0.5 90minandthemediansub-
mersion time was 6.3 min. On arrival of the first EMS unit,
23 victims had spontaneous respiration and circulation,
one had respiratory arrest and 28 children (58%) were in
cardiac arrest. The neurological status of the survivors
were retrospectively evaluated using the POPC-scale from
medical charts at one year after the accident [15]. Of all 48
children 29 (60%) survived with mild or no disability com-
pared with 10 (21%) with attempted CPR. Seventeen
patients died (35%) and two children survived with severe
disability (4%) [8].
The longitudinal profile of a 2.5-year old child, after 66
minutes of submersion in icy cold water in Utah and resus-
citation on CPB, indicated a pronounced pattern of broad
cognitive difficulties [18]. Although, in the original widely
referred case report, the child was reported recovering
completely[17,18]. Subsequent neuropsychological exam-
ination revealed impairment of visual-spatial abilities, mild
dyslexic characteristics, dramatic memory impairment, full
scale IQ of 85, impulsivity, poorconcentration and diffi-
culty in sequential planning and organization. However,
the patient's recent MRI and magneto-electrography were
within normal limits [18].
A recent, retrospective analyses of single center outcome
of nine hypothermic drowning victims treated with CPB in
Southern Finland was reported by Suominen et al. [33].
The median submersion time was 38 min (range, 5
75 min). All nine children were able to be weaned from
CPB. Unfortunately, only one child became a long-term
survivor with mild to moderate neurological deficit based
on the neuropsychological tests performed 3-years after
the incident. Four of the children died in the PICU and
four children within 4 months after discharge from the
hospital [33].
Health-related quality of life (HRQoL) scores were
reported for Finnish children who were long-term survi-
vors [41]. Each child had received either bystander or
emergency medical service personnel initiated CPR after a
drowning incident in childhood [41]. The median interval
between the accident and follow-up was 10.3 years (range:
1.8 21.8 years). According to results of the questionnaire,
a fairly good HRQoL was achieved in the vast majority of
patients surviving long-term after a severe drowning inci-
dentasachild.However,whenthesubmersiontime
exceeded 10 minutes the mean HRQoL total score was sig-
nificantly lower than for those patients with an estimated
submersion time of less than 10 minutes [41].
The variability of definitions of the patient population
and the outcome measurements make it somewhat diffi-
cult to assess and draw absolute conclusions from the
studies described above and in Table 1. The patient selec-
tion in the studies varied from children who had been
drowned for a short time without cardiac arrest to those
hypothermic children who were brought to the hospital
with ongoing CPR and rewarmed by CPB. Therefore, the
survival rates of the study populations varied between 11
and 100 percent [33,40].
The POPC scale was used in a retrospective study by
Suominen et al. [8]. This scale classifies quality of life into
six categories that range from good overall performance to
brain death. However, the POPC and similar scales are
considered too crude to assess neurologic outcome, al-
though POPC is recommended by the Utstein guidelines
for research on drowning [3-15]. The definition of good
outcome often includes patients with normal neurological
function or mild neurological impairment at hospital dis-
charge, and children with ataxia and dysarthria were
included in patients with satisfactory outcome in the study
by Bratton et al. [8,11].
Proper neurological and neurophysiological examina-
tions for drowned children are superior to outcome scales
based chart reviews. Unfortunately in three studies and
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Neurologic long term outcome after drowning in children.pdf
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  • Article
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    Objetivo: Los ahogamientos representan una de las principales causas de mortalidad externa a nivel mundial. El objetivo fue conocer las características del proceso de ahogamiento y su conexión con las condiciones de seguridad de las piscinas de uso colectivo. Método: Se realizó un estudio observacional descriptivo utilizando datos de fuentes judiciales con emplazamiento en la población española durante 2000-2015. Se investigaron datos sociodemográficos, tipos de instalaciones, actividad previa que realizaba la víctima, factores de riesgo y la causa principal del suceso lesivo. Resultados: Se registraron un total de 56 ahogamientos en piscinas, de los que 49 fallecieron. Un 76.8% eran varones, 71.4% menores de edad y el grupo más vulnerable (32.4%) fue el de 5-10 años. El 37.5% de las víctimas no sabía nadar y el 60.7% no estaban solas. Los sucesos se localizaron más habitualmente en piscinas municipales (46.4%). Entre las causas más frecuentes de ahogamiento destacaron la culpa in vigilando del socorrista (19.64%), deficiente supervisión del niño por un adulto (17.86%) y la conducta imprudente de la víctima (14.29%). Se identificaron factores de riesgo relacionados con deficiencias o ausencia de medidas pasivas: barrera de protección del vaso (7.1%), equipamiento de salvamento acuático (7.1%), visibilidad de zona de baño (3.6%) y toma de aspiración de agua desprotegida (1.8%). Conclusiones: Los ahogamientos continúan siendo una importante causa de mortalidad en piscinas de uso colectivo. Para reducir las tasas de ahogamiento y evitar una devaluación de las condiciones de seguridad que malogren los objetivos preventivos es preciso cumplir rigurosamente las normas reglamentarias de piscinas y diseñar estrategias de intervención específicas.
  • Article
    Aim: Long-term outcomes beyond one year after non-fatal drowning are uncharacterized. We estimated long-term mortality and identified prognostic factors in a large, population-based cohort. Methods: Population-based prospective cohort study (1974-1996) of Western Washington Drowning Registry (WWDR) subjects surviving the index drowning through hospital discharge. Primary outcome was all-cause mortality through 2012. We tabulated Utstein-style exposure variables, estimated Kaplan-Meier curves, and identified prognostic factors with Cox proportional hazard modeling. We also compared 5-, 10-, and 15-year mortality estimates of the primary cohort to age-specific mortality estimates from United States Life Tables. Results: Of 2,824 WWDR cases, 776 subjects (5[IQR 2-17] years, 68% male) were included. Only 63 (8%) non-fatal drowning subjects died during 18,331 person-years of follow-up. Long-term mortality differed by Utstein variables (age, precipitating alcohol use, submersion interval, GCS, CPR, intubation, defibrillation, initial vital signs, neurologic status at hospital discharge) and inpatient markers of illness severity (mechanical ventilation, vasopressor use, seizure, pneumothorax). Survival differed by age (HR 1.04;95%CI 1.03-1.05), drowning-related cardiac arrest (HR 3.47;95%CI 1.97-6.13), and neurologic impairment at hospital discharge (HR 5.10;95% CI 2.70-9.62). In adjusted analysis, age (HR 1.05;95%CI 1.03-1.06) and severe neurologic impairment at discharge (HR 2.31;95%CI 1.01-5.28) were associated with long-term mortality. Subjects aged 5-15 years had higher mortality risks than those calculated from Life Tables. Conclusion: Most drownings were fatal, but survivors of non-fatal drowning had low risk of subsequent long-term mortality similar to the general population that was independently associated with age and neurologic status at hospital discharge.
  • Article
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    Purpose: This study aimed to evaluate the clinical features of children who have survived a water submersion incident, and to identify risk factors for prognosis. Methods: We retrospectively reviewed the medical records of patients who experienced submersion between January 2005 and December 2014. The patients were classified into 2 groups, according to complications, and prognostic factors were evaluated. Results: During the study period, 29 children experienced submersion (20 boys and 9 girls; mean age, 83.8±46.4 months). Submersion occurred most commonly in the summer, with the peak incidence in August. The most frequent Szpilman clinical score was grade 5 (13 patients; 44.8%), followed by grade 6 (7 patients; 24.1%), and grades 1 or 2 (3 patients; 10.3%). Five children (17.2%) in the poor prognosis group died or had hypoxic ischemic encephalopathy, and the overall mortality rate was 6.9%. Poor prognosis after submersion was associated with lower consciousness levels (P=0.003), higher Szpilman scores (P=0.007), greater need for intubation and mechanical ventilator support (P=0.001), and longer duration of oxygen therapy (P=0.015). Poor prognosis was also associated with lower bicarbonate levels (P=0.038), as well as higher sodium, aspartate transaminase (AST), and alanine transaminase (ALT) levels (P=0.034, P=0.006, and P=0.005, respectively). Szpilman clinical scores were positively correlated with consciousness levels (r=0.489, P=0.002) and serum liver enzyme levels (AST and ALT; r=0.521, P=0.004). Conclusion: We characterized the prognostic factors associated with submersion outcomes, using the Szpilman clinical score, which is comparable to consciousness level for predicting mortality.
  • Drowning is a major cause of injury and death worldwide. This study aims to expand the evidence in fatal and non-fatal drowning. A retrospective study was conducted to investigate fatal and non-fatal drowning incidents attended by ambulance paramedics in Victoria (Australia) from 2007 to 2012. A total of 509 drowning incidents were identified, 339 (66.6%) were non-fatal, with 170 (33.4%) resulting in death. Children aged 0-4 years had the highest crude drowning rate (7.95 per 100,000 persons). Non-fatal incidents were more likely to be witnessed by a bystander when compared with fatal incidents (43.7% vs. 20.0%, p < 0.001). Spatial analysis indicated that 35 (43.8%) local government areas (LGAs) were considered at 'excess risk' of a drowning event occurring. This study is the first to apply spatial analysis to determine relative risk ratios for fatal and non-fatal drowning. These findings will enable geographically targeted and age-specific drowning prevention activities.
  • Article
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    The Wilderness Medical Society convened a panel to review available evidence supporting practices for the prevention and acute management of drowning in out-of-hospital and emergency medical care settings. Literature about definition and terminology, epidemiology, rescue, resuscitation, acute clinical management, disposition, and drowning prevention was reviewed. The panel graded evidence supporting practices according to the American College of Chest Physicians criteria, then made recommendations based on that evidence. Recommendations were based on the panel's collective clinical experience and judgment when published evidence was lacking.
Literature Review
  • Article
    There is little longitudinal data examining outcome of pediatric near-drowning. Most literature tracks status 5 years or less post insult, focusing primarily on gross neurologic status as opposed to more subtle neurocognitive deficits. The present case tracks the neuropsychological profile of a child who was submerged for 66 min, the longest time documented. Acute medical support was aggressive, and recovery was dramatic. being featured in multiple media reports. Although an article published 6 years after the near-drowning described the child as "recovering completely," the longitudinal profile indicates a pronounced pattern of broad cognitive difficulties. particularly notable for global memory impairment. Neuropsychological test results were significant despite the fact that the patient's recent MRI and MEG were within normal limits. This case demonstrates the need for long-term neuropsychological follow-up of pediatric patients with histories of neurologic injury, as gross neurological examination and MRI and MEG scans may not reveal underlying brain dysfunction.
  • Article
    Drowning and other asphyxial injuries are important causes of childhood morbidity and mortality. In this review, the epidemiology, pathophysiology, and treatments applied to near-drowning victims are discussed, with an emphasis on the difficulties encountered attempting to predict outcome using current methods.
  • Article
    To describe the short-term outcome of pediatric intensive care by quantifying overall functional morbidity and cognitive impairment, I developed the Pediatric Overall Performance Category (POPC) and the Pediatric Cerebral Performance Category (PCPC) scales, respectively. A total of 1469 subjects (1539 admissions) were admitted to the pediatric intensive care unit of Arkansas Children's Hospital from July 1989 through December 1990. Patients were assigned baseline POPC and PCPC scores derived from historical information and discharge scores at the time of discharge from the hospital (or from the pediatric intensive care unit for patients with multiple hospitalizations). Delta scores were calculated as the difference between the discharge scores and the baseline scores. The changes in POPC and PCPC scores were associated with several measures of morbidity (length of stay in the pediatric intensive care unit, total hospital charges, and discharge care needs) and with severity of illness (pediatric risk of mortality score) or severity of injury (pediatric trauma score) (p <0.0001). Interrater reliability was excellent (r = 0.88 to 0.96; p <0.001). The POPC and PCPC scales are apparently reliable and valid tools for assessing the outcome of pediatric intensive care.
  • Article
    Detailed information on drowning in children is not routinely collected by offices of national statistics. Few studies have been carried out in the United Kingdom, and none has been done on British children abroad. In 1988-9, two of the authors (AMK and JRS) combined information from national statistical offices, police forces (Royal Life Saving Society), and from a press cutting service (Royal Society for Prevention of Accidents) for a detailed analysis of deaths by drowning in children.1–3 This analysis found that 149 children had drowned in the United Kingdom during 1998-9. It also identified a safety agenda, which focused on young children in garden ponds and pools and on older children swimming without supervision. Over the past 10 years there have been initiatives on children's safety in water, particularly swimming. We obtained similar information for 1998-9 to identify changes that have occurred in 10 years and assessed whether these initiatives on safety have been successful.
  • • Between April 1979 and September 1984, 66 children were admitted to the intensive care unit (ICU) at Childrens Hospital of Los Angeles after a severe near-drowning episode. Each patient required full cardiopulmonary resuscitation and had an initial Glasgow coma score (GCS) of 3 in a referring emergency room. Patients were reclassified according to results of a neurologic examination (GCS) on arrival in the ICU. The overall results showed 16 patients (24%) with apparently intact survival, 17 patients (26%) with vegetative survival, and 33 deaths (50%). No patient who arrived at the ICU with a GCS of 3 (flaccid) survived neurologically intact. Out of 37 such patients arriving in flaccid coma, 26 patients died and 11 patients suffered severe brain damage. The majority of patients with GCS of less than 6 underwent intracranial pressure (ICP) monitoring and aggressive therapy directed to control ICP. Despite adequate control of ICP and maintenance of cerebral perfusion pressure, 12 monitored patients survived in a vegetative neurologic state. The results justify aggressive emergency room resuscitation of severe pediatric near-drowning victims but suggest that cerebral resuscitative measures must be subjected to critical prospective evaluation. (AJDC 1986;140:571-575)
  • Article
    A 2 1/2year-old girl had a good neurologic recovery after submersion in cold water for at least 66 minutes; as far as we know, this is the longest time ever reported. Cardiopulmonary resuscitation was maintained for more than two hours before the initiation of extracorporeal rewarming in this child who had a core temperature of 19°C. To our knowledge, this is the first successful use of extracorporeal rewarming in a child suffering from accidental hypothermia. Extension of this technique to children offers rapid rewarming and cardiovascular support for pediatric victims of severe hypothermia. We emphasize the importance of a coordinated response by the entire emergency medical system integrated with hospital-based personnel. Where it is geographically feasible, regionalization of triage and care for the pediatric victim of severe accidental hypothermia should be considered. (JAMA 1988;260:377-379)
  • Article
    The retrospective electroclinical evaluation of anoxia by near-drowning in 23 children observed between 1985 and 1989 revealed 2 groups, each with a distinct evolution: the first group, with good prognosis of 17 children, which recovered consciousness without neurological complications between 2 d and 1 wk after the accident. The second group of 6 children with a poor outcome-either i), death; or ii), state of permanent injury; or iii), a high level of clinical deficits. The gravity of the early clinical state, the estimed duration of cardiorespiratory arrest, the severity of the hypothermia, the seizures and the paroxysmic activity, do not determine the severity of near-drowning encephalopathy. The EEG patterns described in correlation with the group and the clinical outcome permitted determination of prognostic criteria. A good prognostic consisted of the following: moderate background activity, sleep patterns, response to auditory and painful stimulations, and numerous beta rhythms. A bad outcome was defined by: high voltage, rhythmic delta waves; biphasic sharp waves; monotonous EEG, “burst-suppression” pattern, absence of beta rhythms. The importance of EEG recordings is emphasized performed as early as possible and until 3 or 7 d after the near-drowning. Any modification in the EEG, with attenuation or disappearance of fast frequencies and painful reactivity, appearance or enhancement of slow and biphasic sharp waves, are ominous signs and may be accompanied by the appearance of cerebral oedema and decerebration
  • Article
    To describe health-related quality of life (HRQoL), quality-adjusted life years (QALYs) gained and school performance in subjects having received either bystander or emergency medical service personnel initiated cardiopulmonary resuscitation (CPR) after a drowning incident in childhood. 64 children admitted to pediatric intensive care (PICU) after successful CPR between 1985 and 2007. Eleven died in the PICU, 9 other within 6 months. In 2009 all long-term survivors, except for two, lived at home. Of the 40 patients eligible for the study, 29 (73%) responded to a questionnaire. HRQoL was assessed with the generic 15D, or its versions for adolescents (16D) or children (17D), and compared to that of general population. These HRQoL scores, age-specific survival probabilities, and HRQoL scores of the general population were used in a Markov model to estimate the number of QALYs gained. Median age of the respondents was 17.3 (range: 3.0-28.4) years and 62% were male. At the time of drowning their median age had been 3.0 (range: 1.2-15.7) years. The drowning incident was associated with a significant loss in HRQoL in the oldest age group (total HRQoL total score 0.881 compared to 0.971 in the general population, P<0.01) but not in children (HRQoL score 0.944 vs. 0.938). When submersion time exceeded 10min mean HRQoL score was significantly lower than in patients with a shorter submersion (0.844 vs. 0.938, P=0.032). The mean undiscounted and discounted (at 3%) number of QALYs gained by treatment were 40.8 and 17.0, respectively. A good HRQoL will be achieved in the majority of patients surviving long-term after a drowning incident in childhood, although HRQoL is affected by the submersion time.
  • Article
    Hypoxic-ischaemic brain injury is common and usually due to cardiac arrest or profound hypotension. The clinical pattern and outcome depend on the severity of the initial insult, the effectiveness of immediate resuscitation and transfer, and the post-resuscitation management on the intensive care unit. Clinical assessment is difficult and so often these days compromised by sedation, neuromuscular blockade, ventilation, hypothermia and inotropic management. Investigations can add valuable information, in particular brain MRI shows characteristic patterns depending on the severity of the injury and the timing of imaging. EEG patterns may also suggest the possibility of a good outcome. There is no entirely reliable algorithm of clinical signs or investigations which allow a definitive prognosis but the combination of careful repeated observations and appropriate ancillary investigations allows the neurologist to give an informed and accurate opinion of the likely outcome, and to advise on management. Overall, the prognosis is extremely poor and only a quarter of patients survive to hospital discharge, and often even then with severe neurological or cognitive deficits.
  • Article
    Full-text available
    In cardiac arrest patients (in hospital and pre hospital) does resuscitation produce a good Quality of Life (QoL) for survivors after discharge from the hospital? Embase, Medline, The Cochrane Database of Systematic Reviews, Academic Search Premier, the Central Database of Controlled Trials and the American Heart Association (AHA) Resuscitation Endnote Library were searched using the terms ('Cardiac Arrest' (Mesh) OR 'Cardiopulmonary Resuscitation' (Mesh) OR 'Heart Arrest' (Mesh)) AND ('Outcomes' OR 'Quality of Life' OR 'Depression' OR 'Post-traumatic Stress Disorder' OR 'Anxiety OR 'Cognitive Function' OR 'Participation' OR 'Social Function' OR 'Health Utilities Index' OR 'SF-36' OR 'EQ-5D' as text term. There were 9 inception (prospective) cohort studies (LOE P1), 3 follow up of untreated control groups in randomised control trials (LOE P2), 11 retrospective cohort studies (LOE P3) and 47 case series (LOE P4). 46 of the studies were supportive with respect to the search question, 17 neutral and 7 negative. The majority of studies concluded that QoL after cardiac arrest is good. This review demonstrated a remarkable heterogeneity of methodology amongst studies assessing QoL in cardiac arrest survivors. There is a requirement for consensus development with regard to quality of life and patient centred outcome assessment in this population.