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The Use of Extracorporeal Rewarming in a Child Submerged for 66 Minutes
Abstract
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)
... On 10 June 1986, a girl fell into a creek near Salt Lake City, U.S.A. [Bolte et al., 1988]. Rescuers later found her underwater, wedged against the upstream side of a rock; they saw no evidence of an air pocket. ...
... At the surface, she was cyanotic, with no palpable pulse. The girl survived, though, with seemingly no serious long-term effects [Bolte et al., 1988]. ...
The vital medical aspects of crucifixion are known to be similar to some medical aspects of drowning. And some people have been able to survive being underwater, without breathing, for tens of minutes (e.g. Bolte et al., Journal of the American Medical Association, 1988). We argue that some of the physiological mechanisms that enabled those people to survive could also account for Jesus being able to survive his crucifixion. Those mechanisms are known to be activated by certain conditions—and the conditions are demonstrated to be described in the biblical story. Thus, the apparent resurrection of Jesus has a reasonable naturalistic explanation.
... On 10 June 1986, a girl fell into a creek near Salt Lake City, U.S.A. [Bolte et al., 1988]. Rescuers later found her underwater, wedged against the upstream side of a rock; they saw no evidence of an air pocket. ...
Some people have survived being underwater, without breathing, for tens of minutes. We draw an analogy between such near-drowning and crucifixion: because modern medical studies of crucifixion have generally concluded that the main cause of death was asphyxiation (induced by the position of the victim on the cross). The physiological mechanisms that enable some people to survive without breathing for tens of minutes are known from prior studies. We demonstrate that some of those mechanisms could also enable a person to survive crucifixion-induced asphyxiation for tens of minutes. The mechanisms are activated by certain conditions—and those conditions are described in the biblical story of the apparent resurrection of Jesus. Witnesses at the time of Jesus could reasonably have believed that Jesus had died; ergo, when Jesus was later found to be alive, they concluded that Jesus had been miraculously resurrected. The apparent resurrection of Jesus, though, has a naturalistic explanation.
... On 10 June 1986, a girl fell into a creek near Salt Lake City, U.S.A. [Bolte et al., 1988]. Rescuers later found her underwater, wedged against the upstream side of a rock; they saw no evidence of an air pocket. ...
Some people have survived being underwater, without breathing, for tens of minutes. We draw an analogy between such near-drowning and crucifixion: because modern medical studies of crucifixion have generally concluded that the main cause of death was asphyxiation (induced by the position of the victim on the cross). The physiological mechanisms that enable some people to survive without breathing for tens of minutes are known from prior studies. We demonstrate that some of those mechanisms could also enable a person to survive crucifixion-induced asphyxiation for tens of minutes. The mechanisms are activated by certain conditions—and those conditions are described in the biblical story of the apparent resurrection of Jesus. Witnesses at the time of Jesus could reasonably have believed that Jesus had died; ergo, when Jesus was later found to be alive, they concluded that Jesus had been miraculously resurrected. The apparent resurrection of Jesus, though, has a naturalistic explanation.
... This percentage drops rapidly, with the risk of death or severe neurological impairment after discharge from the hospital being given as almost 100% if the duration of immersion exceeds 25-27 min [128]. However, if the water is cold, this time can be extended, whereby the current 'record' is 66 minutes immersion with almost complete recovery [129]. In such cases, the water temperature appears to be protective, and cases with underwater survival with minimal long-term consequences have only been described in water below 6 • C [130]. ...
Cold water swimming (winter or ice swimming) has a long tradition in northern countries. Until a few years ago, ice swimming was practiced by very few extreme athletes. For some years now, ice swimming has been held as competitions in ice-cold water (colder than 5 °C). The aim of this overview is to present the current status of benefits and risks for swimming in cold water. When cold water swimming is practiced by experienced people with good health in a regular, graded and adjusted mode, it appears to bring health benefits. However, there is a risk of death in unfamiliar people, either due to the initial neurogenic cold shock response or due to a progressive decrease in swimming efficiency or hypothermia.
Objectives:
Extracorporeal membrane oxygenation (ECMO) is recommended in adults with drowning-associated hypothermia and out-of-hospital cardiac arrest (OHCA). Our experience of managing a drowned 2-year-old girl with hypothermia (23°C) and cardiac arrest (58 min) prompted this summary using the CAse REport (CARE) guideline to address the question of optimal rewarming procedure in such patients.
Design/patients:
Following the CARE guideline, we identified 24 reports in the "PubMed database" describing children less than or equal to 6 years old with a temperature less than or equal to 28°C who had been rewarmed using conventional intensive care ± ECMO. Adding our patient, we were able to analyze a total of 57 cases.
Main results:
The two groups (ECMO vs non-ECMO) differed with respect to submersion time, pH and potassium but not age, temperature or duration of cardiac arrest. However, 44 of 44 in the ECMO group were pulseless on arrival versus eight of 13 in the non-ECMO group. Regarding survival, 12 of 13 children (92%) undergoing conventional rewarming survived compared with 18 of 44 children (41%) undergoing ECMO. Among survivors, 11 of 12 children (91%) in the conventional group and 14 of 18 (77%) in the ECMO group had favorable outcome. We failed to identify any correlation between "rewarming rate" and "outcome."
Conclusions:
In this summary analysis, we conclude that conventional therapy should be initiated for drowned children with OHCA. However, if this therapy does not result in return of spontaneous circulation, a discussion of withdrawal of intensive care might be prudent when core temperature has reached 34°C. We suggest further work is needed using an international registry.
Riassunto
L’ipotermia accidentale è definita come una temperatura interna inferiore a 35 °C e di comparsa involontaria. Questo calo di temperatura influisce su tutte le funzioni dell’organismo. Va ricercata anche quando le circostanze sono poco suggestive, specialmente nel politraumatizzato. In presenza di un’attività circolatoria, la diminuzione del metabolismo tissutale protegge il paziente nonostante un rallentamento emodinamico che va rispettato. Se il paziente trema, può essere riscaldato con metodi non invasivi. Sotto i 32 °C, la vittima corre un rischio vitale. La mobilizzazione del paziente deve quindi essere cauta. È opportuno evitare ogni procedura terapeutica che potrebbe provocare una fibrillazione ventricolare. Se questi metodi di riscaldamento esterno non sono efficaci, soprattutto quando la temperatura interna è inferiore ai 28 °C, i pazienti dovrebbero essere trasportati in un centro in grado di instaurare un ECLS (extracorporeal life support). Questi centri devono accogliere anche i pazienti in arresto cardiaco, che possono essere trasportati con dispositivi di massaggio cardiaco automatizzati. In ospedale, algoritmi decisionali basati su criteri semplici come la kaliemia e il punteggio HOPE (hypothermia outcome prediction after ECLS) consentono di evitare tentativi di ECLS di riscaldamento su pazienti deceduti.
Targeted temperature management (TTM) has become a cornerstone in the treatment of comatose post-cardiac arrest patients over the last two decades. Belief in the efficacy of this intervention for improving neurologically intact survival was based on two trials from 2002, one truly randomized-controlled and one small quasi-randomized trial, without clear confirmation of that finding. Subsequent large randomized trials reported no difference in outcomes between TTM at 33 vs. 36°C and no benefit of TTM at 33°C as compared with fever control alone. Given that these results may help shape post-cardiac arrest patient care, we sought to review the history and rationale as well as trial evidence for TTM, critically review the TTM2 trial, and highlight gaps in knowledge and research needs for the future. Finally, we provide contemporary guidance for the use of TTM in daily clinical practice.
Aim
Patients with hypothermic cardiac arrest may survive with an excellent outcome after extracorporeal life support rewarming (ECLSR). The HOPE (Hypothermia Outcome Prediction after ECLS) score is recommended to guide the in-hospital decision on whether or not to initiate ECLSR in patients in cardiac arrest following accidental hypothermia. We aimed to assess the HOPE-estimated survival probabilities for a set of survivors of hypothermic cardiac arrest who had extreme values for the variables included in the HOPE score.
Methods
Survivors were identified and selected through a systematic literature review including case reports. We calculated the HOPE score for each patient who presented extraordinary clinical parameters.
Results
We identified 12 such survivors. The HOPE-estimated survival probability was ≥10% for all (n = 11) patients for whom we were able to calculate the HOPE score.
Conclusion
Our study confirms the robustness of the HOPE score for outliers and thus further confirms its external validity. These cases also confirm that hypothermic cardiac arrest is a fundamentally different entity than normothermic cardiac arrest. Using HOPE for extreme cases may support the proper calibration of a clinician’s prognosis and therapeutic decision based on the survival chances of patients with accidental hypothermic cardiac arrest.
Introduction: This systematic review and meta-analysis aims at comparing outcomes of rewarming after accidental hypothermic cardiac arrest (HCA) with cardiopulmonary bypass (CPB) or/and extracorporeal membrane oxygenation (ECMO).
Material and Methods: Literature searches were limited to references with an abstract in English, French or German. Additionally, we searched reference lists of included papers. Primary outcome was survival to hospital discharge. We assessed neurological outcome, differences in relative risks (RR) of surviving, as related to the applied rewarming technique, sex, asphyxia, and witnessed or unwitnessed HCA. We calculated hypothermia outcome prediction probability score after extracorporeal life support (HOPE) in patients in whom we found individual data. P < 0.05 considered significant.
Results: Twenty-three case observation studies comprising 464 patients were included in a meta-analysis comparing outcomes of rewarming with CPB or/and ECMO. One-hundred-and-seventy-two patients (37%) survived to hospital discharge, 76 of 245 (31%) after CPB and 96 of 219 (44 %) after ECMO; 87 and 75%, respectively, had good neurological outcomes. Overall chance of surviving was 41% higher ( P = 0.005) with ECMO as compared with CPB. A man and a woman had 46% ( P = 0.043) and 31% ( P = 0.115) higher chance, respectively, of surviving with ECMO as compared with CPB. Avalanche victims had the lowest chance of surviving, followed by drowning and people losing consciousness in cold environments. Assessed by logistic regression, asphyxia, unwitnessed HCA, male sex, high initial body temperature, low pH and high serum potassium (s-K ⁺ ) levels were associated with reduced chance of surviving. In patients displaying individual data, overall mean predictive surviving probability (HOPE score; n = 134) was 33.9 ± 33.6% with no significant difference between ECMO and CPB-treated patients. We also surveyed 80 case reports with 96 victims of HCA, who underwent resuscitation with CPB or ECMO, without including them in the meta-analysis.
Conclusions: The chance of surviving was significantly higher after rewarming with ECMO, as compared to CPB, and in patients with witnessed compared to unwitnessed HCA. Avalanche victims had the lowest probability of surviving. Male sex, high initial body temperature, low pH, and high s-K ⁺ were factors associated with low surviving chances.
Mittermair, Christof, Eva Foidl, Bernd Wallner, Hermann Brugger, and Peter Paal. Extreme cooling rates in avalanche victims: case report and narrative review. High Alt Med Biol 00:000-000, 2021.
Background:
We report a 25-year-old female backcountry skier who was buried by an avalanche during ascent. A cooling rate of 8.5°C/h from burial to hospital is the fastest reported in a person with persistent circulation.
Methods:
A case report according to the CARE guidelines is presented. A literature search with the keywords "avalanche" AND "hypothermia" was performed and yielded 96 results, and the last update was on October 25, 2020. A narrative review complements this work.
Results:
A literature search revealed four avalanche patients with extreme cooling rates (>5°/h). References of included articles were searched for further relevant studies. Nineteen additional pertinent articles were included. Overall, 32 studies were included in this work.
Discussion:
An avalanche patient cools in different phases, and every phase may have different cooling rates: (1) during burial, (2) with postburial exposure on-site, and (3) during transport. It is important to measure the core temperature correctly, ideally with an esophageal probe. Contributing factors to fast cooling are sweating, impaired consciousness, no shivering, wearing thin monolayer clothing and head and hands uncovered, an air pocket, and development of hypercapnia, being slender.
Conclusions:
Rescuers should be prepared to encounter severely hypothermic subjects (<30°C) even after burials of <60 minutes. Subjects rescued from an avalanche may cool extremely fast the more contributing factors for rapid cooling exist. After avalanche burial (≥60 minutes) and unwitnessed cardiac arrest, chances of neurologically intact survival are small and depend on rapid cooling and onset of severe hypothermia (<30°C) before hypoxia-induced cardiac arrest.
During a long‐duration manned spaceflight mission, such as flying to Mars and beyond, all crew members will spend a long period in an independent spacecraft with closed‐loop bioregenerative life‐support systems. Saving resources and reducing medical risks, particularly in mental heath, are key technology gaps hampering human expedition into deep space. In the 1960s, several scientists proposed that an induced state of suppressed metabolism in humans, which mimics ‘hibernation’, could be an ideal solution to cope with many issues during spaceflight. In recent years, with the introduction of specific methods, it is becoming more feasible to induce an artificial hibernation‐like state (synthetic torpor) in non‐hibernating species. Natural torpor is a fascinating, yet enigmatic, physiological process in which metabolic rate (MR), body core temperature (Tb) and behavioural activity are reduced to save energy during harsh seasonal conditions. It employs a complex central neural network to orchestrate a homeostatic state of hypometabolism, hypothermia and hypoactivity in response to environmental challenges. The anatomical and functional connections within the central nervous system (CNS) lie at the heart of controlling synthetic torpor. Although progress has been made, the precise mechanisms underlying the active regulation of the torpor–arousal transition, and their profound influence on neural function and behaviour, which are critical concerns for safe and reversible human torpor, remain poorly understood. In this review, we place particular emphasis on elaborating the central nervous mechanism orchestrating the torpor–arousal transition in both non‐flying hibernating mammals and non‐hibernating species, and aim to provide translational insights into long‐duration manned spaceflight. In addition, identifying difficulties and challenges ahead will underscore important concerns in engineering synthetic torpor in humans. We believe that synthetic torpor may not be the only option for manned long‐duration spaceflight, but it is the most achievable solution in the foreseeable future. Translating the available knowledge from natural torpor research will not only benefit manned spaceflight, but also many clinical settings attempting to manipulate energy metabolism and neurobehavioural functions.
Drowning is a significant cause of childhood morbidity and mortality globally. The underlying mechanisms vary with child development and most are modifiable to public health promotion strategies. This article serves to highlight some of the specific considerations for the clinical management of drowning in children, both prehospital and by the in-hospital paediatric resuscitation team. This includes changes to standard advanced paediatric life support in the presence of hypothermia.
Accidental hypothermia, defined as a core temperature <35 °C secondary to unanticipated cold exposure, is prevalent in all geographic regions and carries significant morbidity and mortality. The adage that “a person is not dead until warm and dead” remains true and aggressive resuscitation is therefore indicated in nearly every patient who presents with accidental hypothermia. Unfortunately, no strong evidence-based guidelines exist as the literature surrounding optimal management consists almost exclusively of case reports. Still, the amount of information on the topic allows the provider to develop a rationale treatment plan specific to the patient’s presentation and available resources. This chapter will review the existing evidence surrounding the accurate diagnosis of accidental hypothermia, basics of rewarming strategies, appropriate selection of rewarming modality, and controversial aspects of management.
0 trabalho indica o papel da alteração da temperatura sobre o mecanismo de morte neuronal isquémica. Faz uma revisão dos principais artigos relacionados, mostrando as perspectivas deste campo tão promissor e ainda não utilizado na pratica médica.
A narrative review is presented on the diagnosis, treatment and management of accidental hypothermia. Although all these processes form a continuum, for descriptive purposes in this manuscript the recommendations are organized into the prehospital and in-hospital settings.
At prehospital level, it is advised to: (a) perform high-quality cardiopulmonary resuscitation for cardiac arrest patients, regardless of body temperature; (b) establish measures to minimize further cooling; (c) initiate rewarming; (d) prevent rescue collapse and continued cooling (afterdrop); and (e) select the appropriate hospital based on the clinical and hemodynamic situation of the patient.
Extracorporeal life support has revolutionized rewarming of the hemodynamically unstable victim or patients suffering cardiac arrest, with survival rates of up to 100%.
The new evidences indicate that the management of accidental hypothermia has evolved favorably, with substantial improvement of the final outcomes.
A narrative review is presented on the diagnosis, treatment and management of accidental hypothermia. Although all these processes form a continuum, for descriptive purposes in this manuscript the recommendations are organized into the prehospital and in-hospital settings. At prehospital level, it is advised to: a) perform high-quality cardiopulmonary resuscitation for cardiac arrest patients, regardless of body temperature; b) establish measures to minimize further cooling; c) initiate rewarming; d) prevent rescue collapse and continued cooling (afterdrop); and (e) select the appropriate hospital based on the clinical and hemodynamic situation of the patient. Extracorporeal life support has revolutionized rewarming of the hemodynamically unstable victim or patients suffering cardiac arrest, with survival rates of up to 100%. The new evidences indicate that the management of accidental hypothermia has evolved favorably, with substantial improvement of the final outcomes.
Copyright © 2018 Elsevier España, S.L.U. y SEMICYUC. All rights reserved.
Drowning is defined as a process resulting in primary respiratory impairment from submersion/immersion in a liquid medium. Worldwide, drowning is the 11th most frequent cause of death in the 0-4 years age group, the third most frequent cause of death in children aged from 5 to 14 years, and the second leading cause of injury related death in childhood. The vast majority of drowning deaths occur in non-Western countries, and as with the majority of accidental deaths, there is a strong male preponderance. The drowning sequence has both pulmonary injury and nonpulmonary sequelae such as hypothermia, electrolyte imbalance, trauma, and hypoxic-ischemic damage. Pulmonary management ranges from the need for some supplemental oxygen to intubation and management of severe acute respiratory distress syndrome. Initial management is often in the field, and care should be taken to evaluate endotracheal tube sizes and ventilation practices as soon as feasible. The strongest predictor of good outcome is duration of immersion. Poor outcomes are observed in 60%-100% of subjects immersed for more than 10 minutes. Predictors of poor outcome include the presence of cardiac (as opposed to respiratory) arrest and the need for prolonged resuscitation defined as more than 20-25 minutes. Medically induced hypothermia has not been shown to change neurological outcome. Drowning disproportionately affects children, and most instances are preventable. Prevention measures through legislative and public health interventions have had modest success.
With an ethnographic focus on cryonics, this chapter explores secular temporalities of death and modalities of suspension. In cryonics, medico‐legally dead bodies are stored at liquid nitrogen temperatures, in suspended animation, in the hope that future science may be able to reanimate them. Since secular endings are final, that is, there is no time after life, continuity as a secular project has had to be constantly reimagined and reinscribed in other terms. The politics of suspension in the age of biotech is one such project, involving the constant and ongoing technoscientific translation of life into time, or rather of chronically incomplete lifetimes into promise‐bearing forms of future life.
New findings:
What is the topic of this review? This is the first review to look across the broad field of 'cold water immersion' and to determine the threats and benefits associated with it as both a hazard and a treatment. What advances does it highlight? The level of evidence supporting each of the areas reviewed is assessed. Like other environmental constituents, such as pressure, heat and oxygen, cold water can be either good or bad, threat or treatment, depending on circumstance. Given the current increase in the popularly of open cold water swimming, it is timely to review the various human responses to cold water immersion (CWI) and consider the strength of the claims made for the effects of CWI. As a consequence, in this review we look at the history of CWI and examine CWI as a precursor to drowning, cardiac arrest and hypothermia. We also assess its role in prolonged survival underwater, extending exercise time in the heat and treating hyperthermic casualties. More recent uses, such as in the prevention of inflammation and treatment of inflammation-related conditions, are also considered. It is concluded that the evidence base for the different claims made for CWI are varied, and although in most instances there seems to be a credible rationale for the benefits or otherwise of CWI, in some instances the supporting data remain at the level of anecdotal speculation. Clear directions and requirements for future research are indicated by this review.
Accidental hypothermia, defined as a core temperature <35 °C secondary to unanticipated cold exposure, is prevalent in all geographic regions and carries significant morbidity and mortality. The adage that “a person is not dead until he is warm and dead” remains true and aggressive resuscitation is therefore indicated in nearly every patient who presents with accidental hypothermia. Unfortunately, no strong evidence-based guidelines exist as the literature surrounding optimal management consists almost exclusively of case reports. Still, the amount of information on the topic allows the provider to develop a rationale treatment plan specific to the patient’s presentation and available resources. This chapter will review the existing evidence surrounding the accurate diagnosis of accidental hypothermia, basics of rewarming strategies, appropriate selection of rewarming modality, and controversial aspects of management.
Background:
Accidental hypothermia with arrested circulation remains a condition associated with high mortality. In our institution, extracorporeal circulation (ECC) rewarming has been the cornerstone in treating such patients since 1987. We here explore characteristics and outcomes of this treatment, to identify significant merits and challenges from 3 decades of experience in ECC rewarming.
Methods:
Sixty-nine patients rewarmed by ECC during the period from December 1987 to December 2015 were analyzed. One patient was excluded from the analyses because of combined traumatic cerebral injury. The analysis was focused on patient characteristics, treatment procedures, and outcomes were focused. Survivors were evaluated according to the cerebral performance categories scale. Simple statistics with nonparametric tests and χ(2) tests were used. Median value and range are reported.
Results:
Median age was 30 years (minimum 1.5, maximum 76), and the cause of accidental hypothermia was cold exposure (27.9%), avalanche (5.9%), and immersion/submersion accidents (66.2%). Eighteen patients survived (26.5%). The survival rate did not improve during the years. Survivors had lower serum potassium (p = 0.002), higher pH (p = 0.03), lower core temperature (p = 0.02), and shorter cardiopulmonary resuscitation time (p = 0.001), but ranges were wide. Although suspected primary hypoxia and hypothermia were associated with lower survival, we observed a 10.5% survival of these victims. Sixteen survivors had good outcome (cerebral performance category 1 or 2), whereas 2 patients with suspected primary hypoxia survived with severe cerebral disability (cerebral performance category 3).
Conclusions:
Despite extended experience with ECC rewarming, improved handling strategies, and intensive care, no overall improvement in survival was observed. Good outcome was observed even among patients with a dismal prognosis.
Background
This paper provides an up-to-date review of the management and outcome of accidental hypothermia patients with and without cardiac arrest. Methods
The authors reviewed the relevant literature in their specialist field. Summaries were merged, discussed and approved to produce this narrative review. ResultsThe hospital use of minimally-invasive rewarming for non-arrested, otherwise healthy, patients with primary hypothermia and stable vital signs has the potential to substantially decrease morbidity and mortality for these patients. Extracorporeal life support (ECLS) has revolutionised the management of hypothermic cardiac arrest, with survival rates approaching 100 % in some cases. Hypothermic patients with risk factors for imminent cardiac arrest (temperature <28 °C, ventricular arrhythmia, systolic blood pressure <90 mmHg), and those who have already arrested, should be transferred directly to an ECLS-centre. Cardiac arrest patients should receive continuous cardiopulmonary resuscitation (CPR) during transfer. If prolonged transport is required or terrain is difficult, mechanical CPR can be helpful. Delayed or intermittent CPR may be appropriate in hypothermic arrest when continuous CPR is impossible. Modern post-resuscitation care should be implemented following hypothermic arrest. Structured protocols should be in place to optimise pre-hospital triage, transport and treatment as well as in-hospital management, including detailed criteria and protocols for the use of ECLS and post-resuscitation care. Conclusions
Based on new evidence, additional clinical experience and clearer management guidelines and documentation, the treatment of accidental hypothermia has been refined. ECLS has substantially improved survival and is the treatment of choice in the patient with unstable circulation or cardiac arrest.
La evolución de la reglamentación y la normalización de los productos han generado grandes adelantos respecto a la información que recibe la población y las categorías profesionales que participan en los accidentes de niños y adolescentes. La mortalidad ha disminuido en el 70% en 20 años. Sin embargo, esta reducción es más clara en lo que atañe a los accidentes de tráfico que a los «accidentes de la vida diaria», que comprenden los accidentes domésticos, deportivos y de tiempo libre, y los accidentes escolares. A pesar de los progresos en los últimos 20 años y del descenso de la morbimortalidad, la patología accidental en la infancia sigue siendo un problema de salud pública. Como se ha dicho, este descenso es más marcado en los accidentes de tráfico que en los domésticos, deportivos y de tiempo libre. La patología accidental evoluciona también en función de las modas y los cambios de la vida diaria en las sociedades contemporáneas. Así, al lado de los accidentes típicos de la vida diaria surgen nuevos accidentes vinculados al uso inadecuado de algunos productos o a nuevas costumbres. La práctica de juegos peligrosos (juego de asfixia y de agresión) por niños en edad escolar o adolescentes se ha convertido en pocos años en un fenómeno preocupante, todavía mal conocido por los profesionales de la infancia o de la salud.
Aquatic sports are included in the top list of risky practices as the environment per se carries a possibility of death by drowning if not rescued in time. Not only are aquatic sports related to a high risk of death, but also all sports practiced on the water, over the water and on ice. Whatever the reason a person is in the water, drowning carries a higher possibility of death if the individual is unable to cope with the water situation, which may simply be caused by an inability to stay afloat and get out of the water or by an injury or disease that may lead to physical inability or unconsciousness. The competitive nature of sports is a common pathway that leads the sports person to exceed their ability to cope with the environment or simply misjudge their physical capability. Drowning involves some principles and medical interventions that are rarely found in other medical situations as it occurs in a deceptively hostile environment that may not seem dangerous. Therefore, it is essential that health professionals are aware of the complete sequence of action in drowning. This article focuses on the pulmonary injury in sports and recreational activities where drowning plays the major role.
Objective:
To describe outcomes and complications in the drowning subgroup from the Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital trial.
Design:
Exploratory post hoc cohort analysis.
Setting:
Twenty-four PICUs.
Patients:
Pediatric drowning cases.
Interventions:
Therapeutic hypothermia versus therapeutic normothermia.
Measurements and main results:
An exploratory study of pediatric drowning from the Therapeutic Hypothermia After Pediatric Cardiac Arrest Out-of-Hospital trial was conducted. Comatose patients aged more than 2 days and less than 18 years were randomized up to 6 hours following return-of-circulation to hypothermia (n = 46) or normothermia (n = 28). Outcomes assessed included 12-month survival with a Vineland Adaptive Behavior Scale score of greater than or equal to 70, 1-year survival rate, change in Vineland Adaptive Behavior Scale-II score from prearrest to 12 months, and select safety measures. Seventy-four drowning cases were randomized. In patients with prearrest Vineland Adaptive Behavior Scale-II greater than or equal to 70 (n = 65), there was no difference in 12-month survival with Vineland Adaptive Behavior Scale-II score of greater than or equal to 70 between hypothermia and normothermia groups (29% vs 17%; relative risk, 1.74; 95% CI, 0.61-4.95; p = 0.27). Among all evaluable patients (n = 68), the Vineland Adaptive Behavior Scale-II score change from baseline to 12 months did not differ (p = 0.46), and 1-year survival was similar (49% hypothermia vs 42%, normothermia; relative risk, 1.16; 95% CI, 0.68-1.99; p = 0.58). Hypothermia was associated with a higher prevalence of positive bacterial culture (any blood, urine, or respiratory sample; 67% vs 43%; p = 0.04); however, the rate per 100 days at risk did not differ (11.1 vs 8.4; p = 0.46). Cumulative incidence of blood product use, serious arrhythmias, and 28-day mortality were not different. Among patients with cardiopulmonary resuscitation durations more than 30 minutes or epinephrine doses greater than 4, none had favorable Pediatric Cerebral Performance Category outcomes (≤ 3).
Conclusions:
In comatose survivors of out-of-hospital pediatric cardiac arrest due to drowning, hypothermia did not result in a statistically significant benefit in survival with good functional outcome or mortality at 1 year, as compared with normothermia. High risk of culture-proven bacterial infection was observed in both groups.
A 3 year old child was brought to the emergency room (ER) by the rescue squad after he was pulled from a freshwater pond. He had fallen through the ice and been submerged for approximately 5min. Initially, the child was apneic, pulseless, and cyanotic. Cardiopulmonary resuscitation (CPR) was started. Upon arrival in the ER, the patient was still receiving CPR and was being ventilated by bag mask. Initial core temperature was 30°C. Arterial blood gas values were pH 6.95, PaO2 250mmHg, PaCO2 68mmHg, HCO−3 12mEqlL. Other laboratory results included Hgb 8.5gmldl, Hct 25.4%, Na+ 135mmol/L, K+ 3.4mmol/L, CL− 97mmol/L.
Whenever an apparently non-breathing victim (unconsciousness) is found in the water, the rescuer is confronted with a difficult choice. Should the rescuer attempt resuscitation procedures in the water and wait for a means of transport where the victim can be resuscitated while transported or should the rescuer bring the victim to shore immediate and there attempt resuscitation?
Der schwere Tauchunfall ist ein potenziell lebensbedrohliches Ereignis, das bei Tauchern und anderweitig überdruckexponierten Personen in der Dekompressionsphase auftreten kann. Durch einen raschen Abfall des Umgebungsdruckes kommt es zur Bildung freier Gasblasen in Blut und Geweben und dadurch zur Dekompressionserkrankung (DCI, von engl. »decompression illness« oder auch »decompression injury«). Abhängig vom Entstehungsmechanismus werden Dekompressionskrankheit (DCS: »decompression sickness«) und arterielle Gasembolie (AGE) unterschieden [1, 2].
Submersion victims represent a minority of lives that can be saved by resuscitation. Yet most submersion victims are young and it has been stated that drowning is the second leading cause of potential life lost. Besides this socio-economic argument, aspects with respect to adequate resuscitation justify special attention. Resuscitation of submersion victims has its own characteristics with respect to rescue, diagnosis, ventilation, prognosis and transport. In the emergency phase, complications that could lead to later hospital deaths can be prevented [1–3]. Because prehospital treatment is most important to reduce the mortality and morbidity of submersion victims, this chapter emphasizes the specific aspects related to the resuscitation of submersion victims.
A search for case reports about drowning with the keywords “drowning” + “case report” in Pubmed identified 660 articles. A selection was made of case reports with possible useful information for daily practice. Like always in case reports, some recommendations are debatable, but these are certainly worthwhile mentioning.
Drowning is an important cause of childhood morbidity and mortality worldwide, with tremendous discrepancy by demography. The epidemiology, pathoyphysiology, and outcome of drowning in children is reviewed. Evaluation and treatment of the drowning victim at various locations of care is discussed. Prediction of neurologic outcome is often difficult but important for decision making. Various means of predicting outcome, including clinical assessment, radiologic examination, and neurophysiological testing are reviewed.
Drowning is responsible for significant preventable morbidity and mortality worldwide causing more deaths than war. Over the past 10 years our understanding of the causative factors, pathophysiology, management, outcomes, and even the terminology used has changed. Aggressive pulmonary support has proven to be essential to optimizing the victim’s chances for a favorable outcome. Hypoventilation, steroids, dehydration, barbiturate coma, and neuromuscular blockade have not been shown to affect outcomes as previously thought. Further, no prognostic scale or clinical presentation has been found which accurately predicts long-term neurologic outcome. Simple preventative measures and educational efforts can be effective in preventing a major cause of morbidity and mortality in often young and healthy members of society.
New Findings
What is the topic of this review?
This review concerns human responses to extreme environmental stresses.
What advances does it highlight?
This review highlights the following factors: the relatively limited and varying value of adaptation; the value of research in this area to inform other medical conditions; the physiological pathways to drowning; the importance of multistressor studies and multistressor adaptation; and the need for a better understanding of the metabolomic and biomolecular basis of responses and their variation in extreme environments.
Professor Sir George Lindor Brown (1903–1971) is known for his pioneering research into cholinergic neuromuscular transmission. However, during World War II he worked in hyperbaric physiology, and his research into underwater physiology greatly improved the safety of divers. It is perhaps fitting, therefore, that this review, which accompanies the Physiological Society's G. L. Brown Prize Lecture for 2015, explores the impact and mitigation of the environmental stresses which, to varying extents, have shaped our past, threaten our present and inform our future. From a whole‐body, integrative perspective, this review examines our current understanding of microgravity, hypo‐ and hyperbaria, heat, cold air and cold water as both individual and combined stresses. Consideration is given to ways of mitigating the threat posed by environmental extremes, including the differing extents to which humans can demonstrate adaptation to them. Finally, recommendations for further study are suggested that might result in both direct and indirect insights.
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