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Clinical Course of 91 Consecutive Near-Drowning Victims
Abstract
Hospital records of 91 consecutive near-drowning victims were studied retrospectively. Eight-one (89 percent) of these patients survived. Patients who were alert on arrival at the emergency room survived, but those who were comatose and had fixed dilated pupils died. Other states of consciousness were unreliable predictors of survival. All patients with a normal chest roentgenogram on admission survived; however, values for arterial oxygen tension (PaO2) did not necessarily correlate with the chest roentgenograms. Values for arterial blood gas tensions and pH varied widely, as follows; PaO2, 25 to 465 mm Hg; arterial carbon dioxide tension (PaCO2), 17 to 100 mm Hg; pH, 6.77 to 7.50; and arterial bicarbonate level, 6.6 to 29.7 mEq/L. The ratio of PaO2 to the fractional concentration of oxygen in the inspired gas (FIo2), which was calculated to standardize PaO2 data for varying concentrations of inspired oxygen, ranged from 30 to 585 mm Hg. Only one patient with a ratio of PaO2/FIo2 greater than 150 mm Hg on admission subsequently died; this was a neurologic rather than a pulmonary death. Serum electrolytic concentrations and values for hemoglobin level and hematocrit reading neither predicted survival nor indicated that a threat to life existed. Steroid and prophylactic antibiotic therapy did not appear to increase the chance of survival. Observations on these patients are discussed in light of previous experiments in animals, and an approach to therapy is suggested.
... These gram-negative bacteria are widely distributed in freshwater and marine environments and are characterized by the production of inducible, chromosomal blactamase. Whether a short course of antimicrobial treatment could be beneficial for patients who have experienced drowning remains unsolved [20,30,31]. In the present study, early antibacterial therapy was started more frequently in the patients with DAP. ...
Objective
Pneumonia is the most frequent infectious complication among drowning patients requiring intensive care unit (ICU) admission. We aimed to describe clinical, microbiological and therapeutic data as well as predictors and impacts on patients ‘outcomes of such pneumonia.
Methods
We conducted a retrospective multicenter study (2013–2020) of 270 consecutive patients admitted for drowning to 14 ICUs in the west of France. Baseline characteristics and outcomes were compared according to the occurrence of drowning associated pneumonia (DAP), defined as pneumonia diagnosed within 48 hours of ICU admission. A Cox model was performed to compare survival at day-28 and logistic regression to identify risk factors for DAP. Microbiological characteristics and empirical antibacterial treatment were also analyzed.
Results
Among the 270 patients admitted to the ICU for drowning, 101/270 (37.4%) and 33/270 (12.2%) experienced pneumonia and microbiologically proven DAP, respectively. The occurrence of pneumonia was associated with higher severity scores at ICU admission (Median SAPS 2 score 34 [Interquartile range 25-55] versus 45 [28-67]; P=0.006) and longer ICU length of stay (2 days [1, 2, 3] versus 4 [2, 3, 4, 5, 6, 7]; P<0.001). Mortality at day-28 was higher among these patients (29/101 (28.7%) versus 26/169 (15.4%); P=0.013). Microbiologically proven DAP remained associated with higher day-28 mortality after adjustments for cardiac arrest and water salinity (adjusted HR 1.86 [95%CI 1.06-3.28]; P=0.03). Microbiological analysis of respiratory samples showed a high proportion of gram-negative bacilli (23/56; 41.1%) with high prevalence of amoxicillin-clavulanate resistance (12/33; 36.4%).
Conclusion
Pneumonia is a common complication in patients admitted in ICU for drowning, associated with increased mortality.
Working knowledge of toxins and environmental injuries is important to the intensivist in any ICU. This chapter focuses on the initial management of the poisoned, drowned, and burned patient with emphasis on resuscitation and the essential points of care following stabilization. The section on toxins and overdose provides information on general resuscitation as well as key toxin-specific points, illustrates a pattern-recognition based framework for dealing with undifferentiated toxidromes, discusses important antidotes, and outlines enhanced elimination and detoxification modalities. The section on drowning discusses epidemiology, the pathophysiology of drowning, and highlights the need to investigate for and treat medical conditions and injuries that frequently occur along with drowning. Finally, the section on thermal burns delves into the special considerations needed for airway assessment and management of burn patients, inhalation injuries, fluid resuscitation, wound care, and indications for transfer to a dedicated burn center.
Background
Improving oxygenation and ventilation in drowning patients early in the field is critical and may be lifesaving. The critical care interventions performed by physicians in drowning management are poorly described. The aim was to describe patient characteristics and critical care interventions with 30-day mortality as the primary outcome in drowning patients treated by the Danish Air Ambulance.
Methods
This retrospective cohort study with 30-day follow-up identified drowning patients treated by the Danish Air Ambulance from January 1, 2016, through December 31, 2021. Drowning patients were identified using a text-search algorithm (Danish Drowning Formula) followed by manual review and validation. Operational and medical data were extracted from the Danish Air Ambulance database. Descriptive analyses were performed comparing non-fatal and fatal drowning incidents with 30-day mortality as the primary outcome.
Results
Of 16,841 dispatches resulting in a patient encounter in the six years, the Danish Drowning Formula identified 138 potential drowning patients. After manual validation, 98 drowning patients were included in the analyses, and 82 completed 30-day follow-up. The prehospital and 30-day mortality rates were 33% and 67%, respectively. The National Advisory Committee for Aeronautics severity scores from 4 to 7, indicating a critical emergency, were observed in 90% of the total population. They were significantly higher in the fatal versus non-fatal group (p < 0.01). At least one critical care intervention was performed in 68% of all drowning patients, with endotracheal intubation (60%), use of an automated chest compression device (39%), and intraosseous cannulation (38%) as the most frequently performed interventions. More interventions were generally performed in the fatal group (p = 0.01), including intraosseous cannulation and automated chest compressions.
Conclusions
The Danish Air Ambulance rarely treated drowning patients, but those treated were severely ill, with a 30-day mortality rate of 67% and frequently required critical care interventions. The most frequent interventions were endotracheal intubation, automated chest compressions, and intraosseous cannulation.
The Wilderness Medical Society convened a panel to review available evidence supporting practices for acute management of drowning in out-of-hospital and emergency care settings. Literature about definitions and terminology, epidemiology, rescue, resuscitation, acute clinical management, disposition, and drowning prevention was reviewed. The panel graded available evidence supporting practices according to the American College of Chest Physicians criteria and then made recommendations based on that evidence. Recommendations were based on the panel's collective clinical experience and judgment when published evidence was lacking. This is the second update to the original practice guidelines published in 2016 and updated in 2019.
Riassunto
L’annegamento rimane un grave problema di sanità pubblica. La sua epidemiologia è meglio conosciuta grazie ai sondaggi estivi della Santé Publique France. L’analisi di queste indagini ci porta a considerare, per la Francia, l’annegamento come un fatto che presenta due facce principali. Quella dell’annegamento dei bambini piccoli, che si verifica maggiormente in acqua dolce e nelle piscine, e quella degli adulti maturi che avviene più in acqua di mare e nella banda dei 300 metri. La definizione di annegamento mette in evidenza il ruolo principale dell’insufficienza respiratoria acuta e dell’induzione dell’edema polmonare. La natura di questo edema polmonare deve essere meglio specificata perché senza dubbio non è esclusivamente lesionale. La gestione dell’annegamento comprende due aspetti complementari: un aspetto di primo soccorso e un aspetto medico. Il primo sottolinea l’importanza della rapida estrazione della vittima e il secondo l’importanza della gestione respiratoria. La prevenzione rimane il modo migliore di considerare il problema dell’annegamento. Pertanto, la prevenzione per i bambini deve concentrarsi sull’apprendimento del nuoto, sulla messa in sicurezza delle piscine e sull’attenzione dei genitori. Per quanto riguarda gli adolescenti e gli adulti, vanno sviluppate la riduzione dei comportamenti a rischio tra i più giovani e la riflessione sulla condizione fisica degli anziani. Infine, sono in corso di sviluppo degli studi sulla modellizzazione dei rischi di annegamento rispetto alle condizioni meteorologiche che potrebbero consentire di allertare i sistemi di emergenza nei periodi di maggior rischio.
Hypothermie entsteht ab einer Körperkerntemperatur von <35 °C. Kinder kühlen infolge ihres größeren Verhältnisses von Körperoberfläche zu -masse deutlich schneller aus als Erwachsene. Hypotherme Patienten sollten nur behutsam in ständiger Reanimationsbereitschaft bewegt werden. Bei 18 °C Körperkerntemperatur kann das Gehirn einen Kreislaufstillstand bis zu 10× länger tolerieren als bei 37 °C. Die Symptome des Ertrinkens (häufig von Hypothermie begleitet) ähneln einer akuten Trachealobstruktion mit rasch zunehmender Hypoxie. Bei der Notfallbehandlung steht die Beseitigung der Hypoxämie im Vordergrund, die Intensivtherapie erfolgt nach evidenzbasierten Standards. Echte Tauchunfälle umfassen Barotraumen und die Dekompressionskrankheit, unterschieden in der Akutphase in Typ 1 (Leitsymptom muskuloskelettale Schmerzen) und Typ 2 (neurologische Leitsymptome). Treten innerhalb der ersten 24 h nach einem Tauchgang Leitsymptome auf, muss an eine Dekompressionskrankheit gedacht werden.
Objective: The aim of the study was to see the effect of intravenous steroids in patients with blunt chest trauma-lung contusion and to compare the effect of steroid use based on improvement in oxygen saturation, ABG, and hospital stay, in the study group and control group. Methods: A prospective and observational study was carried out on patients with blunt chest trauma having lung contusion who were admitted to the multispecialty hospital for 2 years. Data were collected in a predesigned proforma. All patients with radiologically proven lung contusion were observed based on the steroid treatment given or not. Group A was steroid (study) group and Group B was non-steroid (control) group with 25 sample size in each group. Group A patients were treated with steroid (hydrocortisone) 20 mg/kg/day 6 hourly which was tapered over time. Control group patients were treated identically except for steroid use. Results: Most of the injuries affected the middle age group (25 to 65 years) which accounted for a total of 84%. The percentage of males and females in the study were 76% and 24%, respectively. The most common mode of injury was road traffic accidents which account for 76% as compared to non-road traffic accidents (24%). Statistical analysis showed there was an improvement in both groups in parameters such as Spo2, ABG-Pco2, and ABG-Sao2 and were statistically significant. While other improvements like ABG-Po2, radiological CT, and hospital stays were statistically insignificant. Conclusions: As both groups were showing improvements and there was no statistically much difference seen in both groups, we concluded that there is no role of intra-venous steroid use in lung contusion. However, every patient must undergo CT for a better assessment of the injury. Objective scoring systems are required in CT assessment of lung injury and studies with increased sample size and carried out at multiple centers are required for better conclusions.
Objectives:
To study the clinical and microbiological characteristics of children with drowning-associated aspiration pneumonia, so as to provide a reference for empirical selection of antibacterial agents.
Methods:
A retrospective analysis was performed on the medical data of 185 children with drowning-associated aspiration pneumonia who were admitted to Children's Hospital of Chongqing Medical University from January 2010 to October 2020. According to the drowning environment, these children were divided into four groups: fecal group (n=44), freshwater group (n=69), swimming pool group (n=41), and contaminant water group (n=31). The clinical characteristics and pathogen detection results were reviewed and compared among the four groups.
Results:
The 185 children had an age of 4 months to 17 years (median 34 months). Sputum cultures were performed on 157 children, and 103 were tested positive (65.6%), with 87 strains of Gram-negative bacteria (68.5%), 37 strains of Gram-positive bacteria (29.1%), and 3 strains of fungi (2.4%). Gram-negative bacteria were the main pathogen in the fecal group and the contaminant water group, accounting for 88.2% (30/34) and 78.3% (18/23), respectively. The freshwater group had a significantly higher detection rate of Gram-positive bacteria than the fecal group (P<0.008), and the swimming pool group had an equal detection rate of Gram-negative bacteria and Gram-positive bacteria.
Conclusions:
For pulmonary bacterial infection in children with drowning in feces or contaminant water, antibiotics against Gram-negative bacteria may be applied empirically, while for children with drowning in a swimming pool or freshwater, broad-spectrum antibiotics may be used as initial treatment, and subsequently the application of antibiotics may be adjusted according to the results of the drug sensitivity test.
Background
Drowning is a cause of significant global mortality. The mechanism of injury involves inhalation of water, lung injury and hypoxia. This systematic review addressed the following question: In drowning patients with lung injury, what is the evidence from primary studies regarding treatment strategies and subsequent patient outcomes?
Methods
The search strategy utilised PRISMA guidelines. Databases searched were MEDLINE, EMBASE, CINAHL, Web of Science and SCOPUS. There were no restrictions on publication date or age of participants. Quality of evidence was evaluated using GRADE methodology.
Results
Forty-one papers were included. The quality of evidence was very low. Seventeen papers addressed the lung injury of drowning in their research question and 24 had less specific research questions, however included relevant outcome data. There were 21 studies regarding extra-corporeal life support, 14 papers covering the theme of ventilation strategies, 14 addressed antibiotic use, seven papers addressed steroid use and five studies investigating diuretic use. There were no clinical trials. One retrospective comparison of therapeutic strategies was found. There was insufficient evidence to make recommendations as to best practice when supplemental oxygen alone is insufficient. Mechanical ventilation is associated with barotrauma in drowning patients, but the evidence predates the practice of lung protective ventilation. There was insufficient evidence to make recommendations regarding adjuvant therapies.
Conclusions
Treating the lung injury of drowning has a limited evidentiary basis. There is an urgent need for comparative studies of therapeutic strategies in drowning.
Drowning deaths are commonly seen in most forensic pathology practices. Experienced forensic pathologists perform autopsies and assign a cause and manner of death in such cases as a matter of routine. Deaths due to pulmonary overexpansion injury and subsequent air embolism are far less common and typically involve individuals who have been breathing compressed gas at depth, generally SCUBA (self-contained underwater breathing apparatus) divers. This review outlines the pathophysiological basis of these two forensic pulmonary issues and recommends an approach to performing and interpreting the results of a forensic autopsy when faced with such cases.
Objectives
To determine patient demographics, associated primary diagnoses, mortality risk, and inpatient mortality of admitted drowning patients in the U.S.
Methods
Retrospective cross-sectional study using 2016 National Inpatient Sample Healthcare Cost and Utilization Project Agency for Healthcare Research and Quality dataset. External cause codes were used to identify drowning records, excluding self-inflicted/suicides. ICD-10 diagnosis and procedure codes, patient demographics, and admission-related data were collected.
Results
Of the 4,355 admissions in 2016, 68.3% were male (95% CI 65.3-71.3%) and 70.3% were white (95% CI 66.9-73.6%) with mean length of stay of 5.5 days (95% CI 4.9-6.2) and mean total charge of 70926-$92321). 8.2% of admissions resulted in inpatient death. Those that died were significantly younger than those that did not die (χ²=5.9, p=0.02). There was a statistically significant association between primary payer and inpatient mortality (χ²=10.5, p=0.02).
Conclusion
Younger, male, and white patients accounted for the majority of drowning admissions and deaths. A significantly larger proportion of Medicaid patients died compared to inpatient mortality of those with other insurance. Recognizing those most impacted by drowning could help better tailor prevention efforts.
Background:
Management of pediatric drowning often includes evaluation and treatment of infectious disease. There are few data describing the infections associated with pediatric drowning.
Methods:
A descriptive retrospective study was designed, and patients aged < 19 years admitted for > 24 hours to our institution after a drowning were included from January 2011 through June 30, 2017. Data collection included patient demographics, submersion injury details, resuscitation details, patient admission details, chest radiograph on admission, use of intubation and mechanical ventilation, hospital length of stay, culture data, antimicrobial use, and mortality. Descriptive statistical methods (mean and standard deviation, median and range, percentage) were used to characterize the patient population, and Fisher exact test was used to evaluate the association between antimicrobial use in the first 72 hours of admission and mortality.
Results:
A total of 114 patients met study criteria (male, 59.7%; median age, 3.7 years [range, 0.15-17.79 years]). Median hospital length of stay was 2 days (range, 1-60 days). Intensive care unit admission occurred in 80.7%, intubation occurred in 46.5%, and mortality was 18.4%. The most common submersion location was a pool (76.3% [n = 87]) with water primarily characterized as freshwater (82.5% [n = 94]). Reported submersion time for the majority of patients was < 5 minutes (54.4%) with cardiopulmonary resuscitation in 78.1%. In the first 72 hours after admission, culture were obtained in 40 patients (35.1%), and 27.5% of these cultures were positive. The primary organisms identified were consistent oropharyngeal flora. Antimicrobials were initiated in 50% of the patient population with clindamycin as most common. There was not a significant association between antimicrobial use in the first 72 hours after admission and mortality (17.2% vs 19.6%, P = .81).
Conclusions:
Infectious disease associated with pediatric drowning in pools is uncommon. Empiric use of antimicrobials does not appear to affect outcomes.
The Wilderness Medical Society convened a panel to review available evidence supporting practices for acute management and treatment of drowning in out-of-hospital and emergency medical care settings. Literature about definitions and terminology, epidemiology, rescue, resuscitation, acute clinical management, disposition, and drowning prevention was reviewed. The panel graded available evidence supporting practices according to the American College of Chest Physicians criteria and then made recommendations based on that evidence. Recommendations were based on the panel's collective clinical experience and judgment when published evidence was lacking. This is the first update to the original practice guidelines published in 2016.
Although common in human medicine, submersion injury has been infrequently described in veterinary medicine, with only a few studies being available in the literature. Submersion injury is a process that begins with immersion and submersion under water which may or may not lead to death of the patient. The outcome depends on several factors including predisposing factors, water temperature, submersion time, activation of adaptive reflexes and presence of early and effective resuscitation. The main pathophysiological mechanism is the development of hypoxemia leading to hypoxia. Submersion injury has been associated with several complications, especially involving the respiratory and neurological systems. Diagnosis and treatment are mainly focused on identifying oxygenation, ventilation, and cardiovascular abnormalities and minimizing the risk of cerebral injury. Prognosis is variable depending on several factors. To date, no identified prognostic factors have been identified as being 100% accurate.
Recovery of a body from water does not mean drowning. Other causes of death, including trauma, are possible. Drowning is a type of asphyxia that involves complex pathophysiological mechanisms, which contribute to death. Premorbid conditions (e.g., ischemic heart disease, epilepsy, ethanol intoxication) increase the risk of drowning. Despite the complexity of the drowning process, associated external and internal findings are few. The lack of specific signs and submersion artifacts can hinder the determination of the cause of death in a presumed drowning. Various drowning “tests” have been used to assist in this assessment. A bathtub death can be particularly challenging because all manners of death occur. A diver’s death, ironically, can be caused by the artificial air supply.
Ashbaugh et al. (3) beschrieben 1967 ein Syndrom - bestehend aus Atemnot, Tachypnoe, Zyanose und bilateralen Infiltrationen auf der Röntgenaufnahme des Thorax -, das sie in Anlehnung an das Atemnotsyndrom des Neugeborenen als Adult Respiratory Distress Syndrome (ARDS) bezeichneten. Die Diagnose des ARDS basiert auf klinischen, radiologischen und pathophysiologischen Veränderungen: Klinische Zeichen des akuten Atemversagens, schwerste Hypoxämie, erhöhter pulmonaler Rechts-Links-Shunt, gesteigerte Totraumventilation, verringerte pulmonale Compliance sowie radiologisch sichtbare, diffuse bilaterale Lungeninfiltrationen. Ein Linksherzversagen muß ausgeschlossen sein. Oft handelt es sich bei den Erkrankten um vorher gesunde junge Menschen, bei denen das akute Lungenversagen als Folge einer Reihe von Krankheitsbildern auftritt, welche vom „Beinahe-Ertrinken” (28) über die Aspiration von saurem Mageninhalt (33), Trauma, Infektion, bis zum Endotoxin- und hämorrhagischen Schock (7) reicht. Eine eindeutige ursächliche Beziehung dieser Krankheitsbilder zum ARDS kann jedoch in vielen Fällen nicht hergestellt werden.
The Dead Sea contains a hyperconcentrated solution and is an example of the salt lakes which abound along geological fault lines. It is important to study human exposure to such media because of intentional or accidental immersion in these lakes. The present communication reviews the effect of (1) experimental, neck out immersion (NI); and (2) accidental near drowning (ND) in the Dead Sea.
1) NI in Dead Sea water failed to produce the expected natriuresis, diuresis and hypotension that is seen during NI in fresh water. The reason is probably the tourniquet-like effect of the venous system in the lower limbs, due to the high head of pressure of Dead Sea water. Such an increased pressure head may prevent the rise in venous return from the lower body seen during immersion in fresh water.
2) ND in the Dead Sea causes much greater fatality and morbidity than ND in sea water. The reason for this increased danger is, at least partly, due to the augmented load of solutes on ND victims in the Dead Sea. Such an increased solute load may lead to extreme hypercalcemia and hypermagnesemia.
The Dead Sea is a lake that lies at the bottom (minus 400 m below sea level) of the hot, arid area of the Syrian-African Rift. Due to its geographic peculiarities and high rate of evaporation, its solute content is extremely high (specific gravity 1.2). Somewhat similar salt lakes abound along the entire length of the Syrian-African Rift and along other geological rifts, such as those found in the Western United States of America (including the Great Salt Lake of Utah). Many of these lakes are located in scenic environments and are used as recreation and resort areas as well as open mining regions for minerals. Man may be exposed to the water of these salt lakes either intentionally or accidentally. It is therefore important to learn the effects of immersion and of near drowning in hyperconcentrated solutions. The purpose of this communication is to review: (a) the effects of experimental immersion to the neck (NI) on volume control; (b) plasma electrolyte disturbance during near drowning (ND) in the Dead Sea.
Drowning is a major cause of the accidental death of young people. Approximately 6000 persons drown in the United States each year; half of the victims are less than 20 years of age (U.S. Dept. Health and Human Services 1980). The vast majority are male (Kruis et al. 1979; Modell et al. 1976; Orlowski 1979), and at least 35% of the victims have been accomplished swimmers (Modell 1971).
Aspiration is a major cause of anesthetic mortality, a common cause of pulmonary disease in the hospitalized patient, and believed to be a major cause of mirbidity and mortality in critically ill patients. Following Mendelson’s classic description of postpartum aspiration pneumonitis, clinical and laboratory research has established the existence of a broad spectrum of “pulmonary syndromes” resulting from aspiration of various materials under many conditions.
There are approximately 7,000 deaths per year in the United States that are attributed to drowning. In addition, there are approximately 60,000 hospital admissions per year that are associated with water related accidents. Similar experiences in other countries make this a very common and serious clinical problem. Also, water accidents, drowning and near-drowning usually affect younger adults and the pediatric population, the type of patient that may expect a long and productive life if the patient survives and recovers brain function.
A diver who loses consciousness while under water creates a serious and potentially disastrous situation, especially in a deep dive. However, careful planning has made possible many successful rescues, even under the most difficult situation of diving from a bell. This section considers the probable causes of unconsciousness and suggests appropriate responses, including a plan of action for recovering the unconscious diver and performing resuscitation. Since each situation is different and a single plan cannot cover all possible circumstances, the guidelines given here should be reviewed and discussed by diving groups and used as a starting point for team planning, training, and action.
Drowning is an endemic ‘disaster’ all over the world usually related to leisure situations afecting mostly the young that turn into a dramatic and unexpected event for the majority of the population. Parents, friends, relatives, babysitters or guardians may feel not only profound loss and grief, but also guilt for a failure to full protection responsibilities, or intense anger at others who did not provide adequate supervision or medical care.
This chapter discusses risks and injuries relating to water sports. Water-related fatalities are the third leading cause of accidental death in the USA and second in the UK and Australia. Many factors play a role in drowning. They include ignorance or disregard of danger, an unrealistic idea of swimming ability, lack of knowledge of the area, lack of adequate supervision, inability to cope, the temperature of the water and lack of knowledge of safety procedures and first aid. Wet drowning is when hypoxia results because of the aspiration of fluid into the lungs. When large amounts of fresh water are aspirated, it diffuses rapidly from the alveoli into the circulation, resulting in hemodilution and hemolysis. More than 11 ml per kg body weight of fluid must be aspirated. Fresh water affects the surfactant content of the alveoli and in cases of near drowning may result in atelectasis at a later stage. In salt water drowning, when large amounts are inhaled, there is a shift of fluid from the circulation into the alveoli, with resulting pulmonary edema, but the surfactant system is not as affected. It is essential that there is an adequate number of suitably equipped boats with personnel qualified in first aid and water safety to carry out the rescue. The physician in charge should be competent to treat acute trauma and be able to intubate the injured; if necessary, scuba divers wearing wet suits should be a part of the team.
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].
Unter Ertrinken im eigentlichen Sinn versteht man den Tod durch Einatmen von Flüssigkeiten. Beinahe-Ertrinken bezeichnet einen Ertrinkungsunfall, der zumindest einige Zeit überlebt wird. Weltweit sterben 4 von 100 000 Menschen pro Jahr den Ertrinkungstod. Das Alter der Opfer zeigt dabei 2 Häufungsgipfel — den ersten bei Kindern unter 4 Jahren, den zweiten in der Altersgruppe der 15- bis 19-jährigen [20].
Drowning is a leading cause of death in childhood. Accidental submersion always is an unexpected tragedy, in which a previously healthy child is exposed to severe cerebral damage with potentially fatal outcome. With the improvement of emergency medical services and intensive pulmonary and cardiovascular care, the prevention of brain injury in patients who survive submersion has become the major therapeutic challenge. After basic life support has been started at the scene, submerged children should be transported to the nearest emergency room facility to assess whether they need advanced life support. Therefore, every emergency physician or intensivist is “at risk” of being confronted with these usually young children.
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.
Als Ausdruck zerebraler Hypoxie und später als Folge reaktiver Hirndrucksteigerung findet man alle Grade eingeschränkter Bewußtseinslage bis zu tiefer Bewußtlosigkeit, evtl. auch Krampfneigung.
Das schwere akute Lungenversagen des Erwachsenen, in der englischsprachigen Erstbeschreibung als “adult respiratory distress syndrome” (ARDS) bezeichnet, ist durch eine anhaltende, ausgeprägte Störung des pulmonalen Gasaustausches, einen extremen Abfall der Lungencompliance und ein radiologisch erfaßbares interstitielles und/oder alveoläres, nicht kardial ausgelöstes Lungenödem charakterisiert [3]. Oftmals sind sehr junge Patienten ohne wesentliche Vorerkrankungen nach z. B. schwerem Trauma, hämorrhagischem Schock, Aspiration von Mageninhalt, Pneumonie oder „Beinaheertrinken“ betroffen [6, 37, 47]. Obwohl die Ätiologie dieser Erkrankung sehr unterschiedlich sein kann, finden sich bei Fortschreiten der Krankheit schwerste entzündliche Veränderungen der gesamten Lunge. Die Letalität dieser Erkrankung wird bis heute noch mit über 50%, zum Teil bis 90%, angegeben [11, 49, 51, 55]. Einer der Gründe für die hohe Letalität liegt, abgesehen von dem deletären Verlauf weniger spezieller Formen des ARDS, auch in der therapiebedingten zusätzlichen Schädigung der Lunge. Die zur Aufrechterhaltung annähernd normaler Blutgase notwendige aggressive Beatmungstherapie trägt selbst zur weiteren Verschlechterung des vorbestehenden Lungenschadens bei. Aufgrund der erforderlichen hohen Beatmungsdrücke und -volumina und einem inhomogenen Schädigungsmuster kommt es in noch gesunden Lungenarealen zu einer regionalen alveolären Überblähung, d. h. es tritt eine sowohl druck- als auch volumenbedingte mechanische Schädigung bisher funktionstüchtiger Alveolen ein.
Hypothermie entsteht ab einer Körperkerntemperatur von <35 °C. Kinder kühlen infolge ihres größeren Verhältnisses von Körperoberfläche zu -masse deutlich schneller aus als Erwachsene. Hypotherme Patienten sollten nur behutsam in ständiger Reanimationsbereitschaft bewegt werden. Bei 18 °C Körperkerntemperatur kann das Gehirn einen Kreislaufstillstand bis zu 10× länger tolerieren als bei 37 °C.
Die Symptome des Ertrinkens (häufig von Hypothermie begleitet) ähneln einer akuten Trachealobstruktion mit rasch zunehmender Hypoxie. Bei der Notfallbehandlung steht die Beseitigung der Hypoxämie im Vordergrund, die Intensivtherapie erfolgt nach evidenzbasierten Standards.
Echte Tauchunfälle umfassen Barotraumen und die Dekompressionskrankheit, unterschieden in der Akutphase in Typ 1 (Leitsymptom muskuloskelettale Schmerzen) und Typ 2 (neurologische Leitsymptome). Treten innerhalb der ersten 24 h nach einem Tauchgang Leitsymptome auf, muss an eine Dekompressionskrankheit gedacht werden.
Drowning is a frequent, preventable accident with a significant morbidity and mortality in a mostly healthy population. Prompt resuscitation and aggressive respiratory and cardiovascular treatment are crucial for optimal survival. In about two-thirds of patients, the primary injury is pulmonary, resulting in severe arterial hypoxaemia and secondary damage to other organs. Damage to the central nervous system is most critical in terms of survival and subsequent quality of life. Immediate reversal of hypoxia and aggressive treatment of hypothermia and cardiovascular failure are the cornerstones of correct medical treatment in the emergency department (ED) and intensive care unit (ICU). Accurate neurologic prognosis cannot be definitely predicted from initial clinical presentation and laboratory, radiological or electrophysiological examinations. Therefore, aggressive initial therapeutic efforts are indicated in most drowning victims.
The optimal use of inspired O2 is one of the most controversial areas in contemporary resuscitation [1]. Before discussing the studies supporting the recommendation, it is important to review information that is essential to a basic understanding of O2-related physiology.
The studies of Swann in the 1940s and 1950s called attention to the cardiovascular effects of the drowning process [1]. These experiments subjected awake dogs to total submersion until death and resulted in the conclusion that seawater victims died a respiratory death, secondary to pulmonary oedema, but freshwater victims died a cardiac death, secondary to ventricular fibrillation. Subsequent studies showed that only approximately 15 % of human victims died in the water [2]. Virtually, none of those who were rescued, revived and admitted to a hospital aspirated sufficient quantities of water to produce the severe serum electrolyte changes seen in Swann’s dogs [3]. Swann assumed that it was hyponatraemia that provoked ventricular fibrillation in conjunction with profound hypoxia. Yet, ventricular fibrillation has rarely been documented in human victims of drowning.
The drowning process begins when the entrance of the respiratory track has been immersed or submersed under water. Initially, a victim may struggle to remove himself from the aqueous environment. However, during the time that he is submerged he will first voluntarily hold his breath to avoid aspirating water. This usually is followed by a period of involuntary laryngospasm during which time substantial respiratory movement may occur but aspiration does not take place. Once the degree of hypoxia is sufficient so that the victim loses consciousness and no longer has his protective reflexes intact, the laryngospasm will abate, and the victim will actively breathe water into his lungs. During the period of breath holding and laryngospasm, it is not uncommon for victims to swallow significant quantities of water as well. The aspiration of water, obviously, compounds the degree of hypoxaemia, and this then is followed by circulatory arrest from myocardial hypoxia.
Drowning patients are at risk to develop acute lung injury (ALI) or acute respiratory distress syndrome (ARDS) after the rescue. Few data are available regarding the ventilator management of this specific group of patients. However, based on the pathophysiological characteristics of ARDS in drowning, it seems reasonable to use protective lung ventilation which has been previously demonstrated to improve the outcome in patients with ARDS from other causes.
Acute kidney injury (AKI) due to drowning in either salt water or freshwater is a rare but well-recognized disorder [1]. Many attempts of renowned research teams could not entirely unravel its pathophysiology, yet new insights are emerging [1–7]. Much of the literature has concentrated on the effects and management of both early and late respiratory complications of salt water aspiration, such as aspiration pneumonia and adult respiratory distress syndrome (ARDS) [7]. However, drowning may also cause cerebral (hypoxic brain injury), cardiac (atrial fibrillation) and haematologic complications (disseminated intravascular coagulation (DIC) and haemolysis) as well as multi-organ failure [8]. Moreover, drowning at specific locations may produce peculiar electrolyte disorders.
This chapter presents the consensus of a group of international investigators (Fig. 115.1) who met to establish guidelines for the uniform reporting of data from studies of drowning incidents. Similar consensus guidelines for reporting surveillance and resuscitation research have been developed for both adult and paediatric cardiac arrest [1, 2]. The principal purpose of the recommendations is to establish consistency in the reporting of drowning-related studies, both in terms of nomenclature and guidelines for reporting data. The following section highlights the overall concepts published in detail in [3] and [4].
Morbidity and mortality following successful resuscitation from drowning are most commonly related to pulmonary and neurologic injury [1]. The initial hypoxic injury from submersion may be compounded by ischemic injury from hypoxia-induced cardiac arrest and reperfusion injury including hyperoxia. While acute pulmonary injury is usually supportable and resolves, neurologic injury can lead to severe and persistent neurologic damage or death.
During the past 15 years the emphasis in treating near-drowning has shifted from observing changes in fluids and electrolytes to monitoring changes in pulmonary function and gas exchange (1). It has been documented that less than 15% of all drowning victims aspirate quantities of water sufficient to produce life- threatening changes in serum electrolyte concentrations (2). On the other hand, aspiration of even small quantities of fluid will produce persistent arterial hypoxemia (3, 4). If tissue hypoxia and anaerobic metabolism are severe, they lead to metabolic acidosis (5, 6). Although the cause of hypoxemia differs with fresh water (surfactant changes) and sea water (fluid-filled alveoli) (7), the result is the same: mismatched ventilation/perfusion ratios with intrapulmonary shunting that result in arterial hypoxemia (8).
Twenty-eight patients developed severe, progressive acute respiratory insufficiency despite aggressive application of conventional respiratory therapy. Application of increased PEEP (18 torr or greater) resulted in a significant decrease in QA/QT. Selection of the optimal levle of PEEP for each patient required serial determinations of QA/QT and measurement of cardiovascular response. The overall survival rate was 61 percent. Acute respiratory insufficiency was a proximate cause of death in only one patient. Four of the patients (14 percent) developed a pneumothorax following institution of high PEEP therapy. Cardiac output was not affected adversely at any level of PEEP up to 32 torr (44 cm H2O). We conclude that high levels of PEEP can be therapeutic for patients with refractory respiratory failure when combined with intermittent mandatory ventilation and careful cardiovascular monitoring. As with any therapy, the optimum dose should be tailored to each patient according to his needs and response.
Following aspiration of 0.1N hydrochloric acid with pH 1.0, 20 mongrel dogs were ventilated mechanically for four hours. Positive end-expiratory pressure of 10 cm H2O was added continuous positive-pressure ventilation (CPPV). In addition to CPPV, ten of the dogs received methylprednisolone (30 mg/kg body weight). The CPPV improved arterial oxygen tension, decreased venous admixture, increased arterial-venous oxygen content difference, and decreased systemic blood pressure. The addition of methyl-prednisolone did not significantly improve oxygenation, survival, or any other variable measured.
Cardiopulmonary resuscitation and rewarming were successful in a 5-year-old boy who had been submerged for 40 minutes in ice-cold fresh water. Severe metabolic acidosis was corrected by intravenous infusion of sodium bicarbonate solution before spontaneous circulation could be re-established. Fulminant pulmonary œdema developed after re-establishment of spontaneous circulation. This was efficiently reversed by positive-end-expiratory-pressure ventilation. During 2 days of treatment on a respirator the patient gradually regained consciousness; the endotracheal tube was then removed and the patient immediately started talking intelligently. The patient went through a period of slow cerebration and motor dysfunction but recovered rapidly, and on examination 13 months after the accident all findings were normal.
Twelve human near-drowning victims were treated, and their clinical courses were studied with particular attention given to electrolyte and blood gas changes. Ten of these patients made complete uneventful recoveries. The primary pathophysiological disturbance which necessitated emergency therapy was acute asphyxia with persistent arterial hypoxemia and acidosis. Initially the hypoxia appeared to be due to perfusion of nonventilated alveoli. Persistent arterial hypoxemia was present, however, even after a significant intrapulmonary shunt could no longer be demonstrated. The plan of management for each patient should be determined by individual laboratory and clinical studies.
The authors evaluated the efficacy of continuous positive-pressure ventilation (CPPV) and methylprenisolone alone and in combination as therapy for near-drowning in 80 dogs that had aspirated distilled water (22 ml/kg or 44 ml/kg). Forty dogs were treated with mechanical ventilation for one hour and 40 for 24 hours. Blood-gas tensions, pH, cardiac output and intrapulmonary shunt (Qs/Qt) were measured frequently for 24 hours. Blood-gas tensions and pH were again measured 48 and 72 hours and seven days later in survivors. Arterial oxygen tension (PaO2) decreased and Qs/Qt increased in all animals following aspiration and before therapy. Forty dogs received methylprednisolone intravenously (30 mg/kg) (20 breathed spontaneously and 20 had CPPV). There was a significant increase in PaO2 and decrease in pulmonary shunt in dogs that were ventilated mechanically compared with animals that breathed spontaneously. Treatment with methylprednisolone made no difference in blood gases, pulmonary shunt, or survival rates. Thus, no evidence to support the use of methylprednisolone in the treatment of the pulmonary lesion of fresh-water near-drowning was found. (Key words: Drowning, fresh-water; Hormones, adrenal, methylprednisolone.)
The accuracy of thermodilution for measuring cardiac output was studied by comparing this method with measurements obtained by an electromagnetic flowmeter in the dog. Thermal curves were computed by a cardiac output computer and absolute flows were obtained by pump calibration of the flowmeter. Regression analysis showed an excellent correlation (P less than 0.001) between thermodilution measurements with injectates at 0 degrees C and flowmeter measurements using either cannulating probes (n = 105, r = 0.98) or periaortic probes (n = 100, r = 0.96). With the use of normal room temperature injectates, a good correlation was also found with absolute flows (n = 75, r = 0.92, P less than 0.001). Thermodilution overestimated cardiac output by 3% to 9%. In 32 pairs of successive cardiac output determinations by thermodilution, there was no significant difference between the two measurements (P greater than 0.05). In eight patients cardiac output was measured postoperatively by thermodilution with injectates at 0 degrees C and 24 degrees C administered in rapid succession. Regression analysis of 50 pairs of measurements at the two temperatures showed a strong correlation between the two techniques (r = 0.96) and the two results were not significantly different (P = 0.00001).
After baseline studies, 44 dogs aspirated 22 ml./kg. of distilled water. The dogs were divided into 4 groups: control; positive end expiratory pressure (PEEP); respirator only (IPPV); and respirator and PEEP. The dogs treated with IPPV plus PEEP had a significant rise in Pao2 during treatment when compared with values prior to treatment (p<0.001) and also when compared to all other groups (p<0.001), at both F102 values. However, once treatment was discontinued, Pao2 dropped to the same level as in the other groups and then slowly improved over a week. The PaCO2 and pH returned to normal, regardless of therapy, by 4.25 hr.
Endotracheal instillation of 0.1 N HCl in 19 anesthetized dogs caused a severe pulmonary reaction that resulted in hypoxia, hypercarbia, metabolic acidosis, hemoconcentration and death in 80% of the animals. The resultant pulmonary damage was not altered morphologically or physiologically by high (30 mg/kg), low (0.3 mg/kg), or multiple (30 mg/kg every 8 hr for 3 days) doses of methylprednisolone administered intravenously.
DEATH by drowning is one of the major causes of childhood mortality. Studies of the mechanisms of drowning have demonstrated that two types of death may occur.1 Asphyxia without fluid aspiration is responsible for less than 10% of drowning deaths, but fluid aspiration occurs in about 80% to 90% of drowning victims.2
The pathophysiological changes which occur during drowning with fluid aspiration depend upon both the composition and volume of fluid aspirated.3-5 The most consistent finding in studies of drowning by aspiration of fluid is acute asphyxia with persistent arterial hypoxemia.3-7 This suggests that alveolar capillary membrane derangement occurs. This study was designed to see the effects of drowning by total immersion in distilled water, distilled water with chlorine, isotonic saline, and sea water on extracts of the alveolar lining layer (pulmonary surfactant).
Methods
Twenty mongrel dogs weighing 16 to 29 kg and in good physical
Die physiologischen Grundlagen fur die Behandlung von Ertrunkenen
- Modell
Ventilation/perfusion changes during mechanical ventilation
- Modell