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Submersion hypothermia and near-drowning
... This wide range of response may be due to a large number of variables, including the temperature of the water, the rate of cooling, the nature and quantity of the aspirate, and the clinical treatment. 81,82 ...
... Core chilling spares the brain; brain temperatures fall at up to 1°C a minute during the agonal respirations of drowning animals submerged in fresh water at 200-220C. 24 How long should one persist with cardiopulmonary resuscitation? If the victim has a core temperature above 330C and has taken neither drus nor alcohol I have yet to see a survivor without brain damage who did not make his or her first respiratory gasp within 40 minutes of rescue.'4 ...
Immersion accidents are not uncommon, and are always potentially serious with relatively low survival rates. Unlike many types of accidental or traumatic deaths (poisonings, for example), death rates from drowning have not fallen, and in some countries (the United States and Australia) continue to rise. Doctors may be asked to give medical care to the apparently drowned unexpectedly and at any time - at a local sailing club, a holiday beach across the world, the next door swimming pool, the local surgery, or in a hospital intensive care unit. The optimum management of the near drowned included many practical skills - rescue, extraction from the water, resuscitation at rescue site, transport, emergency room management, intensive care treatment, as well as the monitoring of convalescence and making realistic predictions about the prognosis in survivors.
... Drowning and near-drowning have been the subject of many reviews. 15 64 66 74 78 88 While resuscitation and the subsequent respiratory management of the near-drowning patient is now well established and largely non-controversial, the remaining major therapeutic challenge is limitation of brain damage in survivors with its associated consequent human and economic costs. Although the success stories tend to be reported, in the absence of full statistical information it is difficult to obtain an overall picture of the ratio of those who have been resuscitated and left with or without residual brain damage. ...
or death. However, pulmonary complications may follow aspiration of water without cessation of breathing or loss of consciousness. Thus “near-drowning” should be defined as “survival, at least temporarily, after aspiration of fluid into the lungs”. The importance of the distinction between the two definitions is that aspiration of fluid may lead to later pulmonary complications, even in those
... In the literature, ''long-term immersion'' induced by hypothermia, is also referred to as ''cold water immersion'' [25] or acute submersion hypothermia [26]. These terms are used to describe a situation in which certain individuals, usually children [27] but also other victims [28], survive for long periods under water. ...
This study examines the effects of age, gender, a cold water medium versus warm water medium, and salinity on strontium levels determined in left ventricular blood in drownings. Significant differences in the amount of strontium absorbed into the bloodstream (p<0.001) were detected between individuals who drowned in fresh water versus those drowning in seawater, and between those drowning in cold water versus warm water (p=0.030). However, no significant differences were noted in the strontium concentrations of left ventricular blood according to gender or age.
The drowning syndromes should be viewed as a continuum between the aspiration of a relatively small amount of water, causing symptoms and respiratory-based signs, through near-drowning, in which there is loss of consciousness but with survival, to the fatal cases of drowning. The latter rarely involve the gross haemodynamic and biochemical changes seen in some animal experiments. The behaviour of the victims, animal and human, during the incident is reviewed, as are the experiments conducted on animals, with various types and quantities of aspirate, to model the physiology. These experiments are compared with adult human clinical case series. "Quiet" drownings are described and classified. The clinical features of near drowning are reviewed. Factors which influence survival are noted. The pathological findings are discussed, with a critical approach to the concept of "dry" drowning, and some postulates on the findings of cranial haemorrhages. Lungs are the primary and dominant organ involved and hypoxia is the major physiological abnormality. The salt water aspiration syndrome, including its development, clinical and laboratory findings as seen in scuba divers, is also reviewed. Finally a brief review of the literature specific to scuba drownings is given.
The optimal treatment of the submersion victim continues to be revised and debated. Accurate analysis of therapeutic response to resuscitation after submersion will require a validated prognostic scale. The patient population is very heterogenous, with few cases presenting at many sites. We selected 11 potential predictive variables to be reviewed in 39 submersion incidents. These included the five variables comprising the Orlowski score. Three ‘physiologic’ variables were identified which, in combination, also predict neurologic outcome: pH less than or equal to 7.10, PaO2/PAO2 ratio less than or equal to 0.35, and anion gap greater than or equal to 15 mEq−1. Refinement and validation of a submersion outcome score limited to variables accurately ascertained at presentation will facilitate comparison of treatment protocols.
A 2 1/2-year-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 degrees 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.
The current status of fresh water near-drowning including some recent advances has been reviewed, with particular emphasis on cerebral salvage. The goal of paramount importance is intact cerebral survival after near-drowning but sadly death and incomplete recovery remain persistent problems. The use of a neurological classification is presented which has facilitated clinical and therapeutic studies. Aggressive therapeutic measures are described which have reduced morbidity and mortality but may easily lead to "vegetative" survival of some cases who formerly died. Many factors which affect prognosis are discussed but most are uncontrolled and uncontrollable. Experimental investigations are reported which led to the concept of acute submersion hypothermia which is probably the dominating factor in delaying irreversible brain damage while drowning. The "acute submersion hypothermia syndrome" is proposed to emphasize the value of immediate resuscitation under appropriate circumstances, of all cases of near-drowning in cold fresh water.
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