DROWNING - Dr Szpilman

Transcrição

AHA ACEP ECC Textbook - Lippincott Williams and Wilkins edition
Dr John M. Field M.D. <[email protected]>
CHAPTER - DROWNING (15-20 pages)
Authors:
Dr. David Szpilman – Brazil
Fire Department of Rio de Janeiro, Maritime Groupment, Head of Drowning Resuscitation Center in
Barra da Tijuca; Hospital Municipal Miguel Couto – Head of Adult Intensive Care Unit; Founder and ExPresident of Brazilian Life Saving Society – SOBRASA; Member of Board of Director and Medical
Committee of International Life-saving Federation, and Brazilian Resuscitation Council Associate.
Dr. Anthony J Handley – United Kingdom
Honorary Consultant Physician & Cardiologist, Colchester, UK; Chief Medical Adviser, Royal Life
Saving Society UK; Honorary Medical Officer, Irish Water Safety; Honorary Medical Adviser,
International Life Saving Federation of Europe; Chairman, BLS/AED Subcomittee Resuscitation Council
(UK).
Dr. Joost Bierens - Netherlands
Department of anesthesiology, VU University Medical Center Amsterdam, the Netherlands; Professor in
Emergency Medicine; Member of Medical Committee of International Life-saving Federation; Advisory
Board Member Maatschappij tot Reding van Drenkelingen; (The Society to Rescue People from
Drowning; founded in 1767); Medical Advisor The Royal Netherlands Sea Rescue Institution.
Dr. Linda Quan - USA
Attending physician-Emergency Services, Children’s Hospital Regional Medical Center, Seattle
Washington, USA; Professor, Division of Pediatric Emergency Medicine, Department of Pediatrics,
University of Washington School of Medicine, Seattle, WA, USA; Member of American Red Cross
Advisory Council on First Aid and Safety.
Dr. Rafael Vasconcellos - Brazil
Fire Department of Rio de Janeiro, Medical Pre-Hospital Care, Teaching Department; Medical Rescue
Team – Amil Resgate; Intervention Cardiologist.
Corresponding Address: David Szpilman - Av. das Américas 3555, bloco 2, sala 302,
Barra da Tijuca - Rio de Janeiro – RJ - Brazil 22793-004. Phone: 055 021 99983951
Fax: 24307168 [email protected] <www.szpilman.com>
CHAPTER – DROWNING
INTRODUCTION
EPIDEMIOLOGY
DROWNING DEFINITION AND TERMINOLOGY
PATHOPHYSIOLOGY
DROWNING CHAIN OF SURVIVAL – prevention to hospital
Prevention
Recognition & Alarming of incident
Rescue and Basic Water Life Support (BWLS)
On-land Basic Drowning Life Support (BDLS)
Advanced Drowning Life Support (ADLS) on site
Hospital
OUTCOME AND SCORING SYSTEMS
UNIFORM CLINICAL REPORTING OF DROWNING
REFERENCES
CHAPTER – DROWNING
INTRODUCTION
On a sunny weekend day, a family was invited to a barbecue at a friend´s swimming
pool. Suddenly, the mother noticed her four year-old boy was missing. After about 7
minutes he was found at the bottom of the pool and brought up to the pool´s edge. He
appeared dead and no one knew what else to do.
This scenario is usual in many countries and transforms a happy time to a very dramatic
moment and a future for every one involved of profound loss and grief, but also guilt for
failure to protect, or even intense anger at those who did not provide adequate
supervision or medical care.
Drowning is an injury whose treatment may involve many layers of personnel from
laypersons, lifeguards, and pre-hospital care providers as well as highly specialized
hospital staff. Care of the drowning victim is unique in that bystanders or rescuers need
specific skills that allow them to help the victim without becoming another victim.
Furthermore, the rescuer’s role is critical since the opportunity for a good outcome rests
almost entirely with care provided at the scene. If rescue and first aid from bystanders
fail, delayed medical treatment can not compensate any more for the obtained hypoxic
injuries, even when more advanced therapies are started.
Interest in drowning rescue and resuscitation has existed for hundred of years and drove
the development of the first resuscitation instruments, research, protocols, education and
systems. At that time and now, drowning is one of the most frequent causes of injury
deaths. For the current resuscitation community the main focus is on those with cardiac
disease. This chapter will advocate that resuscitation of drowning victims should remain
in the focus of the resuscitation community, at least for those who frequent privately or
professionally aquatic environments. This is 80% of the earth surface. Although
drowning tended to become a neglected, public health problem (1), it just recently has
again started to receive the attention it deserves.
At a medical and societal level, it must be recognized that every drowning related death
or hospitalization signals the failure of prevention.
EPIDEMIOLOGY
•
Drowning is responsible for more than 500,000 deaths around the world.
•
In the age group of 5 to 14 years, drowning is the leading cause of death worldwide
among males and the fifth leading cause for females.
•
Worldwide, it is the leading killer of children 1-17 years in Asia.
•
Numbers of drowning rescues are unknown but vary widely depending on different
geographic, cultural and economic resources available.
Each year, drowning is responsible for more than 500,000 deaths around the world (2).
These figures are an underestimation of the real figures. Especially in developing
countries many drowning deaths are unreported (table 1(3)). Numbers of drowning vary
widely depending on different geographic, cultural and economic resources. In some
European countries many drowning deaths are intentional injuries, due to suicide, while
in Australia, USA and Brazil the majority of drowning deaths are unintentional injuries.
In USA, an estimated 40 to 45% of deaths happen during swimming (4). Mortality and,
less frequently, hospitalization following drowning are the most commonly reported
indicators of drowning injury.
Age, gender, alcohol use, socioeconomic status (income, education, and ethnicity),
exposure, risk behavior and lack of supervision are key risk factors for drowning.
Considering all ages, males die 5 times more often from drowning than females. Young
children, teenagers and older adults are the ages at highest risk of drowning. Worldwide
drowning is the leading cause of death in the age group of 5 to 14 years among males
and the fifth leading cause among females (5) and it is the leading killer of children 1-17
years in Asia. (6).
In USA, drowning is the seventh leading cause of unintentional injury deaths for all
ages and the second leading cause of all injury deaths in children aged 1-14 years (7).
Many of these injuries occur in recreational water settings, including pools, spas/hot
tubs, and natural water settings (e.g., lakes, rivers, or oceans). During 2001-2002, an
estimated 4,174 persons on average were treated annually in U.S. Emergency
Departments for nonfatal unintentional drowning injuries in recreational settings, and
3,372 persons died in 2001. Children aged less than 4 years of age accounted for nearly
50% of the ED visits, and children aged 5-14 years an additional 25%. An estimated
75% of nonfatal injuries occurred in pools, whereas 70% of the fatalities occurred in
natural water settings. Approximately 53% of ED-treated patients required
hospitalization or transfer to another hospital for more specialized care (8).
In Brazil in 2003 with a population of 176 million inhabitants, 6,688 died (3.8/100,000
inhabitants) by drowning, the second leading cause of death for all causes among ages 1
to 14 years. The preponderance of drowning deaths (88%) was unintentional. Fatal
drowning involved mostly 20-29 year-old individuals (22,1%), followed by 15-19
(16%), 30-39 (15%), 10-14 (11%), 40-49 (9%), 1-4 (8%) and 5-9 (7%). There was no
sex distinction in death rates under 1 year of age, but males drowned 8.7 times more in
those ages 20 to 29 (9). As one of the largest year around aquatic recreational areas in
the world, Brazil provides a model for the development of a first responder system for
drowning to compare with EMS systems in other countries. From 1984, a tremendous
emphasis on lifesaving occurred when firefighters assumed the role of life guarding the
beaches and in-land water spots around the country and many more professionals are
available on duty. The development of a large cadre of these professionals on duty on
beaches led to creation, in 1995, of the Brazilian Lifesaving Society supported by the
International Lifesaving Federation (ILS) - the most important World Water Safety
organization. A recently research on that matter analyzed the trends on drowning from
1979 to 2003 in Brazil (10). The effect of this initiative was a 30% reduction in
drowning death rates from 1979 (5,42/100.000) to 2003 (3,78). Most of the decrease in
death rates occurred from 1995 (4,91) to 2003 (3,78), suggesting that two interventions
associated with maturation of the system - more lifeguards on duty and prevention
campaigns - led to the dramatic decrease in drowning deaths (Graphic 1).
On Rio de Janeiro beaches, drowning predisposing conditions are discernable in 13%
of all drowning cases; the most common is use of alcohol (37%), then convulsions
(18%), trauma (including boating accidents; 16.3%), cardiopulmonary diseases (14.1%),
skin diving and SCUBA diving (3.7%), diving resulting in head or spinal cord injuries,
and others (e.g., homicide, suicide, syncope, cramps, or immersion syndrome (11.6%)
(11). This highlights that 87% of drownings occur with no reasons other than a
negligent attitude of adults with themselves and with their children.
In countries where beach culture is prevalent, the need for larger numbers of lifeguards
on duty yearly around allows more prevention activity but also better documentation of
rescues and fewer deaths. But in certain locations with the same beach characteristics,
where resources are not available, lifeguard are scarce and the number of rescue are low
comparing with number of death. As much as drowning prevention is done and more
lifeguard are on duty the less people died in water. Different lifeguard associations have
create their unique nomenclature to report, which make more difficult the understanding
of what is happen on drowning. One of the most difficult tasks for the International
Lifesaving Federation (ILS) is to create a single and unique nomenclature and
terminology to compare and mainly to identify what can be done to improve the save of
life on water environment. The German Life Saving Society (DLRG), a 62,000
lifeguards association working on coast, at inland waters and in public swimming pools,
report 1,079 persons saved from drowning, 8,253 water sport activists cases helped in
emergency situation, 44,346 first aid attendance in and at the water, which 606 died, in
2006 (DRLG, annual report for the year 2006). Surf Life Saving Australia (SLSA)
reported for the season 2004-5, 14,601 rescues, 37,647 people who received first aid,
and 544,789 preventative actions, with 58 death by drowning (251 rescues to 1 death)
(SLSA – Report for the season 2004-5). In 2006, United States Lifesaving Association
(USLA) reported 56,612 rescues on the shores of US beaches with 90 deaths (629
rescues to 1 death). On Rio de Janeiro beaches, in 2003, 14,584 rescues were done
reporting 24 deaths by drowning (607 rescues to 1 death) and one death for each 10
drownings admitted for medical care in the Drowning Resuscitation Center (DRC), a
pre-hospital facility focus on drowning and trauma.
DROWNING: DEFINITION AND TERMINOLOGY
•
“Drowning is the process of experiencing respiratory impairment from submersion
or immersion in liquid”.
•
The term “near-drowning” is abandoned. Confusing terms, like ‘dry’ drowning and
secondary drowning are eliminated.
•
The drowning process is a continuum beginning when the patient’s airway is below
the surface of the liquid, usually water, which - if uninterrupted - may lead or not to
death.
Definition of drowning has been a huge problem for a long period. There was no
consensus in literature and among different water safety and health organizations,
experts in the field and lay-persons (12). Terms and definitions were awkward and
confusing and include sudden death, hypothermia, and diseases which occurred in
water. At the same time, some definitions excluded true cases of drowning which
needed hospitalization and died later from complication of drowning such as
pneumonia, Adult Respiratory Distress Syndrome (ARDS) or ischemic encephalopathy.
Therefore, the global burden of drowning has not only been wrongly measured through
imprecisely national statistics but also through inadequate terms and definitions. Based
on this needs, a Task Force on Epidemiology of Drowning (TFED) was established in
1998 within a dedicated framework of the World Congress on Drowning (WCOD) and
provoke a lively electronic discussion with contributions from many experts around the
world. The TFED released a paper on the website from the beginning of 2002 including
all arguments of this discussion. As part of the scientific program of the WCOD, four
discussion sessions were held based on this discussion paper. This procedure led to a
consensus and the adoption of the following definition by all conference attendees in
June 2002: “Drowning is the process of experiencing respiratory impairment from
submersion or immersion in liquid”. According to this new definition, the drowning
process is a continuum beginning with respiratory impairment, for example when the
patient’s airway is below the surface of the liquid or when there is a splash of waves in
the face. A patient can be rescued at any time during the process and given appropriate
resuscitative measures in which case, the process of drowning is interrupted. Any
submersion or immersion incident without evidence of liquid aspiration or respiratory
impairment should be considered a water rescue. The terms “near-drowning”, “dry’
drowning and secondary drowning (delayed onset of respiratory distress) are eliminated.
Immersion or submersion is a way to drown and not the name of the disease (13).
PATHOPHYSIOLOGY
•
Hypoxia is the most determinant factor in drowning severity and reversal of primary
hypoxia and prevention of secondary hypoxia are the determinant factors to
outcome.
•
Ventricular fibrillation is infrequent and is usually due to hypoxia and acidosis.
•
In drowning, apnea comes first, and if the victim is not ventilated soon enough, then
circulatory arrest will ensue.
•
In drowning survivors, permanent and severe neurologic sequelae usually occur
only following cardiac arrest.
•
Difference between drowning in fresh and salt water has only significance for
epidemiological purpose for planning prevention campaign.
•
Humans rarely aspirate sufficient water to provoke significant electrolyte
disturbances and usually do not need initial electrolyte correction.
There are several scenarios’ that can lead to drowning. These scenarios include the 2years old toddler who crawls into the water, where he will disappear without any sign of
distress and the young athletic swimmer who comes in a rip-current and after a
exhausting struggle finally submerges. Despite some differences between drowning in
fresh and salt water, from a clinical and therapeutic perspective, there are no important
differences in humans. The common significant pathophysiological mechanism in all
these scenarios of drowning is hypoxia (14).
When there is no way to keep the airways out of water, intentional breath holding is the
first automatic response. Water in the mouth is spelt out or swallowed. When after some
time a breath is taken, this may result in a first involuntary water aspiration and
consequently coughing or rarely laryngospasm, leading to hypoxia. If laryngospasm
occurs, the onset of hypoxia will terminates it rapidly. If not, water is gradually but in a
short time aspirated into the lungs, disturbing the ability to obtain oxygen.
Consciousness is lost or deteriorates and progressive hypoxia leads to apnea followed
by cardiac arrest. Involuntary apnea in face of hypoxia can be the result of a very low
oxygen dioxide (CO2) secondary to hyperventilation stress of being drowning, a way to
obtain more oxygen, which usually failure. The higher the hyperventilation the longer
apnea will persist. This whole process of drowning can last from 1 minute to some
times hours.
The respiratory distress of drowning is not a function of water composition but the
pulmonary response to the water aspirated. The aspiration of either fresh or salt water
can produces, pending on the amount, surfactant destruction, alveolitis and a
noncardiogenic pulmonary edema resulting in an increased intrapulmonary shunt and
hypoxia (15). In animal research, the aspiration of 2.2 ml of water per kilogram of body
weight decreases the arterial oxygen pressure (PaO2) to approximately 60 mm Hg
within 3 minutes (16). In humans, as little as 1 to 3 ml/kg of water aspiration produces
profound alterations in pulmonary gas exchange and decreases pulmonary compliance
by 10% to 40% (15). Humans rarely aspirate sufficient water to provoke significant
electrolyte disturbances and victims usually do not need initial electrolyte correction
(17). Ventricular fibrillation (VF) in humans is probably most common as a primary
event on drowning involving elderly in bath tubs, and in rare individuals with prolonged
QT syndromes. More commonly it occurs due to hypoxia and acidosis and not to
hemolysis and hyperkalemia. VF may occur during resuscitation due mostly to the use
of epinephrine. Decreased cardiac output, arterial hypotension, increased pulmonary
arterial pressure and pulmonary vascular resistance are the results of hypoxia. Hypoxia
produces a well-established sequence of cardiac deterioration, with tachycardia,
bradycardia, then a pulseless phase of ineffective cardiac contractions (PEA phase),
followed by complete loss of cardiac rhythm and electrical activity (asystole) (15), the
final common pathway.
A victim can be rescued at any time during the drowning process and may not require
any intervention at all or may receive appropriate resuscitative measures, in which case
the drowning process is interrupted. The victim may recover from the initial
resuscitation efforts, with or without subsequent therapy aimed at eliminating hypoxia,
hypercarbia, and acidosis, and restoring normal organ function. It should be noted that
the heart and brain are the two organs at greatest risk for permanent, detrimental
changes from relatively brief periods of hypoxia. Permanent damage occurs only in case
of cardiac arrest. The development of post-hypoxic encephalopathy with or without
cerebral edema is the most common cause of sequelae and death in hospitalized
drowning victims. However all organ system can be involved in the post-drowning
period including Disseminated Intravascular Coagulopathy (DIC) and Acute Tubular
Necrosis (ATN).
DROWNING CHAIN OF SURVIVAL - prevention to hospital (Figure (18))
•
Drowning has a unique chain of survival that includes a critical action of rescue,
which must take place prior to initiation of Basic Life Support.
•
Prevention remains the most powerful intervention in the chain of survival. Every
rescue conducted represents a failure of prevention.
•
Any health professional must be aware of how to help a drowning victim without
becoming a second victim.
•
Scene resuscitation is the window of opportunity for saving lives
•
Cardiopulmonary arrest from drowning has the highest survival rates compared to
other causes of out of hospital pediatric cardiac arrest (19).
•
In-water resuscitation (ventilation only) can increase by more than threefold a
victim’s chance of survival without sequelae.
•
Vomiting is a common complication and can result in further aspiration and
impairment of ventilation.
•
The Automated External Defibrillator plays a minor role in the resuscitation of
drowning since ventricular fibrillation is rare.
1. Prevention
Despite the emphasis on immediate treatment, the most effective intervention on
drowning is prevention. Prevention remains the most powerful tool and multifaceted
prevention programs are estimated to be effective in preventing more than 85% of
current annual drownings (20, 21). Drowning prevention is multifaceted and involves
education, technology, and legislation. In high income countries, children ages <5 years
have the highest drowning rates and drown in swimming pools into which they fall in
while unsupervised. Fencing swimming pools with 4-sided fencing with unclimbable
fences with self closing, self latching gates have proven to be the most effective
drowning prevention intervention for this age group. Legislation requiring installation
of these barriers has been adopted in several countries. However, enforcement of these
laws is key to maximizing their effectiveness but adequate supervision of children is the
prevention goal to achieve. Supervision must be defined as the complete attention of an
adult, who is unimpaired by alcohol, drugs, or distraction, at hand and capable of
rescue. The increasing presence of life guards in Brazil was associated with decreasing
drowning deaths. Their function is used to base on rescue, but it changes to prevention
now-a-days and their presence decrease risk taking behaviors. Open water drowning
prevention is more problematic as it involves older children and adults involved in a
wide variety of activities. Open water drowning prevention has received less attention
since most open water drowning victims die without medical interface. Life jackets are
a technology that should decrease drowning deaths. In the USA and Canada, greater
than 85-90% of boat related drowning deaths were people who were not wearing life
jackets. Some countries have legislation requiring children to wear life jackets while on
small boats. However, adult males in small boats are those who die and are not required
to wear them. Swimming or water survival skills may also prevent deaths. Recent
experience in low income countries teaching school age children to dog paddle for a few
yards has decreased deaths. Another subpopulation at risk for drowning is those who
have seizures. At all ages, drowning deaths occur in those with a history of seizures.
Most occur in the bath tub or during recreational swimming. Prevention for this group
would be to shower instead of using bath tubs and to swim where there is a lifeguard
(table 2(22)).
2. Recognition & Alarming of Incident
The key initial step in treatment of drowning is to recognize that some one is drowning.
Contrary to popular opinion the victim does not wave or call for help and usually
drowns unnoticed (23). A typically victim that drowns when swimming is a male young
adult who may be initially embarrassed to cry for help and whose decision to ask for
help is made too late, when his arms and legs are exhausted to do any movement and
breathing instinctively takes precedence. While drowning, the victim is typically in an
upright posture, with eyes just above the water surface, with arms extended laterally,
thrashing and slapping powerless on the water surface, in an effort to get his airway
above the water. Exhaustion will cause the inability to scream for help. Bystanders may
not recognize that the victim is struggling and may assume that the victim is playing and
splashing in the water. The victim may submerge and surface his or her head several
times during this struggling activity. Children who can not swim struggle for only 10 to
20 seconds before final submersion and adults may be able to struggle for up to 60
seconds (23).
In swimming pools, the typical notice of a drowning victim is when he or she is
observed under the water surface. This can happen not often in spite of good
surveillance of pool lifeguards. The most effective way of pool surveillance still
remains unclear and is currently under scientific investigations. Legally compulsory
fencing and drowning detection systems can help to reduce the number of pool
drowning.
At the moment drowning is recognized, it is essential to activate the emergency system
to dispatch lifeguards and pre-hospital medical team to the scene and take immediately
action.
3. Rescue and Basic Water Life Support (BWLS)
Rescuers should be aware to not become the second victim. If possible, potential
rescuers stay out of the water and use techniques like “throw before you go” and “reach
(with long objects) before you assist” or can advise the victim on how to get out of this
situation (i.e.; choosing a better way to escape, swim, float or reassuring the assistance
coming).
Decision when to provide BWLS (18) is based on the victim’s consciousness level. The
victim who is panicking and struggling to breathe can drown their would-be rescuer. It
is always best to approach a struggling victim with an intermediary object or from the
back-side. Lifeguards use rescue or torpedo buoys for this purpose that also can be used
as a flotation devices to keep the head and the airways out of the water (23). Other
objects like a plastic refreshment pet, a foam car seat and other children floatation
device can be used on those situations. For the conscious victim, rescue involves
bringing the victim to land without any further medical care (24).
The most important step in BWLS is the immediate institution of ventilation which has
usually ceased by the time the victim becomes unconscious. Cardiac arrest ensues
within minutes if apnea is not corrected. In-water resuscitation providing ventilation
only can increase by more than threefold a victim’s chance of survival without sequelae.
This is possible in well defines circumstances when the rescuer has the support on the
ground by standing or a floatation device. In these circumstances, rescuers should check
ventilation and attempt to provide mouth-to-mouth for 1 minute. Victims in only
respiratory arrest usually respond after a few artificial breaths. If no response, assume
the victim is in cardiac arrest and rescuer should go directly with the victim out of the
water. Assessment for pulse in the water does not serve a purpose. External cardiac
compressions cannot be performed effectively in the water and must be delayed until
the victim is out of the water (24).
A few studies have described the frequency of in-water cervical spine injuries (CSI). A
retrospective evaluation of over 46,000 water rescues on sand beaches demonstrated an
incidence of CSI of 0,009% (25). In another retrospective survey of more than 2,400
drownings attended in a pre-hospital setting, less than 0.5% had a cervical spine injury.
All who were injured had a history of obvious trauma from diving, falling from height,
or a motor vehicle accident (26). Furthermore, valuable time spent immobilizing the
cervical spine in an unconscious victim with no signs of trauma, could lead to a hypoxic
and cardiopulmonary deterioration and ultimately to death. Considering the reported
low incidence of CSI and the risk of wasting a precious time, routine cervical spine
immobilization of water rescues, without strong evidence of a traumatic injury, is not
recommended (25,26). Rescuers who suspect a spinal cord injury should: Float the
supine victim in a horizontal position allowing the airway to be out of to water and
check if there is spontaneously breathing: If there is no spontaneous breathing, the
airways is opened and resuscitation (mouth-to-mouth) is started, while maintaining the
head in a neutral position as much as possible. The jaw thrust has been also shown to
allow small movement of the cervical spine. If there is spontaneous breathing, the hands
of the rescuer can be used to stabilize the neck of the victim in a neutral position. If
possible the victim is kept floating with the help of a back support device before moving
the victim to a dry place. Align and support the head, neck, chest, and body if the victim
must be moved or turned (14).
4. On-land Basic Drowning Life Support (BDLS)
The technique of removing a victim from the water depends on the circumstances where
the drowning has occurred and level of consciousness. Preferably a vertical position
should be adopted to prevent vomiting and further airway complications. If the victim is
exhausted, confused or unconscious transport should be in as near a horizontal position
as possible but with the head still maintained above body level with the exception of
immersion in cold water when victim should be kept horizontal as possible. The airway
must be kept open all the time (27).
When on the land, the first procedure is to place the victim in a position parallel to the
waterline, as horizontal as possible, supine, far enough away from the water to avoid
incoming waves but not so far as to waste time on transportation. If conscious,
reposition the victim supine with head up. If breathing and unconscious place the victim
in recovery position (lateral decubitus) (27). In a 10-year study in Australia, vomiting
occurred in more than 65% of victims who needed rescue breathing and in 86% of those
who required both rescue breathing and chest compressions (28). Even in victims who
required no interventions after water rescue, vomiting occurred in 50% once the victims
had reached shore. The presence of vomit in the airway can result in further aspiration
and impairment of oxygenation by obstruction of the airways and it can also discourage
rescuers from attempting mouth-to-mouth resuscitation (28). Positive pressure
ventilation will force water from the airways into the pulmonary circulation where it is
absorbed while this appropriate intervention will simultaneously provide what the
victim needs: ventilation and oxygenation. Specific efforts to expel water from the
airway and lungs are hazardous. The abdominal thrust (Heimlich) maneuver should
never be used as a means of expelling water from the lungs – it is ineffective and carries
significant risks of vomiting and other injuries. Attempts at active drainage by placing
the victim head down increases the risk of vomiting more than fivefold, and leads to a
small but significant increase in mortality (19%) when compared with keeping the
victim in a horizontal position (27). If vomiting occurs, turn the victim’s mouth to the
side and remove the vomitus with a finger sweep, a cloth or use suction.
One of the most difficult medical decisions a lifeguard or an emergency health
professional must make is how to treat a drowning victim appropriately. The most lifethreatening situation, cardiopulmonary or an isolated respiratory arrest comprise only
0.5% of all rescues (11). Most cases are however less dramatic and many potential
interventions can be considered. The questions that arise are: Should rescuers
administer oxygen, should an ambulance be called, should the drowned person be
transported to a hospital, or observe for a time at the site? To address these questions, a
classification system was developed in Rio de Janeiro (Brazil) in 1972 to assist
lifeguards, ambulance personnel, and physicians at the scene. The update of the
classification system in 1997 (11) was based on analysis of 41,279 rescues between
1972 and 1991 of which 2,304 (5.5%) were drownings and needed medical attention.
The classification system was revalidated in 2001 by a 10-year study with 46,080
rescues (29). This classification (algorithm 1) (11) allows determination of needed
levels of support from the scene to the hospital, recommended treatment and shows the
likelihood of death based on the severity of injury. The severity of the drowning victim
is assessed by an on-scene rescuer, EMT or physician using clinical variables and to an
ED professional receiving the victim at the hospital (11).
5. Advanced Drowning Life Support (ADLS) on site (Algorithm 1) (11)
Different from past thoughts, the best recommendation for drowning is to bring the
medical equipment to the victim instead of the victim to the ambulance in order to
decrease time to intervention (stay and play). Advanced medical treatment is given
according to drowning classification (11).
Dead body – Victim with submersion time over 1 hour in non-icy waters or with obvious
physical evidence of death (rigor mortis, putrefaction or dependent lividity).
Recommendation is to not start resuscitation.
Grade 6 - Cardiopulmonary Arrest - Resuscitation started by layperson or lifeguard
must be continued by advanced life support personnel at the scene until successful. An
exception is the moderate and severe hypothermic victim who should be transported
while receiving resuscitation to a hospital where advanced warming measure can be
accomplished. The first priority in a cardiopulmonary arrest is adequate oxygenation
and ventilation. Medical staff must keep doing cardiac compression while starting
artificial ventilation using bag and facemask with 15 liters of oxygen until cuffed orotracheal tube can be inserted. Suctioning the airways to intubation is usually necessary
to visualize the glottis and Sellick maneuver on this situation can be of an additional
help. Once intubated, victims can be oxygenated and ventilated effectively despite
copious pulmonary edema fluid. In spite of massive foam production after intubation,
additional suctioning is not needed and actual can be regarded as an elementary mistake
in these situations. If possible Positive End Expiratory Pressure (PEE) should be used at
the beginning for better oxygenation.
External defibrillation may have a role to monitoring, at the site, the cardiac rhythm. If
the victim is hypothermic (< 34oC), CPR should continue even if in asystole. Tympanic
temperature is the better way to check body temperature at this situation. Although VF
is uncommon, adults may develop VF possibly as a consequence of coronary artery
disease or advanced life-support therapies, such as epinephrine. Peripheral venous
access is the preferred route for drugs. Although some drugs can be administered
endotracheally, drug doses and absorption in the setting of copious pulmonary edema
fluid may render them ineffective (23). The adrenaline dose for resuscitation remains
controversial perhaps even more so in drowning, where the time elapsed to start
resuscitation can be much longer. Both beneficial and toxic physiological effects of
epinephrine administration during CPR have been shown in animal and human studies.
Initial or escalating high-dose epinephrine has occasionally improved initial return of
spontaneous circulation and early survival. Higher doses of epinephrine have not
improved long-term survival and neurological outcome in general causes, when used as
initial therapy. Nor have higher doses definitively been shown to cause harm. Therefore,
high-dose epinephrine is not recommended in general causes for routine use but can be
considered if 1-mg doses fail (30). Some drowning specific studies have shown high
dose epinephrine provides no improvement in neurological outcome and may possibly
worsen the victim’s outcome. However, other studies report that high epinephrine doses
in drowning improve chances to resuscitate (11, 31) and its use can be recommended
until proven inappropriate by better multicenter research based on the Utstein-Style
guidelines. One recommendation on that is to use a first dose of 0.01mgr/kg I.V after 3
minutes of CPR (30) and if no response is achieved increase to 0.1mgr/kg each 3 to 5
min. of CPR (14).
Grade 5 - Respiratory arrest is usually reversed with a few mouth-to-mouth
ventilations. Then follow protocols for grade 4. When the victim remains in apnea,
mechanical ventilatory support is required.
Grade 4 - Acute pulmonary edema with hypotension - Oxygen with positive pressure
ventilation support is the first-line therapy. Initially some of these victims will able to
maintain adequate arterial blood gases (ABG) by an abnormally high respiratory rate or
effort. Early intubation and mechanical ventilation is always indicated, as patient is
consuming large amounts of energy breathing and is likely to tire (23). Oxygen should
be administered by facemask with 15 liters per minute until a cuffed orotracheal tube
can be inserted by rapid sequence induction. At this point, patients should be kept with
drugs (sedative, analgesic and muscular blockers if needed) to tolerate intubation and
artificial mechanical ventilation with a Tidal Volume of at least 5 ml/kgr of body
weight. Oxygen inspired fraction (FiO2) can start at 100% but as soon as possible
should be reduced to 0.45 or less. A positive end expiratory pressure (PEEP) should be
added initially at a level of 5 cm H2O and then by 2 to 3 cm H2O increments until the
desired intra-pulmonary shunt (QS:QT) of 20% or less, or PaO2:FiO2 of 250 or more is
achieved. If low blood pressure is not corrected after the administration of oxygen and
mechanical ventilation, a rapid crystalloid infusion (regardless of drowning water type)
should be administered (15, 23).
Grade 3 - Acute pulmonary edema without hypotension – Some victims (28%) keep
their arterial oxygen saturation above 90% with the use of 15 liters of oxygen by
facemask and can tolerate no-invasive ventilatory support. Most, however, 72%, need
intubation and mechanical ventilation and should follow the protocols for grade 4 (11).
Grade 2 - Abnormal auscultation with rales in some pulmonary fields – Most victims
(93%) need only 5 liters of oxygen by nasal cannula.
Grade 1 - coughing with normal lung auscultation - victims do not need any oxygen or
respiratory assistance.
Rescue – No coughing, foam, or difficulty breathing - Evaluate and release from the
accident site without further medical care if there is no associated disease or condition.
6. Hospital
In severe cases (grades 5 and 6) hospital attendance is possible only if an adequate and
prompt BLS and ALS pre-hospital was available. If this is not the case, appropriate
approach is to step back and follow the ALS on accident site protocols. Hospitalization
care is recommended for grades 2 to 6. Decision making in the emergency department
about admission to an ICU or hospital bed versus observation in an emergency
department or discharge home should include a thorough history of the drowning
incident and previous illness, a physical examination and a few diagnostic studies,
including chest radiography and ABG measurement. Electrolytes, blood urea nitrogen,
creatinine, and hemoglobin also should be assessed serially, although perturbations in
these laboratory tests are unusual. For adolescents and adults a toxicological screen for
suspected alcohol or drug ingestion is also warranted. Grade 3 to 6 victims should be
admitted to an ICU for close observation and therapy. Patients grade 2 can be observed
in emergency room for 6 to 24 hours, but grade 1 and rescue cases with no complains or
associated illness should be released home. Table 3 shows general mortality rates for
each grade of severity, hospitalization need, and in-hospital mortality rates (11).
Patients grade 4 to 6 usually, except in rare situation, will arrives from pre-hospital ALS
care in mechanical artificial ventilation with acceptable oxygenation. If not, emergency
room MD should step back and follow grade 4 ventilation protocols. Grade 3 depends
on clinical evaluation in the field. Once the desired oxygenation is achieved at a given
level of positive airway pressure, that level of PEEP should be maintained unchanged
for 48 hours before attempting to decrease it to allow adequate surfactant regeneration.
During that time if the patient begins to breath on his own without fighting, continuous
positive airway pressure (CPAP) plus ventilatory pressure support mode (PSV) can be
introduced. In selected cases, CPAP may be provided only by mask (e.g., in cooperative
adolescents) or nasal cannula (in infants who are obligate nasal breathers), but usually
this is not tolerated by the patients and pulmonary edema usually necessitates
intubation. A clinical picture very similar to acute respiratory distress syndrome
(ARDS) is common after significant drowning episodes (grade 3 to 6). The difference is
that the acute respiratory distress seen with drowning has a much faster time to recovery
and usually has no pulmonary sequalae. Management is similar to that of other patients
with ARDS, including efforts to minimize volutrauma and barotrauma. Lung salvage
involving permissive hypercapnia probably is not suitable for drowning victim grade 6
with significant hypoxic-ischemic brain injury, however. Instead, mild to moderate
hyperventilation, aiming for a PaCO2 in the range of 30 to 35 mm Hg probably is
indicated, together with other therapeutic measures to control cerebral edema.
In patients who are hemodynamically unstable or have severe pulmonary dysfunction
(grade 4 to 6), pulmonary artery catheterization or other correlate non-invasive
technique can improve the ability to assess and treat the victim. Colloid solutions should
only be used for refractory hypovolemia when replacement with crystalloid was not
enough to restore blood pressure promptly. No evidence exists to support the routine
administration of hypertonic solutions and transfusions for drowning in fresh water, or
the use of hypothonic solutions in salt-water drownings (15, 23). Pulmonary artery
catheterization or other less invasive techniques also enable the clinician to monitor
cardiac function, pulmonary function, and tissue adequacy of oxygenation and perfusion
and to assess the response of these parameters to various therapies. Echocardiography to
assess cardiac function and ejection fractions can help guide the clinician in deciding on
inotropic agents, vasopressors or both, if volume crystalloid replacement had failed.
Some studies have shown that cardiac dysfunction with low cardiac output is common
just after severe drowning cases (grades 4 to 6) (15). Important supportive measures
include Foley catheter placement to monitor urine output. Low cardiac output is
associated with high pulmonary capillary occlusion pressure, high central venous
pressure, and high pulmonary vascular resistance and can persist for days after
reoxygenation and reperfusion. The result is the addition of cardiogenic pulmonary
edema to the noncardiogenic pulmonary edema. Despite a depressed cardiac output,
furosemide therapy is not a good idea. One study even has suggested that volume
infusion benefits drowning victims. Studies suggest that dobutamine infusion to
improve cardiac output is the most logical and potentially beneficial therapy.
Metabolic acidosis occurs in 70% of patients arriving at the Hospital (17). It should be
corrected when PH is < 7.2 or the bicarbonate <12mEq/l. if the victim has adequate
ventilatory support (10). Significant depletion of bicarbonate is rarely present in the first
10 to 15 minutes of CPR, contraindicating its use initially (30).
Usually, pools and beaches don’t have high enough bacterial counts to promote
pneumonia just after the incident (32). If the victim needs mechanical respiratory
assistance the incidence of secondary pneumonia increases from 34 to 52% in the third
or fourth day of hospitalization when pulmonary edema usually is almost resolved (33).
Vigilance for not only pulmonary, but also other septic complications is important.
Prophylactic antibiotics are of doubtful value in the intensive care management and tend
to select out only more resistant and more aggressive organisms. An altered chest x-ray
should not be interpreted as pneumonia, because it is usually the result of pulmonary
edema and aspirated water in the alveoli and bronchi. A preferable approach is daily
monitoring of tracheal aspirates with Gram stain, culture, and sensitivity. At the first
sign of pulmonary infection, usually after the first 48 to 72 hours, as gauged by
prolonged fever, sustained leukocytosis, persistent or a new pulmonary infiltrates, and
leukocyte response in the tracheal aspirate, antibiotic therapy is selected on the basis of
predominant organism and their sensitivities. Fiberoptic bronchoscopy may be useful
for bacterial evaluating through quantitative cultures, for determining the extent and
severity of airway injury in cases of solid aspiration, and in rare occasion for therapeutic
clearing of sand, gravel and others solids. Likewise, corticosteroids for pulmonary
injury are, at best, of doubtful value and probably should not be used, except for
bronchiospasm. A persistent systemic inflammatory response has being reported in the
first 24 hours after successful resuscitation with scarce response to different approaches
and explains the very common low grade fever that is seen in this time period.
The clinician must be aware of and constantly vigilant for potential complications of
therapy and underlying pulmonary injury, namely, volutrauma and barotraumas (32).
Spontaneous pneumothoraces are common (10%) secondary to positive pressure
ventilation and local areas of hyperinflation. Any sudden change in hemodynamic
stability after mechanical ventilation should be considered a pneumothorax or other
barotrauma until proved otherwise. After a secure airway is guaranteed, a nasogastric
tube placement reduces gastric distention and prevents further aspiration. Rarely,
drowning victims who seem healthy on assessment in the emergency department,
including having normal chest radiography, develop fulminant pulmonary edema as late
as 12 hours after the incident. Whether this late-onset pulmonary edema is a delayed
acute respiratory distress syndrome (ARDS) is unclear, but none of the authors have
seen any of this complication.
Renal insufficiency or renal failure is rare in drowning victims but can occur secondary
to anoxia, shock, or hemoglobinuria.
Despite aggressive management, severe neurological sequelae, from no self help skills
to persistent vegetative state, are problematic in the management of grade 6. In fact,
pediatric intensive care units report that drowning survivors are among their most
devastated survivors. The most important complication of drowning injury is the
anoxic-ischemic cerebral insult that occurs in pos-resuscitation cases. Most late deaths
and long-term sequelae of drowning are neurologic in origin (32). Although the highest
priority is restoration of spontaneous circulation, every effort in the early stages after
rescue should be directed at resuscitating the brain and preventing further neurologic
damage. These steps include all measures to provide adequate oxygenation (SatO2 >
92%) and cerebral perfusion (medium arterial pressure around 100 mmHg). Any victim
who remains comatose and unresponsive after successful CPR or deteriorates
neurologically should undergo careful and frequent neurologic function assessment for
the development of cerebral edema and should: Use the head of the bed by 300 (if there
is no hypotension), avoid jugular vein compressions and situations that could provoke
Valsalva maneuver; Secure a good mechanical ventilation without unnecessary effort;
make an appropriate respiratory toilet without provoking hypoxia; treat the convulsive
crises and the unnecessary muscular waste; avoid metabolic sudden corrections; Avoid
anything that will increase intracraneal pressure (ICP), including urinary retention, pain,
hypotension or hypoxia before prolong sedation or muscular relaxant; and maintain as
much as possible the blood glucose concentration monitored and in normoglycemic
values (8). Continuous monitoring of core and/or brain (tympanic) temperature is
mandatory in the emergency department and intensive care unit (and in the pre-hospital
setting if possible). Drowning victims with restoration of adequate spontaneous
circulation who remain comatose should not be actively rewarmed to temperature
values >32-34oC. If core temperature exceeds 34 oC, hypothermia (32-34oC) should be
achieved as soon as possible and sustained for 12-24 hours. Hyperthermia should be
prevented at all times in the acute recovery period. Unfortunately, studies that have
evaluated the results of cerebral resuscitation measures in drowning victims have failed
to demonstrate that therapies directed at controlling intracranial hypertension and
maintaining cerebral perfusion pressure (CPP) improve outcome. These studies have
shown poor outcomes (i.e., death or moderate to profound neurologic sequelae) when
the intracranial pressure was 20 mm Hg or more and the CPP was 60 mm Hg or less,
even when therapies are directed at controlling and improving these pressures. More
research is needed to evaluate specific efficacy of neuro-resuscitative therapies in
drowning victims.
New therapeutic interventions for drowning victims, such as extracorporeal membrane
oxygenation, artificial surfactant, nitric oxide, and liquid lung ventilation, and early
initiation of mild hypothermia are still in the investigational stage.
OUTCOME AND SCORING SYSTEMS
Almost all (95%) of drowning grade 1 to 5 victims return home safely without sequelae
(11). Although grade 3 to 6 has potential to provoke multisystem organ failure (17),
grade 6 victims are at major risk. Questions like “how can we know who we should
make the effort to resuscitate; how long we should continue CPR; how different should
be the treatment and what we should expect as life quality after successful resuscitation?
Need to be answered. Both at the rescue site and in the hospital, no one indicator for
grade 6 can reliably predict outcome (34).
Opinions on indications for starting and prolonging resuscitation vary. Multiple studies
although have established that outcome is almost solely determined by a single fate
factor - duration of submersion (table 4) (11, 24, 28, 32, 35, 36, 37, 38, 39). However
the effect of rapidly induced hypothermia may alter the value of submersion time as an
outcome predictor. Body heat exchanges very quickly in the water environment. Rapid
cooling may be achieved by contact with large body surface area by waters whose
temperature is usually lower than human, and often flowing so that conductive cooling
is enhanced. Based on one reported case who had the longest submersion time (66
minutes) with recovery (23), the recommendation is to initiate resuscitation without
delay in every victim without carotid palpable pulse who has been submerged for less
than one hour in very cold or icy water, or does not present obvious physical evidence
of death (rigor mortis, putrefaction or dependent lividity). However, the concept that
long time submersion and successful resuscitation is only possible in cold or icy water
has been challenged by several anecdotal drowning cases in warm water with survival
without sequelae (11, 35, 36). Basic and advanced life support professionals enable
victims to achieve their best outcome possible given the duration of cardiopulmonary
arrest (submersion time included). Based on a report of a drowning victim successful
resuscitated after 2 hours of CPR (32), effort should stop only if asystole persists after
rewarming the victim above 340C. “No one is dead until warm and dead” (Southwick &
Dalglish). However, in the NW USA, where drowning most often occurs in cold but not
icy waters, one large study of 194 hospitalized children and adolescents, an age group
most easily cooled during a submersion, had no survivors who required more than 25
minutes of CPR by EMS.(40).
After successful CPR, is crucial to stratify neurological severity, which will allow
comparing different therapeutic approaches. Various prognostic scoring systems have
been developed to predict which patient will do well with standard therapy and which
are likely to have a significant cerebral anoxic encephalopathy and will require
aggressive measures to protect the brain. The most powerful predictor is the
consciousness level related to the Glasgow Coma Scale at the period immediately after
resuscitation (first hour). Alert patients should survive; most comatose patients will die.
(Conn & Modell Neurological Classification) (11, 41, 42) (table 5). Because of delay of
2 to 6 hours between rescue and transfer from the scene to an outlying emergency
facility to an ICU, many patients with severe anoxic-ischemic cerebral insults and coma
have had multiple determinations of neurological status and level of consciousness
before definitive therapy is begun. In the comatose patient, clinical and laboratory
indicators of brain stem death such as absent papillary reflex and lack of spontaneous
breathing, as measured by severe acidosis and severe hyperglycemia predict death or
severe neurologic sequeleae, including persistent vegetative state (40). Prognostic
variables are important in counseling family members of drowning victims in the early
stages after the incident and mostly in deciding which patients are likely to have a good
outcome with standard supportive therapy and which victims should be candidates for
more aggressive cerebral resuscitation therapies (37).
UNIFORM CLINICAL REPORTING OF DROWNING (algorithm 2)
Standardization of definition, terminology, nomenclature and classification of drowning
is extremely important to distingue different pathologies from drowning and to let all
know of what severity of drowning we are referring to. It allows comparing statistics
from different parts of the world from any lifeguard service, pre-hospital or hospital
facility.
“Drowning represent a tragedy that all too often was preventable. Perhaps the majority
are the end result of common sense violations, alcohol consumption, and neglect of
responsible childcare. This picture needs a radical preventive intervention”
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18. Szpilman D, Morizot-Leite L, Vries W, Scarr J, Beerman S, Martinhos F, Smoris L,
Lofgren B; First aid courses for the aquatic environment; section 6 (6.7) Resucitation, in
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TABLES, FIGURES AND ALGORITHM
Developed
Sub-Saharan
Latin
Middle
Asia and
countries
Africa
America
East
Pacific
Data available
Data not available
Total
Total
55
4
29
9
18
115
2
42
4
12
17
77
57
46
33
21
35
192
Table 1 - Global Coverage of Death Registration Data (WHO presentation: “Mortality
and causes of death”) (3).
XXXXXXXXXXXXXXXXXXXXXXXXXXXXX
Drowning death in Brazil
Death/100.000 inhabitants
7
Death/100.000 inhab
6
5
4
3
2
1
0
79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 00 01 02 03
19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20
Y ears
Graphic 1 – Drowning death trends on Brazil from 1979 to 2003, selecting 3 different periods (10).
XXXXXXXXXXXXXXXXXXX
Figure 1 – Drowning Chain of Survival (18) (attached in TIFF)
XXXXXXXXXXXXXXXXXXXXXXXXXXXXX

Watch children carefully, 84% of drownings occur because of bad adult supervision.
Begin swimming lessons from 2 years old but be very careful at this time.
Avoid inflatable swimming aids such as "floaties" They can give a false sense of security. Use lifejacket!
Never try to help rescue someone without able to do it. Many people died trying to do so.
Avoid drinking alcohol and heaving lunch before swimming.
Don’t dive in shallow water – cervical spine injury can happen.
BEACHES
POOLS and Similar
Over 65% of deaths occur in fresh water, even on the
Always swim in a lifeguard-supervised area.
coast.
Ask the lifeguard for safe places to swim or play.
Read and follow warning signs posted on the beach. Fence off your pool and include a gate. Recommended
fencing approved can decrease drowning by 50 a 70%.
Do not overestimate your swimming capability –
45% of drowning victims thought they knew how to Avoid toys around the pool, is very attractive to
children.
swim.
Whenever infants or toddlers are in or around water,
Swim away from piers, rocks and stakes
be within arm's length, providing "touch supervision".
Take lost children to the nearest lifeguard tower
Turn off motor filters when using the pool.
Over 80% of drowning occurs in rip currents (the
Always use portable phones in pool areas, so you are
rip is usually the most falsely calm deeply place
not called away to answer.
between two sand bars). If caught in a rip, swim
Don’t try to do hyperventilation to increase the
transversally to the sand bar or let it take you away
submersion time.
without fighting and wave for help If you are
Use warning sign of shallow water on the pool.
fishing on rocks be cautions about waves that may
Learn CPR. Over 42% of pools owner are not aware
sweep you into the ocean.
about first aid techniques – Be careful!
Keep away from marine animals.
Table 2 (22)
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
CLASSIFICATION, MORTALITY and HOSPITAL NEEDS (n = 1831^)
GRADE
No.
Overall Mortality(%) Admission to Hospital (%)
Rescue
38.976
0 (0.0%)
0 (0.0%)
1
1189
0 (0.0%)
35(2.9%)
2
338
2 (0.6%)
50(14.8%)
3
58
3 (5.2%)
26(44.8%)
4
36
7 (19.4%)
32(88.9%)
5
25
11 (44%)
21(84%)(@)
6
185
172 (93%)
23(12.4%)(@)
Total
1.831(&)
195 (10.6%)
187 (10.2%)*
P < 0.0001
Hospital Mortality (%)
0 (0.0%)
0(0.0%)
2(4.0%)
3(11.5%)
7(19.4%)
7(33.3%)
10(43.5%)
29 (15.5%)
TABLE 3 - (^) Overall mortality was 10.6%(1); (&) The rescues cases were excluded. (*) Need of
overall hospitalization (10.2%) in ND/D cases in association with the grade and mortality. Mortality in
the hospital was 15.5%. (@) Four patients grade 5 and 162 grade 6, out of this table, were pronounced
dead and thus taken directly to the morgue (11).
XXXXXXXXXXXXXXXXXXXXXXX
ALGORITHM 1 - Drowning Classification Algorithm - Advanced Cardiac Life
Support (ADLS) (11). (file attached in PDF, TIFF)
XXXXXXXXXXXXXXXXXXXXXX
Probability of Neurologically Intact Survival to Hospital Discharge Based on
Duration of Submersion
Duration of submersion (minutes)
Death or severe neurological impairment
0 to <5 minutes
10%
5 to <10 minutes
56%
10 to <25 minutes
88%
> 25 minutes
100%
Table 4 - Note in these data how 5 more minutes of submersion in the 5 to <10 min
group increases mortality almost 6 times compared to the 0 to <5-minute group
(Extrapolated on many different published data 11, 24, 28, 32, 35, 36, 37, 38, 39)
XXXXXXXXXXXXXXXXXXXXXXXXXXXXXX
NEUROLOGIC PROGNOSTIC SCORE
Pos successful CPR on Drowning
A – FIRST HOUR
B – AFTER 5 to 8 h
Alert - 10
Alert - 9.5
Confused - 9
Confused - 8
Torpor - 7
Torpor - 6
Coma with normal brainsteam - 5
Coma with normal brainsteam - 3
Coma with abnormal brainsteam - 2
Coma with abnormal brainsteam - 1
A+B
RECOVERY WITHOUT SEQÜÊLAE
Excellent (>= 13)
> = 95%
Very good (10-12)
75 to 85%
Good (8)
40 to 60%
Regular (5)
10 to 30%
Poor (3)
< = 5%
Table 5 – Clinical Prognostic Score for the immediate period pos successful CPR, based on Glasgow
Coma Score (Elaborated by Szpilman 1998, based on 11, 41, 42 references).
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UNIFORM CLINICAL REPORTING OF DROWNING
DROWNING
An event that results in respiratory distress(&) due to submersion/immersion in liquid.
Hypoxia results in death
at the scene or in ED.
NO respiratory distress
No resuscitation attempted (morgue)
Released to home
DEATH
Cardiopulmonary
Arrest
Grade 6
Isolated
respiratory
Arrest
Grade 5
Classify the severity
Acute pulmonary
Acute pulmonary
edema without
edema with
hypotension
hypotension
Grade 3
Grade 4
Worse to lighter severity
RESCUE
Cough with normal
pulmonary
auscultation
Grade 1
Rales in some
pulmonary fields
Grade 2
The ultimate outcome should be reported whether it be survival without any residual organ damage or whether the patient has a
continuing morbidity which should be identified and quantified. (&) Respiratory distress - altered pulmonary auscultation or cough
or documented hypoxia.
Algorithm 2 - Guidelines for uniform Clinical Reporting of Drowning (Unpublished data Szpilman – 2002)