Pre hospital military drowning treatment

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  • Utstein template style reporting
  • Explain location of these deaths.
  • The remaining 30% are trauma, hypothermia, CO poisoning, and other causes. Temporary Insanity II Impaled on Channel Marker Near Bay Bridge Marina on Kent Island: Just before 2 a.m., a 1992, 38-ft. Fountain power boat slammed into a fixed, channel marker, ripping a 17-ft. gash in the forward hull & becoming impaled on the steel piling holding the channel marker. A passenger suffered a broken arm & lacerations; a passing boater rescued the two men. DNR police cited the skipper, who "claimed to have been blinded by the lights of a sailboat", for negligence, traveling at an unsafe speed, & failure to maintain a proper lookout.
  • http://www.centcom.mil/news/marine-gives-life-trying-to-save-afghan-policeman
  • Jan 14 2011 http://www.10news.com/news/26510935/detail.html
  • http://www.armytimes.com/news/2011/05/ap-fort-rucker-soldier-body-recovered-053111/
  • http://www.navytimes.com/news/2009/06/navy_seal_drowned_061709w/
  • 1831 cases
  • 1831 cases
  • 0.5% of 2244 submersion victims had c-spine injuries.
  • Pre hospital military drowning treatment

    1. 1. Drowning Justin Sempsrott, MD University of Nevada Emergency Medicine Residency www.LifeguardsWithoutBorders.org [email_address]
    2. 2. Who am I?
    3. 3. History of drowning treatment The “Great of Aleppo” held upside down after drowning. 1237 B.C.E From the Pylon of the Ramesseum, Thebes. Photographed by Mr. W. M. F. Petrie
    4. 4. History of drowning treatment
    5. 5. History of drowning treatment
    6. 6. Dr. Frank Eve Popular Science July 1946
    7. 7. History of drowning treatment
    8. 8. Objectives <ul><li>Understand definition of drowning </li></ul><ul><li>Appreciate epidemiology </li></ul><ul><li>Management </li></ul><ul><li>Disposition of drowning patients </li></ul><ul><li>Don’t blow smoke up pt’s (or colleagues) asses </li></ul>
    9. 9. Definition <ul><li>Before 2002 </li></ul><ul><ul><li>33 Different Definitions </li></ul></ul>
    10. 10. Definition <ul><li>“ The process of experiencing respiratory impairment from submersion/immersion in liquid” </li></ul><ul><li>Only 3 outcomes – </li></ul><ul><ul><li>Death </li></ul></ul><ul><ul><li>No Morbidity </li></ul></ul><ul><ul><li>Morbidity </li></ul></ul>http://publications.nigms.nih.gov/findings/mar07/otto_files/textmostly/slide9.html
    11. 11. Definition <ul><li>Old terms that should NOT be used </li></ul><ul><ul><li>Dry </li></ul></ul><ul><ul><li>Wet </li></ul></ul><ul><ul><li>Active </li></ul></ul><ul><ul><li>Passive </li></ul></ul><ul><ul><li>Secondary </li></ul></ul><ul><ul><li>Near  Especially </li></ul></ul><ul><li>No difference between salt, chlorine, and freshwater </li></ul>Lima, Peru, 2009
    12. 12. Who is Drowning? <ul><li>WHO Global Burden of Disease </li></ul><ul><ul><li>388,000 Drowning Deaths* </li></ul></ul><ul><ul><ul><li>97% in low to middle income countries </li></ul></ul></ul><ul><ul><ul><li>+1.55 million unreported drowning deaths </li></ul></ul></ul><ul><ul><ul><li>+6.08 million drowning “incidents” </li></ul></ul></ul><ul><ul><li>* 7.63 million Drowning persons </li></ul></ul>
    13. 13. Who is Drowning? <ul><li>2 nd leading cause of unintentional injury death (1 st is MVC’s) </li></ul><ul><li>~10 Deaths/Day in US </li></ul><ul><ul><li>10-20 Drown with morbidity </li></ul></ul><ul><ul><li>20-30 Drown w/o morbidity </li></ul></ul><ul><li>Male:Female 4:1 </li></ul>
    14. 14. Who is drowning? <ul><li>Disease of youth </li></ul><ul><ul><li>64% of deaths are<30 yrs </li></ul></ul><ul><ul><li>¼ of deaths are < 5 yrs </li></ul></ul><ul><li>Alaska , Arizona , California , Florida, Hawaii , Montana , Nevada , Oregon , Utah, & Washington </li></ul><ul><ul><ul><li>Drowning surpasses all other causes of death to children age 0-14 </li></ul></ul></ul><ul><ul><ul><li>Nationally, In 2007, of all children 1-4 years old who died, 30% died from drowning </li></ul></ul></ul>
    15. 15. Who is Drowning? <ul><li>Excludes Floods/Boating/Natural Disasters </li></ul><ul><ul><li>2006 USCG Responded to 4,967 incidents </li></ul></ul><ul><ul><ul><li>3,474 injuries </li></ul></ul></ul><ul><ul><ul><li>710 deaths </li></ul></ul></ul><ul><ul><ul><ul><li>70% Drowning </li></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>90% without lifejackets </li></ul></ul></ul></ul></ul><ul><ul><ul><ul><ul><li>50% (+) EtOH </li></ul></ul></ul></ul></ul>http://nicedeb.files.wordpress.com/2008/05/sinking-boat.jpg
    16. 17. Who is Drowning? <ul><li>Hurricane Katrina </li></ul><ul><li>4/6 Rio Flood </li></ul><ul><ul><li>200+ dead </li></ul></ul><ul><li>8/1 Pakistan Flood </li></ul><ul><ul><li>1100+ dead </li></ul></ul><ul><li>Indonesia Tsunami </li></ul><ul><ul><li>169,752 dead </li></ul></ul><ul><ul><li>127,294 missing </li></ul></ul>http://www.gearbits.com/images/banda_aceh_tsunami.jpg CDC MMWR March 10, 2006 / 55(09);239-242
    17. 18. So what?
    18. 19. “ His boots were weighing him down, and his uniform dragged and resisted the water as he tried to swim. He had trouble staying afloat and started making his way back to shore but couldn’t. He succumbed to the river.”
    19. 22. Pvt. Cody Hendrickson
    20. 25. Chief Special Warfare Operator (SEAL) Eric Shellenberger
    21. 28. <ul><li>16 y/o ♀ </li></ul><ul><ul><li>HPI </li></ul></ul><ul><ul><ul><li>Pulled from ocean </li></ul></ul></ul><ul><ul><ul><li>No LOC </li></ul></ul></ul><ul><ul><ul><li>+ Submersion </li></ul></ul></ul><ul><ul><li>PE </li></ul></ul><ul><ul><ul><li>A- Small foam at </li></ul></ul></ul><ul><ul><ul><li>mouth/nose </li></ul></ul></ul><ul><ul><ul><li>-Active cough </li></ul></ul></ul><ul><ul><ul><li>B- Tachypneic </li></ul></ul></ul><ul><ul><ul><li>C- Cool extremities </li></ul></ul></ul><ul><ul><ul><li>D- Combative </li></ul></ul></ul><ul><ul><ul><li>Confused </li></ul></ul></ul><ul><ul><ul><li>AYUDAME !!!!!! </li></ul></ul></ul>
    22. 29. <ul><li>15 y/o ♂ </li></ul><ul><ul><li>HPI </li></ul></ul><ul><ul><ul><li>Pulled from ocean </li></ul></ul></ul><ul><ul><ul><li>No LOC </li></ul></ul></ul><ul><ul><ul><li>+ Submersion </li></ul></ul></ul><ul><ul><li>PE </li></ul></ul><ul><ul><ul><li>A- Large foam at </li></ul></ul></ul><ul><ul><ul><li>mouth/nose </li></ul></ul></ul><ul><ul><ul><li>- Active cough </li></ul></ul></ul><ul><ul><ul><li>B- Tachypneic </li></ul></ul></ul><ul><ul><ul><li>C- Cool extremities </li></ul></ul></ul><ul><ul><ul><li>D- Confused, somnolent, </li></ul></ul></ul><ul><ul><ul><li>GCS – E2 V4 M5 </li></ul></ul></ul>
    23. 30. Maldito!! <ul><li>What next? </li></ul><ul><ul><li>Sick or Not Sick </li></ul></ul><ul><ul><li>Transport or </li></ul></ul><ul><ul><li>No Transport </li></ul></ul><ul><li>First, a review of physiology </li></ul>
    24. 31. Physiology of Drowning <ul><li>Breath holding during struggle </li></ul><ul><li>Attempt to inhale water results in laryngospasm </li></ul><ul><ul><li>Usually little (30mL) or NO fluid in lungs </li></ul></ul>
    25. 32. Physiology <ul><li>Water may enter (1-3mL/kg) </li></ul><ul><ul><li>Before laryngospam </li></ul></ul><ul><ul><li>Relaxation after unconsciousness </li></ul></ul>© 2009 Nucleus Medical Art, Inc.
    26. 33. Mechanism <ul><li>Surfactant wash-out </li></ul><ul><li>Direct cellular injury </li></ul><ul><li>Hypoxic Vasoconstriction </li></ul><ul><li>Bronchospasm </li></ul><ul><li>Inflammation </li></ul>
    27. 34. Physiology <ul><li>V/Q Mismatch </li></ul><ul><li>Compliance </li></ul><ul><li>O2 Delivery </li></ul><ul><li>to brain </li></ul>
    28. 35. Physiology <ul><li>Cause of death or morbidity </li></ul><ul><ul><li>Anoxic Brain Injury </li></ul></ul><ul><ul><li>Acidosis </li></ul></ul><ul><li>Treatment  </li></ul><ul><li>Oxygen to the Brain </li></ul>
    29. 36. Physiology <ul><li>&quot;A lack of oxygen does not simply involve stoppage of the engine, but total ruin of what we took to be the machinery. &quot;   </li></ul><ul><li>-JS. Haldane  </li></ul>“ The drum generally heals up; and if a hole remains in it, although one is somewhat deaf, one can blow tobacco smoke out of the ear in question, which is a social accomplishment.&quot;
    30. 37. When to Transport? <ul><li>41,729 oceanfront lifeguard rescues in </li></ul><ul><li>Rio de Janeiro from 1972 – 1991 </li></ul><ul><ul><li>93% Released at scene without further treatment </li></ul></ul><ul><ul><li>2,304 required additional medical care </li></ul></ul><ul><ul><ul><li>89% lived </li></ul></ul></ul><ul><ul><ul><li>11% died </li></ul></ul></ul>
    31. 38. When to Transport? Grade Signs/Symptoms (s/sx) Mortality Treatment 1 Cough, no foam at mouth/nose -LCTAB 0% Thorough history – Release home with education 2 Small amt foam in mouth or nose, +Rales 0.6% N/C O 2 - Hospital 3 Large amt foam, normal BP (+radial pulse) 5.2% ETT/NRB O 2 - Hospital 4 Large amt foam, LOW BP (-radial pulse) 19.4% ETT/NRB O 2 , IV Fluids - Hospital 5 Respiratory Arrest 44% ETT/NRB O 2 , IV Fluids - Hospital 6 Cardiopulmonary Arrest 93% ETT/NRB O 2 , IV Fluids, AED – Hospital Do not resuscitate if down >1 hour
    32. 39. When to Transport? Grade Signs/Symptoms (s/sx) Mortality Treatment 1 Cough, no foam at mouth/nose -LCTAB 0% Thorough history – Release home with education 2 Small amt foam in mouth or nose, +Rales 0.6% N/C O 2 – Hospital 3 Large amt foam, normal BP (+radial pulse) 5.2% ETT/NRB O 2 - Hospital
    33. 40. Do we transport? <ul><li>16 y/o ♀ </li></ul><ul><ul><li>HPI </li></ul></ul><ul><ul><ul><li>Pulled from ocean </li></ul></ul></ul><ul><ul><ul><li>No LOC </li></ul></ul></ul><ul><ul><ul><li>+ Submersion </li></ul></ul></ul><ul><ul><li>PE </li></ul></ul><ul><ul><ul><li>A- Small foam at </li></ul></ul></ul><ul><ul><ul><li>mouth/nose </li></ul></ul></ul><ul><ul><ul><li>-Active cough </li></ul></ul></ul><ul><ul><ul><li>B- Tachypneic </li></ul></ul></ul><ul><ul><ul><li>C- Cool extremities </li></ul></ul></ul><ul><ul><ul><li>D- Combative </li></ul></ul></ul><ul><ul><ul><li>Confused </li></ul></ul></ul><ul><li>15 y/o ♂ </li></ul><ul><ul><li>HPI </li></ul></ul><ul><ul><ul><li>Pulled from ocean </li></ul></ul></ul><ul><ul><ul><li>No LOC </li></ul></ul></ul><ul><ul><ul><li>+ Submersion </li></ul></ul></ul><ul><ul><li>PE </li></ul></ul><ul><ul><ul><li>A- Large foam at </li></ul></ul></ul><ul><ul><ul><li>mouth/nose </li></ul></ul></ul><ul><ul><ul><li>- Active cough </li></ul></ul></ul><ul><ul><ul><li>B- Tachypneic </li></ul></ul></ul><ul><ul><ul><li>C- Clammy extremities </li></ul></ul></ul><ul><ul><ul><li>D- Confused, somnolent, </li></ul></ul></ul><ul><ul><ul><li>GCS – E2 V4 M5 </li></ul></ul></ul>Grade Signs/Symptoms (s/sx) Mortality Treatment 2 Small amt foam in mouth or nose, +Rales 0.6% N/C O 2 – Hospital 3 Large amt foam, normal BP (+radial pulse) 5.2% ETT/NRB O 2 - Hospital
    34. 45. <ul><li>15 y/o ♂ </li></ul><ul><ul><li>“ Emergency Dept” “Treatment” </li></ul></ul><ul><ul><ul><li>O 2 N/C @ 2 LPM </li></ul></ul></ul><ul><ul><ul><li>1 mg IM Dexamethasone </li></ul></ul></ul><ul><ul><ul><li>B12 – 10,000 μ g IM </li></ul></ul></ul><ul><ul><ul><li>N-Acetylcysteine 20% IV </li></ul></ul></ul><ul><ul><ul><ul><li>30 mL (200mg/mL) </li></ul></ul></ul></ul>
    35. 47. Thomas Eakins' The Gross Clinic, (1875) “ A rude unhinging of the machinery of life”
    36. 48. You assume care of 16 y/o <ul><li>A- Patent, copius secretions </li></ul><ul><li>B- Tachypneic, RR 36, perioral cyanosis </li></ul><ul><li>C- Cool extremities – ST 130 bpm, thready </li></ul><ul><li>Critical Actions? </li></ul>
    37. 49. Airway <ul><li>Sedate and intubate </li></ul><ul><ul><li>Pediatric </li></ul></ul><ul><ul><li>Laryngospasm </li></ul></ul><ul><ul><ul><li>RSI, PPV, Jaw thrust </li></ul></ul></ul><ul><ul><ul><li>Cricothyrotomy, Lidocaine </li></ul></ul></ul><ul><ul><li>Airway obstruction? </li></ul></ul><ul><ul><ul><li>Sand, Mud, Del Taco </li></ul></ul></ul><ul><ul><li>Dec Compliance </li></ul></ul><ul><ul><li>Vomitus </li></ul></ul><ul><ul><ul><li>86% of Drowning resuscitations </li></ul></ul></ul>http://www.emsresponder.com/article/photos/1130360989690_10.jpg
    38. 50. Hypoxic Arrest <ul><li>Cardiac BLS/ACLS </li></ul><ul><ul><li>Heart stops, oxygen in blood needs circulating </li></ul></ul><ul><ul><li>C,A,B </li></ul></ul><ul><li>Drowning & Ped Arrest BLS/ACLS </li></ul><ul><ul><li>Heart stops because no oxygen in blood </li></ul></ul><ul><ul><li>A,B,C </li></ul></ul>
    39. 51. Survival <ul><li>Bottom Line </li></ul><ul><ul><li>Pt’s who make it to hospital alert, seldom die </li></ul></ul><ul><ul><li>Pt’s comatose on arrival are difficult to predict </li></ul></ul><ul><ul><li>Current guidelines </li></ul></ul><ul><ul><ul><li>Continue resuscitation for 25 total minutes of CPR </li></ul></ul></ul><ul><ul><ul><li>Continue if <1 hr submersion time </li></ul></ul></ul><ul><ul><ul><li>Continue to core temp 90°F </li></ul></ul></ul><ul><ul><ul><li>In Hospital - continue ICU care for 48 hours </li></ul></ul></ul>
    40. 52. Pre-Hospital Prognosis? <ul><ul><li>“ Resuscitation attempts should always be continued in the pre-hospital setting because of the difficulty of predicting outcome with sufficient accuracy at the scene” </li></ul></ul>Bangladesh, Lifeguards Without Borders, Aug2009
    41. 53. What about sending them home?
    42. 54. OK to send home after 4-6 hours <ul><li>Asymptomatic </li></ul><ul><ul><li>GCS >13 </li></ul></ul><ul><ul><li>Respiratory Efforts </li></ul></ul><ul><ul><li>SpO 2 > 95% on room air  </li></ul></ul><ul><ul><li>No ACLS PTA </li></ul></ul>
    43. 55. Special considerations
    44. 56. Hypothermia <ul><li>Hypothermia? </li></ul><ul><ul><li>Is it protective? Harmful? What about post-resus? </li></ul></ul><ul><ul><ul><li>Water at 91.4°F is thermally neutral </li></ul></ul></ul><ul><ul><ul><li>Conductivity is 25-30 x air </li></ul></ul></ul><ul><ul><li>Case Reports? </li></ul></ul><ul><ul><ul><li>21 y/o ♀ , 45 min 4°C </li></ul></ul></ul><ul><ul><ul><li>5 y/o ♂, 40 min 0°C </li></ul></ul></ul><ul><ul><ul><li>3 y/o ♀, 30 min 8°C </li></ul></ul></ul><ul><ul><ul><li>2.5 y/o ♀, 66 min (19°C) </li></ul></ul></ul>Special considerations
    45. 57. Hypothermia <ul><li>Hypothermia? </li></ul><ul><ul><li>Mammalian Diving Reflex </li></ul></ul><ul><ul><ul><li>15%-30% of Humans </li></ul></ul></ul><ul><ul><li>Cold and Dead? </li></ul></ul><ul><ul><ul><li>Rewarm </li></ul></ul></ul><ul><ul><li>What about post-resus? </li></ul></ul><ul><ul><ul><li>Therapeutic Hypothermia has been shown to decrease cerebral oxygen demand and improve neurologic outcomes </li></ul></ul></ul><ul><ul><ul><li>Area of active research </li></ul></ul></ul>Special considerations
    46. 58. Therapeutic Hypothermia <ul><li>Bottom line </li></ul><ul><ul><li>Warm pt to 90°F </li></ul></ul><ul><ul><ul><li>If dead, their dead </li></ul></ul></ul><ul><ul><ul><li>If not dead, stay there * </li></ul></ul></ul><ul><ul><ul><li>*Only if hospital protocols are in place </li></ul></ul></ul>Special considerations
    47. 59. C-Spine <ul><li>Less than 1% of Drowning patients, all with significant mechanism of injury </li></ul><ul><ul><li>Routine C-Spine immobilization is unnecessary </li></ul></ul>Special considerations
    48. 60. AED’s in Drowning <ul><li>V-Fib/V-Tach? </li></ul><ul><li>Rescuer Safety </li></ul><ul><li>Do not delay chest compressions </li></ul><ul><li>Minimize interruptions </li></ul>Special considerations
    49. 61. Heimlich Manuever <ul><li>Increased risk of aspiration </li></ul><ul><ul><li>Delays ventilation </li></ul></ul><ul><ul><li>Usually <30mL fluid in lungs </li></ul></ul><ul><ul><li>Watch for vomiting !!! </li></ul></ul>Special considerations
    50. 62. “ Do it by the book… but be the author.” Manual techniques of artificial respiration. Copyright 1950 American Medical Association.
    51. 63. “ Death is not the enemy but occasionally needs help with timing. ” http://lifeinthefastlane.com/2009/04/laws-for-the-navigation-of-life/ Dr. Peter Safar (12 April 1924 – 2 August 2003)
    52. 64. Summary <ul><li>Understand definition of drowning </li></ul><ul><ul><li>Process, not an outcome </li></ul></ul><ul><li>Appreciate epidemiology </li></ul><ul><ul><li>Highly prevalent worldwide, children <4 </li></ul></ul><ul><li>Management </li></ul><ul><ul><li>O 2 O 2 O 2, Laryngospasm, Vomitus, warm pt to 90°F </li></ul></ul><ul><ul><li>Hypoxic vs Cardiac cause of arrest </li></ul></ul><ul><li>Disposition of drowning patients </li></ul><ul><ul><li>Home or ICU </li></ul></ul><ul><li>Don’t blow smoke up pt’s (or colleagues) asses </li></ul><ul><ul><li>Bring your “A” game, be able to back it up </li></ul></ul>
    53. 65. Discussion [email_address]
    54. 66. <ul><li>Part 12: Pediatric Advanced Life Support. Circulation. December 13, 2005 2005;112(24_suppl):IV-167-187. </li></ul><ul><li>Part 10.3: Drowning. Circulation. December 13, 2005 2005;112(24_suppl):IV-133-135. </li></ul><ul><li>Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation. Apr 27 2004;109(16):1960-1965. </li></ul><ul><li>Bernius M, Thibodeau B, Jones A, et al. Prevention of Pediatric Drug Calculation Errors by Prehospital Care Providers. Prehospital Emergency Care. 2008;12(4):486 - 494. </li></ul><ul><li>Bierens JJ, Knape JT, Gelissen HP. Drowning. Curr Opin Crit Care. Dec 2002;8(6):578-586. </li></ul><ul><li>Bierens JJLM, Maatschappij tot Redding van Drenkelingen. Handbook on drowning : prevention, rescue treatment . Berlin ; New York: Springer; 2006. </li></ul><ul><li>Chochinov AH, Baydock BM, Bristow GK, et al. Recovery of a 62-year-old man from prolonged cold water submersion. Ann Emerg Med. Jan 1998;31(1):127-131. </li></ul><ul><li>Christensen DW, Jansen P, Perkin RM. Outcome and acute care hospital costs after warm water near drowning in children. Pediatrics. May 1997;99(5):715-721. </li></ul><ul><li>Ducharme MB, Lounsbury DS. Self-rescue swimming in cold water: the latest advice. Appl Physiol Nutr Metab. Aug 2007;32(4):799-807. </li></ul><ul><li>Giesbrecht GG, Pretorius T. Survey of public knowledge and responses to educational slogans regarding cold-wate immersion. Wilderness Environ Med. Winter 2008;19(4):261-266. </li></ul><ul><li>Hudson D, Ekman R, Svanstrom L. Survival of immersions during recreational boating events in Alaska, 1999-2004. Accid Anal Prev. May 2007;39(3):437-443. </li></ul><ul><li>Idris AH, Berg RA, Bierens J, et al. Recommended guidelines for uniform reporting of data from drowning: the &quot;Utstein style&quot;. Circulation. Nov 18 2003;108(20):2565-2574. </li></ul><ul><li>Larson CP, Jr. Laryngospasm--the best treatment. Anesthesiology. Nov 1998;89(5):1293-1294. </li></ul><ul><li>Orlowski JP, Szpilman D. Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am. Jun 2001;48(3):627-646. </li></ul><ul><li>Papa, Systematic review of definitions for drowning incidents. Resuscitation. 2005 Jun;65(3):255-64. </li></ul><ul><li>Roppollo L WJ, Pepe PE. Emergency Ventilatory Management as a detrimental factor in resuscitation practicees and clinical research efforts . Berlin: Springer; 2004. </li></ul><ul><li>Szpilman D. Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1,831 cases. Chest. Sep 1997;112(3):660-665. </li></ul><ul><li>Szpilman D, Soares M. In-water resuscitation--is it worthwhile? Resuscitation. Oct 2004;63(1):25-31. </li></ul><ul><li>USLA B. Open Water Lifesaving: The United States Lifesaving Association Manual . 2nd ed: Pearson Custom Publishing; 2003. </li></ul><ul><li>van Beeck EF, Branche CM, Szpilman D, et al. A new definition of drowning: towards documentation and prevention of a global public health problem. Bull World Health Organ. Nov 2005;83(11):853-856. </li></ul><ul><li>van Berkel M, Bierens JJ, Lie RL, et al. Pulmonary oedema, pneumonia and mortality in submersion victims; a retrospective study in 125 patients. Intensive Care Med. Feb 1996;22(2):101-107. </li></ul><ul><li>Watson RS, Cummings P, Quan L, et al. Cervical spine injuries among submersion victims. J Trauma. Oct 2001;51(4):658-662. </li></ul><ul><li>WHO. Drowning Fact Sheet. Available at: http://www.who.int/violence_injury_prevention/publications/other_injury/en/drowning_factsheet.pdf . 2009. </li></ul><ul><li>Wigginton J, Pepe P, Idris A, et al. Pivotal role of bystander cardiopulmonary resuscitation in pediatric drowning incidents. Critical Care. 2004;8(Suppl 1):P288. </li></ul><ul><li>Lu TH, Lunetta P, Walker S. Quality of cause-of-death reporting using ICD-10 drowning codes: a descriptive study of 69 countries. BMC Med Res Methodol. 2010;10(1):30. </li></ul><ul><li>World Health Organization: Global Burden of Disease 2004 Update.   Available at: http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html.   Accessed Sepr 14, 2010. </li></ul><ul><li>Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) [online]. (2009) [cited 2009 Nov 24]. Available from: URL: http://www.cdc.gov/injury/wisqars </li></ul><ul><li>CDC MMWR March 10, 2006 / 55(09);239-242 </li></ul><ul><li>Modell JH, Graves SA, Ketover A. Clinical course of 91 consecutive near-drowning victims. Chest 1976; 70(2):231-238. </li></ul><ul><li>Martin TG: Near-drowning and cold water immersion, Ann Emerg Med 1984; 13:263 </li></ul><ul><li>Giammono ST, Modell JH. Drowning by total immersion. Effects on Pulmonary surfactant of distilled water, isotonic saline, and sea water. Am J Dis Children 1967; 114(6):612-616 </li></ul><ul><li>Layon AJ, Modell JH Drowning - Update 2009. Anesthesiology 2009; 110; 6; 1390-1401. </li></ul><ul><li>Gregorakos L, Markou N, Psalida V et al Near-Drowning: clinical course of lung injury in adults. Lung 2009; 187: 93-97. </li></ul><ul><li>Manolios N, Mackie I. Drowning and near-drowning on Australian beaches patrolled by life-savers: a 10-year study, 1973-1983. Med J Aust. 1988 Feb 15;148(4):165-7, 170-1. </li></ul><ul><li>Larson CP, Jr. Laryngospasm--the best treatment. Anesthesiology. Nov 1998;89(5):1293-1294. </li></ul><ul><li>Dottorini M, Eslami A, Baglioni S, et al. Nasal-continuous positive airway pressure in the treatment of near-drowning in freshwater. Chest 1996; 110:1122-1124. </li></ul><ul><li>Kram JA, Kizer KW: Submersion injury, Emerg Med Clin North Am 1984; 2:545-552. </li></ul><ul><li>Modell JH: Near-drowning. In Callaham ML (ed); Current Therapy in Emergency Medicine. St. Louis, Mosby, 1986 </li></ul><ul><li>Orlowski JP: Drowning, near-drowning and ice-water submersions. Pediatr Clin North Am 1987;34:75 </li></ul><ul><li>Pearn J: Why children drown. Aust J Paediatr 1986;22:161 </li></ul><ul><li>Modell JH, Davis JH. Electrolyte changes in human drowning victims. Anesthesiology 1969;30:414-420. </li></ul>
    55. 67. <ul><li>Gonzalez-Rothi RJ: Near drowning: consensus and controversies in pulmonary and cerebral resuscitation. Heart Lung J Acute Crit Care 1987; 16(5):474-482. </li></ul><ul><li>Oakes DD, Sherck JP, Maloney JR, et al: Prognosis and management of victims of near-drowning. J Trauma Inj Infect Crit Care 1982;22(7):544-9 </li></ul><ul><li>Mehta SR, Srinivasan KV, Bindra MS, et al: Near drowning in cold water. J Assoc Phys India 2000; 48:674-676. </li></ul><ul><li>Modell JH, Graves SA, Ketover A. Clinical course of 91 consecutive near-drowning victims. Chest 1976; 70(2):231-238. </li></ul><ul><li>Walmrath D, Gunther A, Ghofrani HA, et al:  Bronchoscopic surfactant administration in patients with severe adult respiratory distress syndrome and sepsis.  Am J Respir Crit Care Med 1996;154:57-62 </li></ul><ul><li>Haitsma JJ, Lachmann U, Lachmann B.   Exogenous surfactant as drug delivery agent.  Adv Drug Deliv Rev 2001;47;197-207 </li></ul><ul><li>Haitsma J, Lachmann B.   Surfactant therapy.  In Bierens JJLM, Maatschappij tot Redding van Drenkelingen. Handbook on drowning : prevention, rescue treatment. Berlin ; New York: Springer; 2006 </li></ul><ul><li>Anzueto A, Baughman RP, Guntupalli KK, et al.  Aerosolized surfactant in adults with sepsis-induced acute respiratory distress syndrome.  N Engl J Med 1996:334;1417-1421 </li></ul><ul><li>Kesecioglu J.  Treatment of acute lung injury (ALI/ARDS) with surfactant.  Am J Respir Crit Care Med 2002;163:819 </li></ul><ul><li>Walmrath D, Grimminger F, Papper D, et al:  Bronchoscopic administration of bovine natural surfactant in ARDS and septic shock: impact on gas exchange and haemodynamics. Eur Respir J 2002;19:805-810 </li></ul><ul><li>Weg JG, Balk RA, Tharratt RS, et al:  Safety and potential efficacy of an aerosolized surfactant in human sepsis-induced adult respiratory distress syndrome.  JAMA 1994:272;1433-1438 </li></ul><ul><li>Gommers D, Lachmann B.  Surfactant therapy: does it have a role in adults? Clin Intensive Care 1993:4;284-295 </li></ul><ul><li>Lachmann B.  The role of pulmonary surfactant in the pathogenesis and therapy of ARDS.  in:  Vincent JL (ed).  Update in intensive care and emergency medicine.  1987: Spring, Berlin Heidelberg, 123-134 </li></ul><ul><li>Staudinger T, Bankier A, Strohmaier W, et al:  Exogenous surfactant therapy in a patient with adult respiratory distress syndrome after near drowning.  Resuscitation 1997;35:179-182 </li></ul><ul><li>Suzuki H, Ohta T, Iwata K, et al:  Surfactant therapy for respiratory failure due to near-drowning.  Eur J Pediatr 1996;144:383-384 </li></ul><ul><li>Nowak RM: Asthma. In Rosen P et al (5th ed) : Emergency Medicine: Concepts and Clinical Practice, St. Louis, Mosby, 2002, pp. 938-956 </li></ul><ul><li>Robertson C, Levison H: Bronchodilators in asthma.  Chest 1985:87:64S </li></ul><ul><li>Bennett P, Elliott D: The Physiology and Medicine of Diving, 4th ed. Philadelphia, Saunders, 1993 </li></ul><ul><li>Hoff BH: Multisystem failure: a review with special reference to drowning, Crit Care Med 1979; 7:310-320 </li></ul><ul><li>Levinson R et al: Comparison of the effects of water immersion and saline infusion on central hemodynamics in man, Clin Sci Mol Med 1977; 52:343 </li></ul><ul><li>Perk L, Borger van de BF, Berendsen HH, et al: Full recovery after 45 min accidental submersion. Intens Care Med 2002;28(4):524 </li></ul><ul><li>Siebke H, Rod T, Breivik H, et al: Survival after 40 minutes; submersion without cerebral sequelae. Lancet 1975;1:1275-1277 </li></ul><ul><li>Thalmann M, Trampitsch E, Haberfellner N, et al: Resuscitation in near drowning with extracorporeal membrane oxygenation. Ann Thoracic Surg 2001;72(2):607-8 </li></ul><ul><li>Bolte RG, Black PG, Bowers RS.  The use of extracorporeal rewarming in a child submerged for 66 minutes.  JAMA 1988;260:377. </li></ul><ul><li>Gooden BA: Drowning and the diving reflex in man. Med J Aust 1972;2:583. </li></ul><ul><li>Hypothermia After Cardiac Arrest Study Group. Mild Therapeutic Hypothermia to Improve the Neurologic Outcome After Cardiac Arrest. N Engl J Med 2002; 346: 549-556. </li></ul><ul><li>Quan L, Cummings P: Characteristics of drowning by different age groups. Injury Prevention 2003;9(2):163-8 </li></ul><ul><li>Warner D, Knape J: Brain resuscitation in the drowning victim: consensus and recommendations. In Bierens JJLM (ed): Handbook on drowning: prevention, rescue, treatment, Berlin, Springer, 2006, pp 436-438. </li></ul><ul><li>Conn AW, Barker GA: Fresh water drowning and near-drowning-an update.  Can Anaesth Soc J 1984;31:38-44. </li></ul><ul><li>Graf WD, Cummings P, Quan L, Brutocao D: Predicting outcome in pediatric submersion victims. Ann Emerg Med 1995; 26(3):312-319 </li></ul><ul><li>Modell JH, Graves SA, Ketover A: Clinical course of 91 consecutive near-drowning victims. Chest 1976;70:231. Fandel I, Bancalari E: Near-drowning in children: Clinical aspects. Pediatrics 1976;58:573-579. Peterson B: Morbidity of childhood near-drowning. Pediatrics 1977;59:364-370. Orlowski JP: Prognostic factors in pediatric cases of drowning and near-drowning. J Am Coll Emerg Phys 1979;8:176-179. Pearn JH, Bart RD Jr, Yamaoka R: Neurologic sequelae after childhood near-drowning: A total population study from Hawaii. Pediatrics 1979;64:187-191. Conn AW, Montes JE, Barker GA, et al: Cerebral salvage in near-drowning following neurological classification by triage. Can Anaesth Soc J 1980;27:201-210. Modell JH, Graves SA, Kuck EJ: Near-drowning: Correlation of level of consciousness and survival. Can Anaesth Soc J 1980;27:211-214. Dean JM, Kaufman ND: Prognostic indicators in pediatric near-drowning: The Glasgow coma scale. Crit Care Med 1981;9:536- 539. Dean JM, McComb JG: Intracranial pressure monitoring in severe pediatric near-drowning. Neurosurgery 1981;9:627-630. Frates RC Jr: Analysis of predictive factors in the assessment of warm-water near-drowning in children. Am J Dis Child 1981;135:1006-1008. Oakes DD, Sherck JP, Maloney JR, et al: Prognosis and management of victims of near-drowning. J Trauma 1982;22:544-549. Nussbaum E, Galant SP: Intracranial pressure monitoring as a guide to prognosis in the nearly drowned, severely comatose child. J Pediatr 1983;102:215-218. Jacobsen WK, Mason LJ, Briggs BA, et al: Correlation of spontaneous respiration and neurologic damage in near-drowning. Crit Care Med 1983;11:487-489. Sarnaik AP, Preston G, Lieh-Lai M, et al: Intracranial pressure and cerebral perfusion pressure in near-drowning. Crit Care Med 1985;13:224-227. </li></ul>
    56. 68. <ul><li>Bell TS, Ellenberg L, McComb JG: Neuropsychological outcome after severe pediatric near-drowning. Neurosurgery 1985;17:604-608. Nussbaum E: Prognostic variables in nearly drowned, comatose children. Am J Dis Child 1985;139:1058-1059. Simcock AD: Treatment of near drowning: A review of 130 cases. Anaesthesia 1986;41:643-648. Weinberg HD: Prognostic variables in nearly drowned, comatose children (letter). Am J Dis Child 1986;140:329. Allman FD, Nelson WB, Pacentine GA, et al: Outcome following cardiopulmonary resuscitation in severe pediatric near-drowning. Am J Dis Child 1986;140:571-575. Nichter MA, Everett PB: Childhood near-drowning: Is cardiopulmonary resuscitation always indicated? Crit Care Med 1989;17:993-995. Nagel FO, Kibel SM, Beatty DW: Childhood near-drowning factors associated with poor outcome. S African Med J 1990;78:422-425. Quan L, Wentz KR, Gore EJ, et al: Outcome and predictors of outcome in pediatric submersion victims receiving prehospital care in King County, Washington. Pediatrics 1990;86:586-593. Bierens JJLM, van der Velde EA, van Berkel M, et al: Submersion in the Netherlands: Prognostic indicators and results of resuscitation. Ann Emerg Med 1990;19:1390-1395. Ashwal S, Schneider L, Thompson J: Prognostic implications of hyperglycemia and reduced cerebral blood flow in childhood near-drowning. Neurology 1990;40:820-823. Kemp AM, Sibert JR: Outcome in children who nearly drown: A British Isles study. BMJ 1991;302:931-933. Quan L, Kinder D: Pediatric submersions: Prehospital predictors of outcome. Pediatrics 1992;90:909-913. Lavelie JM, Shaw KN: Near drowning: Is emergency department cardiopulmonary resuscitation or intensive care unit cerebral resuscitation indicated? Crit Care Med 1993;21:368-373. </li></ul><ul><li>Christensen DW, Jansen P, Perkin RM. Outcome and acute care hospital costs after warm water near drowning in children [erratum appears in Pediatrics 1998; 101(1 Pt 1):105]. Pediatrics 1997; 99(5):715-721.   </li></ul><ul><li>Simcock A:  Hospital Treatment: Treatment Protocols - Emergency Room.  In Bierens JJLM (ed): Handbook on drowning: prevention, rescue, treatment, Berlin, Springer, 2006, pp 392-6. </li></ul><ul><li>Causey AL, Tilelli JA, Swanson ME. Predicting discharge in uncomplicated near-drowning. Am J Emerg Med 2000;18(1):9-11. </li></ul>[email_address]

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