First 5 min of cold water immersion - sudden death and prolonged survival - lessons for resuce and resus At talk by Mike Tipton at TBS23

1. The first 5 minutes of cold water immersion: sudden death &
prolonged survival - lessons for rescue & resuscitation
Mike Tipton

2. e.g. Impact of water safety lesson in Schools
e.g. Beach lifeguard surveillance
e.g. Lifejacket & PPE design and function
e.g. Treatment
e.g. Physiology/pathophysiology of CWI and rescue
Drowning Chain of Survival
Szpilman, Tipton, Semsprott & Queiroga, (2016)
Drowning timeline: a new systematic model of the
drowning process. The American journal of
Emergency Medicine 34(11): 2224-2226

3. Drowning 80% of deaths from Malnutrition; 56% of deaths from Malaria.
More deaths than TB, HIV or Polio.
Biggest killer of sportspeople doing their sport - including divers
1,000 people drown every day, 2 every 3 minutes, 41 per hour
Source: UN WHO 2002, ILSF 2011, WCDP 2019
World’s 3rd leading cause of accidental
death: 3.6 million people over 10 years
Disease of youth
64% < 30 years old
43% < 15 years old
25% < 5years old
Males 2x number v. females
40% +ve for alcohol

4. DROWNING
DEFINITION 2002
“The process of experiencing respiratory impairment from
submersion/immersion in liquid”
Only 3 outcomes
– Death
– No Morbidity
– Morbidity

9. 1989
“Cold Shock”

10. Skin Cooling
Cold Shock

11. RESOURCES AVAILABLE TO HELP YOU WITH THESE CONVERSATIONS
RTW@rnli.org.uk
RTW packs: launch/event and pub packs
Pint glasses
Stickers
Pin badges
Calling for
help keyrings

13. 2017-present

14. 2017-present

15. Impact

16. 999 Coastguard

17. “Cold Shock”
Heart Rate Breathing Rate BreathingVolume
(Bts.min-1) (Breath.min-1) (Litres.min-1)
Pre-immersion 90 12 16
1st min Immersion 156 66 114
5th min Immersion 108 23 67
Lethal aspiration = Sea water 22mL.kg-1 (Approx 1.5 L). Fresh water 44mL.kg-1
Aspirating 2.2mL.kg-1 reduces PaO2 from 13-8kPa (100-60mmHg)
Aspirating 2.5mL.kg-1 increases pulmonary shunt from 10-75%
Modell & Moya, 1966; Tipton, 1989

19. 1989
1870

20. Initial Responses to Cold Water
Immersion
• Cold Shock
– Head out immersion & submersion
– Sympathetic stimulation – increases heart rate
and force of contraction
• Diving Response
– Submersion / Periodic face immersion
– Parasympathetic (vagal) stimulation – decreases
heart rate and force of contraction

21. Cold shock & Diving bradycardia
Cold shock Tachycardia HR 120 beats/min
Head out/in immersion
Diving bradycardia HR 33 beats/min
Face immersion
Sympathetic stimulation – increases heart rate and force of contraction
Parasympathetic (vagal) stimulation – decreases heart rate and force of contraction

22. End Breath hold
End Breath hold
ECG
ECG
+
Respiration
Tipton, Kelleher & Golden (1994); Datta & Tipton (2006)
Fit & healthy participants incidence of dys/arrhythmia. Head out, free breathing (naked): 1-3%;
Head out breath holding (naked) 63%; Head in, breath holding (immersion suit) 82%

23. Immunohistochemical identification of nuclear profiles of fos protein in dorsal
medullary nuclei of a a urethane-anesthetized rat brain following immersion (39°C,
2 hours). NTS = nucleus tractus solitarius; DMNX = dorsal motor nucleus of the
vagus
Tipton & Harris in Datta & Tipton (2006) J Appl Physiol

24. Immunohistochemical identification of nuclear profiles of fos protein in dorsal
medullary nuclei of a a urethane-anesthetized rat brain following immersion (39°C,
2 hours). NTS = nucleus tractus solitarius; DMNX = dorsal motor nucleus of the
vagus
Tipton & Harris in Datta & Tipton (2006) J Appl Physiol
c-fos proto-oncogene staining (39 °C, 2 hours).
There is no staining in areas known to be responsible for
cardiorespiratory integration. NTS, nucleus tractus solitarius;
DMNX, dorsal motor nucleus of tenth cranial nerve (vagus);
VIV fourth ventricle, area postrema.

25. Immunohistochemical identification of nuclear profiles of fos protein in dorsal
medullary nuclei of a urethane-anesthetized rat brain following cold immersion (8°C,
60 seconds). NTS = nucleus tractus solitarius; DMNX = dorsal motor nucleus of the
vagus
Tipton & Harris in Datta & Tipton (2006) J Appl Physiol

26. Whole body human Isolated heart (Rat)
Shattock & Tipton (2012) Journal of Physiology
Perfused with a constant background
concentration of adrenaline (75nM) and nor-
adrenaline (313nM) and a one-minute
period of acetylcholine (Ach: 5µM) was
superimposed as indicated

27. Shattock & Tipton, 2012

28. DRUGS
• Certain drugs prolong the QT interval
– Antihistamines (quinidine, procainamide)
– Class III antiarrhythmics (amiodarone, sotalol)
– Antibiotics (erythromycin, clarithromycin)
– Gastrointestinal prokinetics (cisapride, domperidone)
– Antipsychotics (chlorpromazine, haloperidol, thioridazine,
mesoridazine)
• Individuals on such drugs may be at greater risk of cardiac arrhythmias
on immersion when breath holding
2018
“not yet widely
appreciated, the
risk of fatal
consequences
from QT-
prolonging drugs
is increased by the
dive reflex”

29. Avoiding “Autonomic Conflict”
Avoid coincident face immersion and long breath holds in water

33. Fainer et al (1951)

34. Protection
• The hypoxic survival time of the
brain is extended by hypothermia
• Cerebral activity and therefore
oxygen demand fall close to
minimal levels at a brain
temperature of 22 °C (72 °F)
• The critical question: what was
brain temperature at cardio-
respiratory arrest?
Adams RD, Victor M. Hypoxic hypotensive encephalopathy. In: Adams
RD, Victor M, editors. Principles in neurology. New York: McGraw-Hill
Book Co.; 1977. p. 732–4.
HYPOTHERMIA
LIFE-THREATENING
LIFE-PRESERVING

35. Points represent individual cases in which the period of immersion was followed by full
recovery (n=26, excluding submersions in vehicles and incidents for which no water
temperatures were stated)
Water temperature and submerged survival time
Tipton & Golden (2011)
43°F

36. Review of the Literature (n=43)
• Age/size
– Child or small adult
– 67% of cases involved children 12 years old or younger
• Salinity of water
– Fresh
• Body temperature
– In 37 cases deep body temperature was 30°C or below in 30 cases
(81%).
• Water temperature
– Unable to identify any case in which an individual survived for longer
than 30 minutes submerged in water warmer than 6°C
Prolonged u/w survival: important factors

37. Mechanism: Cooling?
Golden, Tipton & Scott (1997)

38. Mechanism: Cooling?
• Surface cooling insufficient
– 2.5°C in 10 minutes
Golden, Tipton & Scott (1997)

39. Mechanism: Cooling?
• Surface cooling insufficient
– 2.5°C in 10 minutes
• Alternative mechanism required
– Pulmonary heat exchange and selective
brain cooling
Golden, Tipton & Scott (1997)

40. Surviving Prolonged Submersion (Tw 4°C)
PULMONARY COOLING (Conn et al, 1995)
FRESH SALT CONTROL
Fall in Carotid Artery Temp (°C)
2 Minutes 8.5 7.5 0.8
2-10 Minutes 2.4 3.1
Increase in Body Mass (kg)
10 Minutes 1.5 0.6 0
NB Significant deep body cooling during drowning

41. Search: survival/resuscitation
extremely unlikely if submerged
longer than 30 minutes
Is the water warmer than 6 degC?
YES it is NO it is not
Search: survival/resuscitation
extremely unlikely if submerged
longer than 90 minutes
Submersion (head under) time unknown?
Start clock on arrival at the scene
Decision-making guide for immersion incidents involving total (head under) submersion
Tipton & Golden (2011) Resuscitation, 82: 819– 824

42. The model is designed to give casualties every
reasonable chance of rescue and
resuscitation and is balanced against the risk
of harm to responders when carrying out
rescues.
Available physiological evidence suggests that
water temperatures in the region of 6-7°C (43
°F) or less are required for prolonged survival
times in submerged casualties.
http://www.ukfrs.com/Blog/Post/65/Water-
rescue-and -flooding
Based on: Tipton, M. J. & Golden, F. St.C. (2011) Decision-making
guide for the search, rescue and resuscitation of submerged
(head under) victims. Resuscitation 82: 819-824
Δpplied Physiology

43. Golden, 1980; Szpilman et al (2017); Evans et al (2020)

44. Drowning (non-fatal): diffuse
pulmonary oedema, gastric
distension (air/water)
Golden, 1980; Szpilman et al (2017); Evans et al (2020)

45. Drowning (non-fatal): diffuse
pulmonary oedema, gastric
distension (air/water)
Up to 89% swallow water
Golden, 1980; Szpilman et al (2017); Evans et al (2020)

46. Drowning (non-fatal): diffuse
pulmonary oedema, gastric
distension (air/water)
Up to 89% swallow water
Vomiting - most frequent
complication during drowning
resuscitation:
>65% of victims who need rescue
breathing alone
86% of victims who require CPR
Golden, 1980; Szpilman et al (2017); Evans et al (2020)

47. Drowning (non-fatal): diffuse
pulmonary oedema, gastric
distension (air/water)
Up to 89% swallow water
Vomiting - most frequent
complication during drowning
resuscitation:
>65% of victims who need rescue
breathing alone
86% of victims who require CPR
Active efforts to expel water from
the airway (abdominal thrusts or
placing the victim head down)
should be avoided
Golden, 1980; Szpilman et al (2017); Evans et al (2020)

48. Drowning (non-fatal): diffuse
pulmonary oedema, gastric
distension (air/water)
Up to 89% swallow water
Vomiting - most frequent
complication during drowning
resuscitation:
>65% of victims who need rescue
breathing alone
86% of victims who require CPR
Active efforts to expel water from
the airway (abdominal thrusts or
placing the victim head down)
should be avoided
Finger sweep as necessary
Golden, 1980; Szpilman et al (2017); Evans et al (2020)

49. Prognostic indicators
Good prognosis: depends on length of anoxic period and degree of secondary damage
• Submersion <5 to 10 min – strongest predictor of the risk of death or severe neurological
impairment after hospital discharge (NB. water temperature)
• No aspiration
• Child
• Tw <6 °C; Tcore < 33-35 °C
• Time to effective basic life support <10 min
• Neurologically intact on arrival at hospital
• Min blood pH > 7.1, Blood glucose <11.2 mmol.L-1
• If cardiac arrest responds to first aid at scene. Early ROSC (<10 minutes)
• Spontaneous respirations in emergency department after cardiac arrest at the scene
Orlowski et al (1989); Szpilman, (1997); Szpilman & Morgan (2021);Tipton & Morgan 2022

50. • Relief of hypoxia – speed greatest influence on outcome (every minute CPR delayed
= 10% less chance of success)
• O2 goal: pre-hospital peripheral saturation of >92%
• 5 rescue breaths (airway expansion) then 30:2 (compressions: breaths)
• Tracheal intubation early if indicated (e.g. patients with severe respiratory failure
or cardiac arrest)
• Deliver high FIO2 (e.g. face mask 100% O2 at a rate of 15 L.min-1)
• If available, PEEP @ 5cmH20, then increase by 2-3 increments as needed
Schmidt et al (2016)

51. • Relief of hypoxia – speed greatest influence on outcome (every minute CPR delayed
= 10% less chance of success)
• O2 goal: pre-hospital peripheral saturation of >92%
• 5 rescue breaths (airway expansion) then 30:2 (compressions: breaths)
• Tracheal intubation early if indicated (e.g. patients with severe respiratory failure
or cardiac arrest)
• Deliver high FIO2 (e.g. face mask 100% O2 at a rate of 15 L.min-1)
• If available, PEEP @ 5cmH20, then increase by 2-3 increments as needed
• Foam may be copious in the airway, DO NOT waste time attempting to suction.
Ventilate with BVM through foam (suction water and vomit only when present)
Schmidt et al (2016)

52. • Relief of hypoxia – speed greatest influence on outcome (every minute CPR delayed
= 10% less chance of success)
• O2 goal: pre-hospital peripheral saturation of >92%
• 5 rescue breaths (airway expansion) then 30:2 (compressions: breaths)
• Tracheal intubation early if indicated (e.g. patients with severe respiratory failure
or cardiac arrest)
• Deliver high FIO2 (e.g. face mask 100% O2 at a rate of 15 L.min-1)
• If available, PEEP @ 5cmH20, then increase by 2-3 increments as needed
• Foam may be copious in the airway, DO NOT waste time attempting to suction.
Ventilate with BVM through foam (suction water and vomit only when present)
• VF is rare in drowning (<10% in literature) so incorporation of AED in initial minutes
of drowning should not interfere with oxygenation and ventilation. Otherwise AED
use should be considered and is not contraindicated in a wet environment
Schmidt et al (2016)

53. • Relief of hypoxia – speed greatest influence on outcome (every minute CPR delayed
= 10% less chance of success)
• O2 goal: pre-hospital peripheral saturation of >92%
• 5 rescue breaths (airway expansion) then 30:2 (compressions: breaths)
• Tracheal intubation early if indicated (e.g. patients with severe respiratory failure
or cardiac arrest)
• Deliver high FIO2 (e.g. face mask 100% O2 at a rate of 15 L.min-1)
• If available, PEEP @ 5cmH20, then increase by 2-3 increments as needed
• Foam may be copious in the airway, DO NOT waste time attempting to suction.
Ventilate with BVM through foam (suction water and vomit only when present)
• VF is rare in drowning (<10% in literature) so incorporation of AED in initial minutes
of drowning should not interfere with oxygenation and ventilation. Otherwise AED
use should be considered and is not contraindicated in a wet environment
• Restoration of CV stability; Prevention of further heat loss; Speedy evacuation to
hospital
Schmidt et al (2016)

54. Transport to Hospital?
Grade Sign/Symptom Mortality (%) Action
1 Cough, no foam at
mouth/nose
0 Thorough history – release
home with education
2 Small volume of foam in
mouth or nose, +Rales
0.6 Hospital
3 Large amount of foam,
normal BP (+radial pulse)
5.2 Hospital
4 Large amount of foam,
Low BP, (-ve radial pulse)
19.4 Hospital
5 Respiratory arrest 44 Hospital
6 Cardiopulmonary arrest 93 Hospital
Bierens (2014); Tipton & Morgan (2023)
• Predicting prognosis in prehospital setting is difficult and does not correlate with
mental status. Unless obvious death, transport
• Direct transportation to an ECLS centre should be considered in patients that
have suffered a cardiac arrest following cold water immersion

55. Drowning is a process
• Cough, breathlessness, abnormal mentation or other worrisome symptoms
within 8 hours of a drowning incident - seek medical advice
• No case in the medical literature of a patient who underwent clinical
evaluation, was initially without symptoms, and deteriorated and died more
than 8 hours after the incident
Drowning can take up to 4 hours, watch for up to 8 hours
Szpilman et al (2018)

56. Summary

57. Back Row
Joe Costello
Zoe Saynor
Jo Corbett
Harry Mayes
Danny White
Geoff Long
Chris Mills
Front Row
Clare Eglin
Tom James
Mitch Lomax
Heather Massey
Tom Williams
Also: Gemma Milligan, Jenny Wright, Matt
Wilkes, Paddy Morgan, Dan Roiz de Sa,
Carol House

58. Thank you
@ProfMikeTipton
https://www.researchgate.net/profile/Mike_Tipton
michael.tipton@port.ac.uk

59. Summary
• Time to “drown” following submersion: 2 minutes
• Best chance of resuscitation <5-10 min (Tw > 6 °C)
• Risk of death or severe neurological impairment after hospital discharge is given as
“nearly 100%” when the duration of submersion exceeds 25 min (Tw > 6 °C)
• Chance of resuscitation to 90 min if Tw < 6 °C, in this situation selective brain cooling
mean other measure of Tc have no prognostic value
• Objective of treatment: oxygenation
Golden & Tipton (2011); Szpilman et al (2012)

60. Primary CA (heart disease) Drowning CA (special case)
Oxygen Content: Moderate
Oxygen Content: Very Low
BLS: Compression only
BLS: Breaths + Compression
Cardiac Arrest (VF/VT)
Hypoxemia
Acidosis
Hypoxemia
Acidosis +++
Micro-infarct
Oedema
Cardiac Arrest
(PEA/Asystole)
5 rescue breaths (airway expansion) then 30:2
(compressions: breaths)

62. Predisposing Factors:
QT/RR hysteresis
The failure of the action potential to adapt to an abrupt change
in rate may seriously predispose to ventricular arrhythmias
during periods of Autonomic Conflict
• On a rapid reduction in HR, if the AP duration remains short as the
diastolic interval prolongs, then the relative refractory period will
decrease leaving the heart more vulnerable to re-entrant arrhythmias
• If the AP remains long following a rapid increase in HR, the
myocardial cells spend a greater proportion of the cardiac cycle
depolarised. This, in the face of a rate-dependent increase in calcium
influx, will increase the likelihood of cellular calcium overload – a
trigger for ventricular automaticity and arrhythmias

63. • Background (steady-state) adrenergic activation suppresses arrhythmia
associated with vagus nerve stimulation (VNS) in hearts with drug-
induced LQTS
• However, sudden adrenergic stress, during periods of sustained VNS,
acts to increase the severity of observed arrhythmia, including sustained
ventricular tachyarrhythmia
• There is a complex relationship between autonomic tone and sudden
cardiac death in LQTS

64. In-water resuscitation
• Rescue breaths only when rapid extraction
not possible
• Rescue breaths in deep water requires a
two highly trained rescuers and a flotation
aid. Increases rescue time.
• 19 unconscious and not breathing
casualties up to 1 min of IWR:
– Pre-hospital survival rate 94.7 v. 37% (27 controls
without IWR).
– Rate better at discharge (87.5 v. 25%) and for
neurological outcome (52.6 v. 7.4%)
• Chest compressions ineffective – do not
attempt
• NB. Cervical spine injury (0.009- 0.5%);
routine stabilisation not recommended Szpilman & Soares (2004)
Parenteau et al (2018)
ANZCOR Guidelines 9.3.2 (2021)

65. Need for Evidence (2021)
Prognostic factors
Submersion time
EMS time
Salt water
No evidence found regarding
Resuscitation in water
Resuscitation in boats
Airway management
Oxygen administration
AED use
Bystander CPR
Ventilation strategy
ECMO
Discharge protocols

66. Enough data? Oxygen Use
Resuscitation & emergency care in drowning: A scoping review (2021)
• No randomised controlled trials were identified for the topics reviewed
• There is relatively limited evidence from observational studies to inform clinical
practice guidelines for drowning
• The evidence identified was from predominantly high-income countries and lacked
consistency in the populations, interventions and outcomes reported
• No studies were identified which specifically examined the prehospital use of
oxygen in adults or children who had sustained a submersion incident
• Indirect evidence from observational studies found associations between hypoxia,
oxygen administration and worse outcomes
• If we need to use physiological mechanistic insight and deductive
reasoning, we should at least recognise it as a valid method and
not pretend our conclusions come from what, by any assessment,
is an inadequate literature and likely to remain so (Tipton, 2023)
Bierens et al (2021)