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7/27/2019 Bierens_ Drowning Resuscitation Requires another state of mind.pdf
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Please cite this article in press as: Bierens JJLM, Warner DS. Drowning resuscitation requires another state of mind. Resuscitation (2013),
http://dx.doi.org/10.1016/j.resuscitation.2013.09.005
ARTICLE IN PRESSGModel
RESUS572013
Resuscitationxxx (2013) xxxxxx
Contents lists available at ScienceDirect
Resuscitation
journal homepage: www.elsevier .com/ locate / resusci tat ion
Editorial
Drowning resuscitation requires another state ofmind
This issue of resuscitation includes a large prognostic Utstein-
based drowning resuscitation study from Osaka, Japan, which at
first glance reports very disappointing outcomes. Of the 1737
drowning victims who were in a cardiac arrest at arrival of emer-
gency medical services (EMS), only 0.8% were alive with normal
neurological function after one month.1 The study is consistent
with another Japanese cohort study,2 but contrasts with casereports where more optimistic outcomes have been reported.3,4
A conclusion of the current publication could be that resuscitation
of drowning victims is useless and that we should perhaps return
to the 17th century when the laws in many European countries
required that drowning victims remain untouched with at least
their feet hanging in the water so as to allow police to determine
the cause of death.5
Theworkof Nitta etal.1 emphasisestherealityof thedown-side
of resuscitation efforts and the importance of effective drowning
prevention strategies.68 At the same time, the study allows us to
learnmoreaboutsomekeyelementsof drowningresuscitationand
drowning resuscitation research.
Indrowningvictims, importantpredictors forsurvival arewater
temperature,3,9
submersion time,9,10
adequacy of bystander car-diopulmonary resuscitation (CPR),2,11 andEMS response time.12,13
Nitta et al.1 correctly mention that their study has been based on
Utstein template of data collection for cardiac arrest,14 andnot on
theUtstein template for drowning.15 Their study, therefore, could
notprovidedataon thesepredictors invaluabledetail. Thereported
average EMS response timeof 7min however provides an estimate
of the out-of-water anoxic interval. The total (under-water plus
out-of-water) anoxic intervalmusthavebeensubstantial. Notably,
almost 60% of the victims did not receive any bystander CPR and
an additional 20% received compression-only CPR. Also the time
to install the automated external defibrillator (AED), ultimately
superfluous as reported inmany drowning studies,2,12,13,16,17may
have to be added to the total anoxic period. Taking these factors
into account, it is not surprising that the EMS providers could not
achieve restoration of spontaneous circulation (ROSC) in 84% of
overall study population.1 It is a reasonable finding that severe
anoxic brain damageoccurred inmany of the remaining victims.
Nitta et al.1 do provide important newdata regarding effects of
victimageon resuscitation success. ROSC wasrestored by theEMS
in 53% (19/36) of 04 year old children, in 28% (9/32) of 517 year
olds. This markedly contrasts with a rate of 12.5% (208/1669) in
those older than 17 years. Interestingly, this study does not iden-
tify any patient in which ROSC was achieved after arrival in the
hospital.4,13,18,19 For those in whom ROSC was achieved, survival
after 1 month in 04 year oldswas 53% (10/19), 33% (3/9) in 517
year olds, and14% (28/208) in those>17years ofage. Thefrequency
of neurologically intact survival, assessed at 1 month, showed an
oppositeage-related trend:20% (2/10)of 04 year olds, 33%(1/3) of
517 year olds and39%(11/208)of thoseabove17yearsofage. This
doesnot necessarilypredict long-termfunctionalrecovery. Several
casereportsofdrowningresuscitationhaveobservedimprovement
ofneurological functionafterthefirstpost-resuscitationmonthasaresultofneuro-rehabilitation.20,21Ontheotherhand,moredetailed
neurological andneurophysiological investigationsaftermonthsor
years show complications that had before gone unnoticed.6,22
A further remark needs to be made. This regards the com-
plex relationship between outcome, drowning mechanisms, and
drowning populations.23 Notably the large number of elderly vic-
tims included in the Nitta el al.1 study population (mean age 77
years; interquartile range 6784) is remarkable and indicates fur-
ther investigation of the drowning mechanisms.24 It may be that
particular mechanisms or populations have a poorer prognosisper
se.
Taking these factors in to consideration, let us go back to the
physiologyof drowning and again lookat the dataofNitta et al.1 to
better understandwhytheoutcome in their studywasso tragicallylow.
First, it is essential to understand that cardiac arrest in drown-
ing is not like the onoff physiological mechanism occurring in
most out-of-hospital cardiac arrests (OHCA). In drowning, cardiac
function gradually deteriorates over several minutes as a result of
progressive hypoxia. Drowning physiology implicates that early
ventilation and oxygenation are essential for survival. It is also
known that airway resistance maybe extremely high in drowning
victims. This can prevent effective ventilation in the pre-hospital
setting and during transportation.4,25,26 In other situations, where
rescue and resuscitation have been performed by the same per-
son, extremely large tidal volumes are often inflated which result
in outflow limitations of the right ventricle and lower perfusion
pressures during cardiac compressions.27,28 The ventilatory com-
ponent of treatment is not only relevant during resuscitation but
also during in-hospital treatment. A number of drowning victims
will dieduring thefirstweek asa resultof adult respiratorydistress
syndrome and pneumonia.29 These respiratory aspects may have
contributed to the high number of patients who died in hospital
after ROSC.
Children are an important proportion of drowning vic-
tims. Bystanders, EMS and physicians are less competent in
airway management in children.30,31 Previous studies have
expressed concerns that regional differences in paediatric OHCA
in Japan may be attributed to an EMS system that is yet
0300-9572/$ see front matter 2013 Published by Elsevier Ireland Ltd.
http://dx.doi.org/10.1016/j.resuscitation.2013.09.005
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http://localhost/var/www/apps/conversion/tmp/scratch_2/dx.doi.org/10.1016/j.resuscitation.2013.09.005http://localhost/var/www/apps/conversion/tmp/scratch_2/dx.doi.org/10.1016/j.resuscitation.2013.09.005http://localhost/var/www/apps/conversion/tmp/scratch_2/dx.doi.org/10.1016/j.resuscitation.2013.09.005http://www.sciencedirect.com/science/journal/03009572http://www.elsevier.com/locate/resuscitationhttp://localhost/var/www/apps/conversion/tmp/scratch_2/dx.doi.org/10.1016/j.resuscitation.2013.09.005http://localhost/var/www/apps/conversion/tmp/scratch_2/dx.doi.org/10.1016/j.resuscitation.2013.09.005http://www.elsevier.com/locate/resuscitationhttp://www.sciencedirect.com/science/journal/03009572http://localhost/var/www/apps/conversion/tmp/scratch_2/dx.doi.org/10.1016/j.resuscitation.2013.09.005http://localhost/var/www/apps/conversion/tmp/scratch_2/dx.doi.org/10.1016/j.resuscitation.2013.09.0057/27/2019 Bierens_ Drowning Resuscitation Requires another state of mind.pdf
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7/27/2019 Bierens_ Drowning Resuscitation Requires another state of mind.pdf
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Please cite this article in press as: Bierens JJLM, Warner DS. Drowning resuscitation requires another state of mind. Resuscitation (2013),
http://dx.doi.org/10.1016/j.resuscitation.2013.09.005
ARTICLE IN PRESSGModel
RESUS572013
Editorial / Resuscitationxxx (2013) xxxxxx 3
27. Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilation-induced hypotension during cardiopulmonary resuscitation. Circulation2004;109:19605.
28. Barcala-FurelosR, Abelairas-GomezC, Romo-PerezV, Palacios-AguilarJ. Effectofphysicalfatigueon thequalityCPR:a waterrescue studyof lifeguards:physicalfatigue and quality CPR in a water rescue. AmJ Emerg Med 2013;31:4737.
29. van BerkelM, Bierens JJ,Lie RL,et al.Pulmonary oedema, pneumonia andmor-tality in submersion victims; a retrospective study in 125patients. IntensCareMed 1996;22:1017.
30. Gerritse BM, Draaisma JM, Schalkwijk A, vanGrunsvenPM, Scheffer GJ. ShouldEMS-paramedics performpaediatric trachealintubation in thefield? Resuscita-
tion 2008;79:2259.31. Lammers R, Byrwa M, FalesW. Root causesof errorsin a simulatedprehospital
pediatricemergency. AcadEmerg Med2012;19:3747.32. Okamoto Y, Iwami T, Kitamura T, et al. Regional variation in survival following
pediatricout-of-hospital cardiac arrest. Circ J 2013.33. RoYS, ShinSD,SongKJ, etal. Acomparisonof outcomesof out-of-hospitalcardiac
arrest with non-cardiac etiology between emergency departments with low-andhigh-resuscitationcasevolume. Resuscitation 2012;83:85561.
34. TopjianAA, Berg RA, Bierens JJ,et al.Brain resuscitation in thedrowning victim.Neurocrit Care 2012.
35. Handley AJ. Compression-only CPR-to teach or not to teach? Resuscitation2009;80:7524.
36. Kochanek PM, Bayir H. Optimizing oxygenation and ventilation after cardiacarrest in little adults. Resuscitation 2012;83:14256.
Joost J.L.M. Bierens (MD, PhD) Q
Maatschappij tot Redding van Drenkelingen (Society
to Rescue People from Drowning), Rokin 114 B, 1012
LB Amsterdam, The Netherlands
David S.Warner (M.D)
Department of Anesthesiology, Duke UniversityMedical Center, Durham, NC 27710, USA
Corresponding author. Fax: +1 9196846692.
E-mail addresses:[email protected] (J.J.L.M.
Bierens), [email protected] (D.S.Warner)
3 September 2013
Available online xxx
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