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To describe cerebral (structural and functional MRI) and neuropsychological long term changes in moderate drowning victim's compared to healthy volunteers in working memory and motor domains. We studied 15 adult drowning victim's in chronic stage (DV - out of 157 eligible cases of sea water rescues with moderate drowning classification) paired to 18 healthy controls (HC). All participants were investigated using intelligence, memory, and attention neuropsychological standard tests and underwent functional (motor and working memory tasks) and structural magnetic resonance imaging (MRI) in a 3 T system. All images were preprocessed for head movement correction and quantitative analysis was performed using FSL and freesurfer software packages. We found no between group differences in neuropsychological assessments. No MRI brain lesion was observed in patients, neither difference on morphometric parameters in any cortical or subcortical brain structure. In constrast, functional MRI revealed that patients showed increased brain response in the motor (left putamen and insula) and memory (left cuneus and lingual gyrus - not the classical memory network) tasks. Functional brain changes in motor and visual brain regions in victims of moderate drowning may indicate reduced brain reserve, despite the lack of structural and behavior alterations. More attention should be given to investigate ageing effects in this nonfatal drowning group.

Drowning is a global problem that affects all populations. The events leading up to and the sequelae from a drowning incident vary greatly based on numerous factors, but the primary physiologic insult is always hypoxia. This is the starting point for all morbidity and mortality, and it must remain the focus of treatment. This issue discusses the initial resuscitation and treatment of adult drowning patients in the emergency department. Primary focus is placed on the key components of pathophysiology that require immediate attention. From there, evidence is presented to help guide the management of associated clinical concerns such as hypothermia, mechanical ventilation, and traumatic injuries, and to help form safe and reasonable disposition plans.

Drowning is an important public health problem, but the mechanism of acute lung injury induced by near-drowning is rarely reported. The aim of this study is to investigate the role of hypertonicity and HIF-1α in seawater aspiration-induced lung injury. Diverse solutions were used to study the effect of hypertonicity on hypoxia, inflammation, vascular leakage, edema, and HIF-1α expression in lungs of rats. The relationship between hypertonicity and hypoxia, when they induced HIF-1α, was studied and the roles of ATM, PI3K, and p38 in the course of hypertonicity inducing HIF-1α were investigated. At last, our conclusion was verified with HIF-1α inhibitor and inducer in seawater aspiration rats. The results showed that hypertonicity, but not isotonicity and hypotonicity, promoted hypoxia, inflammation, vascular leakage, edema, and HIF-1α expression in lungs. Hypertonicity not only induced HIF-1α in a time- and dose-dependent manner but also could increase HIF-1α synergistically with hypoxia in AEC. Furthermore, hypertonicity increased HIF-1α by promoting its mRNA expression through both ATM and PI3K activation and by suppressing its protein degradation through p38 activation. During hyperosmotic stress, the increased HIF-1α promoted the production of the inflammatory cytokines in NR8383 and elevated monolayer permeability through increasing VEGF in RLMVEC. In conclusion, hypertonicity induced by aspirated seawater aggravated lung injury through increasing HIF-1α which promoted inflammation and edema in lung tissues in rats.

Drowning and submersion injuries are highly prevalent, yet preventable, causes of childhood mortality and morbidity. Although much of the resuscitation of the drowning pediatric victim is basic to all respiratory and cardiac arrest situations, there are some caveats for treatment of this type of injury. Risk factors for drowning victims include epilepsy, underlying cardiac dysrhythmias, hyperventilation, hypoglycemia, hypothermia, and alcohol and illicit drug use. Prehospital care should focus on restoring normal ventilation and circulation as quickly as possible to limit the extent of hypoxic insult. Diagnostic testing for symptomatic patients may include blood glucose level, arterial blood gas level, complete blood count, electrolytes levels, chest radiography, and cardiorespiratory monitoring with pulse oximetry and a rhythm strip. In this review, passive external, active external, and active internal rewarming techniques for treatment of hypothermic patients are discussed. A systematic approach to treatment and disposition or admission of pediatric drowning victims is also included, with extensive clinical pathways for quick reference.

Childhood water submersion remains a major public health problem. The aim of this article is to present an updated overview of the topic with data from our region and special attention to prevention strategies. Children less than 5 years and males are particularly at risk. Infants are at higher risk of drowning in bathtubs, toilets, or washing machines, while most drowning in older children occurs in swimming pools. Poor supervision by inexperienced caregivers is a common factor and contributes to most deaths. Adolescents drown more often during outdoor water activity. Acute management should start as soon as possible in order to prevent unfavorable neurological outcome. Cardio-pulmonary resuscitation should be started at the scene. Most children who were rescued quickly will recover neurologically intact. Restricting access to water and close adult supervision are paramount in preventing near-drowning and drowning. High-risk groups, such as new or young parents, and lower socioeconomic families, should be targeted by such prevention programs.

The article will give a brief introduction to what we understand by the term Asphyxiation. The main focus will then turn to how Asphyxiation is used as a method of torture, (often euphemistically called a "method of interrogation") with an overview of wet methods such as immersion in water or the pouring of water over the mouth and nose, and dry methods such as the use of bags/sacks/masks and how exacerbating factors such as the use of contaminants or irritants are used. The recently published International Forensic Expert Group Statement on Hooding will be introduced and the notion will be explored that during socalled 'enhanced interrogation' asphyxiation or drowning can be "simulated."

Approximately 500,000 deaths due to drowning are reported annually, 30,000 of which are reported in Europe. Because of the relatively low incidence of drowning victims at emergency departments, most emergency physicians do not routinely handle drowning victims. Although confusion regarding the classification and pathophysiology of drowning could be reduced by following the Utstein style consensus, the application of therapeutic modalities and, most important, the estimation of probable prognostic outcomes remain difficult for emergency physicians. This article presents an overview of the classification, pathophysiology, emergency-department treatment and prognostic outcomes of drowning accidents.

Aim: Immediate delivery of oxygen is the most important treatment for victims of drowning at the rescue site. Monitoring oxygen saturation with pulse oximetry is potentially useful, but its use may be limited by poor peripheral perfusion due to hypothermia. This preliminary study explores the feasibility of pulse oximetry in simulated minor drowning scenarios., Materials and Methods: Six different pulse oximeters were tested on ten healthy volunteers after brief submersion, after ten minutes of swimming in a swimming pool (warm water, temperature 21°C), and in the sea (cold water, temperature 16°C). A measured oxygen saturation reading ≤ 94% was assumed to be incorrect., Results: There was considerable variability between each pulse oximeter. In warm water, 5.8% of measurements were outside the predicted range (8.3% after submersion, 3.3% after swimming), compared to 34% in cold water (20% after submersion, 48% after swimming). The spurious measurements came from two pulse oximeters in warm water, but from all six in cold water. The best and worst performing pulse oximeters showed 5% and 33% measurements respectively outside the predicted range., Conclusion: The performance of pulse oximeters varies considerably in healthy volunteers submersed or immersed in warm or cold water. Further studies are needed to understand these differences., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

There is some confusion, and consequent variation in policy, between the agencies responsible for the search, rescue and resuscitation of submersion victims regarding the likelihood of survival following a period of submersion. The aim of this work was to recommend a decision-making guide for such victims. This guidance was arrived at by a review of the relevant literature and specific case studies, and a "consensus" meeting on the topic. The factors found to be important for determining the possibility of prolonged survival underwater were: water temperature; salinity of water; duration of submersion; and age of the victim. Of these, only water temperature and duration are sufficiently clear to form the basis of guidance in this area. It is concluded that if water temperature is warmer than 6°C, survival/resuscitation is extremely unlikely if submerged longer than 30 min. If water temperature is 6°C or below, survival/resuscitation is extremely unlikely if submerged longer than 90 min., (Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.)

We report the failure of an i-gel and an Ambu AuraOnce supraglottic airway to ventilate a drowning victim. Failure was attributed to changes in lung physiology following submersion and inhalation of water that may have required ventilation pressures up to 40 cmH2O to treat the victim's hypoxaemia. The ease of use and rapid insertion of supraglottic airways without interrupting cardiac compression has prompted recommendations for their use during resuscitation. The relatively low leak pressures attainable from many supraglottic airways, however may cause inadequate lung ventilation and entrainment of air into the stomach when these devices are used in drowning victims.

400,000 incidents of sea drowning take place every year. We report the case of a woman, 34 years old, attended on the beach by external hospital emergency services after suffering immersion in seawater resulting in drowning due to acute respiratory failure. She was admitted to the critical care unit and an emergency fiberoptic bronchoscopy was performed, extracting a large quantity of sand and algae. The respiratory function improved and FiO2 requirements were gradually reduced following the procedure. After 8 days of mechanical ventilation the patient was extubated, with good clinical tolerance and was transferred to a ward.

Drowning and near-drowning is often associated with severe hypothermia requiring active core rewarming.We performed rewarming by cardiopulmonary bypass(CPB). Between 1987 and 2007, 13 children (9 boys and 4 girls) with accidental hypothermia were rewarmed by extracorporeal circulation (ECC) in our institution. The average age of the patients was 3.2 years. Resuscitation was started immediately upon the arrival of the rescue team and was continuously performed during the transportation.All patients were intubated and ventilated. Core temperature at admission ranged from 20 to 29°C (mean 25.3°C). Connection to the CPB was performed by thoracic (9 patients) or femoral/iliac means (4 patients). Restoration of circulation was achieved in 11 patients (84.6%). After CPB termination two patients needed an extracorporeal membrane oxygenation system due to severe pulmonary edema.Five patients were discharged from hospital after prolonged hospital stay. During follow-up, two patients died(10 and 15 months, respectively) of pulmonary complications and one patient was lost to follow-up. The two remaining survivors were without neurological deficit.Modes of rewarming, age, sex, rectal temperature, and serum electrolytes did not influence mortality. In conclusion,drowning and near-drowning with severe hypothermia remains a challenging emergency. Rewarming by ECC provides efficient rewarming and full circulatory support.Although nearly half of the children may survive after rewarming by ECC, long-term outcome is limited by pulmonary and neurological complications.

The microcirculation is essential for delivery of oxygen and nutrients to tissue. However, the human microvascular response to cardiopulmonary resuscitation (CPR) is unknown. We report on the first use of sidestream dark field imaging to assess the human microcirculation during CPR with a mechanical chest compression/decompression device (mCPR). mCPR was able to provide microvascular perfusion. Capillary flow persisted even during brief mCPR interruption. However, indices of microvascular perfusion were low and improved vastly after return of spontaneous circulation. Microvascular perfusion was relatively independent from blood pressure. The microcirculation may be a useful monitor for determining the adequacy of CPR., (Copyright 2009 Elsevier Ireland Ltd. All rights reserved.)

Death has occurred when there is irreversible loss of integration of the organism as a whole, and brain death is said to be a criterion for death. In the present case, a 10-month-old boy was found submerged in a bathtub and was given cardiopulmonary resuscitation for 37 minutes. He had received therapeutic dosing of phenobarbital and midazolam up to 5 hours prior to a brain death examination. He fulfilled all criteria for brain death according to Canadian Neurological Determination of Death Forum recommendations on an examination 42 hours after the drowning event, but started breathing another 15 hours later. Eleven previously published cases of purported reversal of findings of brain death are discussed here, including two infants who fulfilled all criteria for brain death for more than 24 hours. Recommendations for brain death determination may require revision for infants, to more clearly define a time interval between examinations and to incorporate consideration of confounding sedative drug effects. Together with previous reports, the present case calls into question the assumption that brain death as currently diagnosed is irreversible, and therefore equivalent to death of the patient.

Dangers exist wherever water is present, and death resulting from submersion in water is likely to occur rapidly. This article discusses the management of drowning and hypothermia. Information on water hazards and preventive measures, the risks associated with rescuing people from water, and the pathophysiology of drowning and hypothermia is provided, enabling practitioners to translate theory into practice. The emphasis of first aid in this setting is on quick, effective action, including alerting the emergency services and maintaining the safety of all potential rescuers.

Over the past four decades, we have learned considerably more about the pathophysiology and treatment of drowning. This, coupled with increased emphasis in improvement in water safety and resuscitation, has produced a threefold decrease in the number of deaths, indexed to population, from drowning in the United States yearly. This review presents the current status of our knowledge of the epidemiology, the pathophysiology of drowning and its treatment, updates the definitions of drowning and the drowning process, and makes suggestions for further improvement in water safety.

Drowning associated with hypothermia and cardiopulmonary resuscitation has a very poor prognosis. We report two such cases, where impossible oxygenation due to severe pulmonary oedema was treated with extracorporeal membrane-oxygenation (ECMO). Following cardiac arrest, mild therapeutic hypothermia for 24h was maintained as recommended, but subsequent rewarming precipitated additional pulmonary oedema. Little is currently known about how long to maintain therapeutic hypothermia to optimize neurological outcome and suppress reperfusion injury. In our patients, therapeutic hypothermia during veno-venous ECMO-treatment was extended for up to 6 days. Both patients survived with no neurological sequelae. We speculate that prolonged hypothermia was not only neuroprotective, but also minimized reperfusion injury including pulmonary oedema. Extension of hypothermia for several days seems safe and feasible in selected cases.

Two men, 56 and 33 years old, (case 1 and case 2) were examined neuropsychologically after successful resuscitation from circulatory arrest following extreme accidental hypothermia and near drowning. After submersion in ice water for at least 20 minutes they received CPR for 45 to 60 minutes. Body-core temperature at start of CPB was 24 degrees C and 22 degrees C, respectively. A neuropsychological examination was performed within two months after the accident and 1 year later. An additional follow-up interview was made 3 years after the accidents. Both had severe problems with memory, visuospatial performance, executive function, and verbal fluency. The follow-up demonstrated improvement in the visuospatial test in both and in the verbal learning, recall, and logical reasoning tests in case 2. Both still had problems with executive function, and case 2 also in verbal fluency. Case 1 also had problems with flexibility, planning and abstract ability. Despite the protective effects of hypothermia and gradual improvement of symptoms over time, some of the deficits were permanent. A thorough neuropsychological examination of patients suffered from anoxia is advisable, because gross neurological examination and MRI scans may not always reveal underlying brain dysfunction.

Cold water near-drowning is often thought to be neuroprotective in individuals with anoxia of a longer duration than that usually required to produce irreversible neurologic damage. There is a paucity of data in adults with cold water near-drowning that assess neuropsychological outcomes. Information regarding long-term effects of near cold water near-drowning on neuropathology, neuropsychological and neurobehavioral outcomes are uncommon. This paper provides an introduction to two cases of cold water near-drowning reported in this issue of JINS by Sameulson and colleagues and provides background information for interpretation of the findings of these cases in the context of outcomes following anoxia.

During summer, near drowning is a common accident in Taiwan. It may lead to multiple organ damages in cases where severe hypothermia and hypoxemia occur. We present a case of myocardial infarction after near drowning. The patient was sent to our ED by the emergency medical services called by the witness. On arrival to our ED, hypothermia and hypoxemia overcame him. Endotracheal intubation and warm intravenous fluid were applied at once owing to drowsy consciousness, respiratory distress, and hypothermia. Electrocardiogram showed diffuse ST-segment elevation over the precordial leads V2-V6. The initial level of cardiac enzymes was within normal limit but elevated in troponin I on the second day after hospitalization. We presumed that the possibility of myocardial infarction resulted from near drowning-related hypoxemia. To our knowledge, this is the first case describing myocardial injury with electrocardiogram changes after near drowning.

Introduction: We report a case of twin toddlers who both suffered near drowning but with different post-trauma treatment and course, and different neurological outcomes., Methods and Results: Two twin toddlers (a boy and girl, aged 2 years and 3 months) suffered hypothermic near drowning with protracted cardiac arrest and aspiration. The girl was treated with mild hypothermia for 72 hours and developed acute respiratory dysfunction syndrome and sepsis. She recovered without neurological deficit. The boy's treatment was conducted under normothermia without further complications. He developed an apallic syndrome., Conclusion: Although the twin toddlers experienced the same near drowning accident together, the outcomes with respect to neurological status and postinjury complications were completely different. One of the factors that possibly influenced the different postinjury course might have been prolonged mild hypothermia.

Background: The Dead Sea in Israel has a very high mineral content. Near-drowning in the Dead Sea is expected to result in severe electrolyte abnormalities and respiratory failure. Previous limited studies reported a high mortality rate., Objective: To evaluate the clinical and biochemical manifestations and disease outcome of near-drowning in the Dead Sea., Methods: Data were abstracted from the archives of Soroka University Medical Center. The cohort comprised 69 patients who nearly drowned in the Dead Sea., Results: The median age of the patients was 68 years (range 21-84). There were two major manifestations of near-drowning in the Dead Sea: electrolyte imbalance and acute lung injury. Serum calcium, magnesium and phosphorus (but not sodium, potassium and chloride) were abnormal in most patients. Median serum electrolyte levels (and range) on admission were 10.9 mg/dl (9-24) for calcium, 4.3 mg/dl (1-30) for magnesium, and 4.1 mg/dl (2-9) for phosphorus. These levels quickly normalized with forced diuresis within 24 hours. Acute lung injury--namely, hypoxic bilateral pneumonitis--occurred in 29 patients. Mechanical ventilation was required in 11 patients. Sixty-five patients recovered fully, while the remaining 4 had minor sequelae., Conclusions: Near-drowning in the Dead Sea is a syndrome of severe electrolyte abnormalities and lung injury. Early treatment with forced diuresis and supportive care results in prompt recovery.

Background: Near-drowning is common in children and has a high mortality rate. Some survivors remain in a vegetative state after the accident and are a great burden to their family and society., Objectives: To find out whether outcomes on near drowning can be reliably identified early in the course of illness., Method: Medical records of 72 children admitted to Queen Sirikit National Institute of Child Health, Bangkok, Thailand, for treatment of near drowning from January 1993 to December 2001 were retrospectively studied. Stepwise multivariate discriminant analysis was used to identify the power of variables achieving highest overall accuracy in minimizing errors for predicting poor outcome in intact survivors., Results: The patients were identified into three groups: functionally intact, vegetative and dead groups, it was found that a combination of physical examination in the emergency department (ED), the need for cardiopulmonary (CPR) in the ED, amount of adrenaline given during CPR, and high blood sugar achieved an overall accuracy of 83 per cent. When categorizing patients into good outcome versus poor outcome (the combination of the vegetative and dead group were the poor outcome group). The variables mentioned above achieved an overall accuracy of 98 per cent. Good outcome survivors could be correctly predicted with no error, but error occurred when poor outcome survivors were predicted to be good outcome in 3 per cent. Glasgow coma score > or = 5, the need for CPR in the ED and blood sugar > 300 mg/dl were selected clinical variables found to have optimum predictive abilities with an overall accuracy of 96 per cent, but showed an error of 6 per cent in predicting poor outcome from functional intact survivors (unpredicted good outcome)., Conclusion: From the present study discrimination analysis cannot accurately separate all intact survivors from the vegetative groups, but can prospectively differentiate unpredicted good outcome from vegetative or dead groups. When using only simple clinical classification systems, unpredicted good outcome patients are detected. Since outcome cannot be accurately predicted in the ED, all near drowning victims should receive vigorous and aggressive treatment in the early course of illness and need close monitoring for respiratory complications and neurological signs.

We report on monitoring oxygen saturation with a jugular bulb fiber-optical catheter in an 18-month-old girl after fresh water near-drowning followed by acute respiratory failure. The first measured cerebral oxygen saturation was 22% despite normal values for arterial and central venous oxygen saturation. After conventional therapy had failed to improve cerebral oxygen saturation, we started veno-venous extracorporeal membrane oxygenation. Normal levels of cerebral oxygen saturation were achieved after six hours. The girl was extubated after seven days and discharged after twenty-five days in good general condition and without obvious evidence of neurological damage. We believe that in this case of near-drowning, monitoring cerebral oxygen saturation with a jugular bulb catheter was important for surveillance of cerebral hypoxia.

Water immersion is a frequent cause of accidental death and hospital admission. This article outlines the pathogenesis and principles of treatment. Drowning is defined as death by asphyxia due to submersion in a liquid medium. Near-drowning is defined as immediate survival after asphyxia due to submersion.

Recent epidemiologic data have shown that the burden of drowning is much greater than expected. Prevention and timely rescue are the most effective means of reducing the number of persons at risk. Early bystander cardiopulmonary resuscitation is the most important factor for survival after submersion. Cerebral damage is a serious threat when the hypoxic period is too long. In most situations, low body temperature is an indication of the severity of the drowning incident. Sometimes hypothermia that occurs during the submersion period can be brain protective. There is also new evidence to support the strategy of inducing mild hypothermia for a period of 12 to 24 hours in comatose drowning victims. In immersed patients, hypothermia should be treated. The most appropriate technique will depend on the available means in the hospital and the condition of the patient. Treatment of pulmonary complications depends on the lung injury that occurred during aspiration and the bacteria involved in aspiration. Understanding the pathophysiology of drowning may help us to understand lung injuries and ischemic brain injuries.

Drowning and other asphyxial injuries are important causes of childhood morbidity and mortality. In this review, the epidemiology, pathophysiology, and treatments applied to near-drowning victims are discussed, with an emphasis on the difficulties encountered attempting to predict outcome using current methods.

This paper reviews literature on the topic of cold stress, near-drowning and hypothermia, written mainly since the last review of this type in this journal. The main effects of cold stress, especially in cold water immersion, include the "cold shock" response, local cooling causing decrements in physical and mental performance, and ultimately core cooling as hypothermia occurs. The section on cold-water submersion (near-drowning) includes discussion regarding the various mechanisms for brain and body cooling during submersion. The mechanisms for cold-induced protection of the anoxic brain are discussed with attention given to decreased brain temperature and the Q10 principle, the mammalian dive reflex and a newly considered mechanism; cold-induced changes in neurotransmitter release (i.e., glutamate and dopamine). The section on the post-cooling period includes the post-rescue collapse and subsequent rewarming strategies used in the field, during emergency transport or in medical facilities. Recent research on topics such as inhalation warming, body-to-body warming, radio wave therapy, warm water immersion, exercise, body cavity lavage, and cardiopulmonary bypass is reviewed. Information on new methods of warming, including arteriovenous anastomoses (AVA) warming (by application of heat- with or without negative pressure application-to distal extremities in an effort to increase AVA blood flow), forced-air warming, and peripheral vascular extracorporeal warming, are discussed.

To determine if routine, noninvasive parameters could be measured which predict early (4-6 hour) discharge from the emergency department (ED) in mildly symptomatic and asymptomatic victims of childhood near-drowning, a retrospective cohort study was undertaken. Patients with fresh water near-drowning were studied over a 3-year period who presented with Glascow Come Scale (GCS) > or =13 and required no advanced life support prior to or < or =4 hours after ED presentation. Three groups of patients were found: 39 patients (81%) had normal pulmonary examination (PEx) and normal room air oxygen saturation (RASaO2) by 4 to 6 hours and did not deteriorate during the hospital admission (<24 hours); 5 patients (10%) had normal PEx by 4 to 6 hours and RASaO2 by 8 to 12 hours and did not deteriorate during hospitalization (<24 hours). Four patients (8%) were hospitalized for more than 24 hours. No patient with normal RASaO2 at 6 hours deteriorated while in the hospital (CI 92.3-100%). Children who present to the ED with GCS > or =13 and have normal PEx/respiratory effort and RA-SaO2 more than 95% at 4 to 6 hours after ED presentation can be safely discharged home.

A variety of conditions can lead to rhabdomyolysis. Only a few cases of rhabdomyolysis resulting from near-drowning exist in the literature. We describe a victim of near-drowning who developed rhabdomyolysis and acute renal failure requiring dialysis. We review the existing literature on near-drowning-induced rhabdomyolysis and discuss the possible pathogenesis.

We investigated the relation between heart rate and the QT interval using face immersion in cold water in children with long QT syndrome (LQTS) without a family history of this condition, and in control children. The face immersion test revealed that all children with high probability of LQTS had a significantly longer QT interval than control children during face immersion, and that the test could induce T-wave alternans or a notched T-wave in all children with a high probability of LQTS.

Submersion accidents continue to be a significant cause of morbidity and mortality in children and adults. The key to successful management is prevention of these accidents. Proactive efforts to minimize submersion accidents in the community should be made by medical and legislative groups. Anticipatory guidance by primary care physicians, particularly for families and individuals at increased risk, should be performed. Outcomes of individuals who have become victims of submersion accidents can be optimized by the development of a rapid response system, because successful initial resuscitation efforts clearly improve outcomes. For individuals who have nearly drowned and who have arrived in the emergency department, a systematic and aggressive approach needs to be followed with particular emphasis on cardiorespiratory support to optimize neurologic outcome. Despite many studies aimed at developing predictors of outcomes, there is limited information that can be used in a prospective manner to guide the emergency-room physician in limiting the level of interventions. Thus, all aggressive supportive care and resuscitation should be performed at this stage, except in clearly futile situations. Once patients arrive in the ICU, meticulous care, including monitoring of cardiorespiratory and neurologic status and attention to electrolytes and acid-base status, needs to be continued. Besides providing basic supportive measures, the ICU physician should investigate for other associated trauma and medical conditions that may need to be addressed once the patient is stabilized. Patients who have nearly drowned are likely to have long ICU stays, predisposing them to nosocomial infections. Despite efforts at minimizing barotrauma and volutrauma, many patients who have nearly drowned and who need ventilatory support may develop ARDS. The management of these patients is similar to other patients who have ARDS. However, strategies like permissive hypercapnia that are used commonly in patients who have ARDS may not be suitable in patients who have CNS injury. Despite aggressive care, neurologic injury with long-term sequelae secondary to hypoxic ischemic injury remains a major problem in the management of victims of submersion accidents. It is important for the clinician to keep the pathophysiologic and cellular mechanisms of CNS injury in mind, because future interventions are likely to be based on these pathways. Besides providing care for the patient, it is important for the ICU physician to be sensitive to the needs of the family and to support them through this catastrophe that is likely to place a tremendous financial and emotional burden on most of them.

A retrospective study was conducted to evaluate the outcome of near-drowning patients admitted to the intensive care unit (ICU) comparing seawater and freshwater drownings. A chart review was used to identify near-drowning patients admitted to ICU from 1 April 1989 to 1 May 1996 for biodata, physiological data and outcome. Seventeen near-drowning patients were admitted to ICU over a period of nearly 7 years. There were 3 deaths (17.6%) and 8 patients (47%) required cardiopulmonary resuscitation. Freshwater near-drowning occurred in 8 patients and saltwater near-drowning occurred in 9 patients. Nearly all (94%) the patients had a PaO2/FiO2 ratio < 300 mm Hg. Pulmonary oedema was present on the chest radiographs of all patients. Mechanical ventilation was required for 8 patients (47%), and nearly all (94%) received prophylactic antibiotics. None of the patients developed pneumonia. Serum electrolytes and haemoglobin concentration were not grossly abnormal although, those with saltwater near-drowning had a significantly higher level of haemoglobin, sodium and urea compared to those with freshwater near-drowning. Patients that survived to hospital discharge had full neurological recovery and stayed an average of 4.5 days. We concluded that near-drowning victims that survive to be admitted to ICU have significant oxygenation defect with nearly half requiring ventilatory support. Mortality is appreciable, but those that survive to hospital discharge had full neurological recovery.

The overall prognosis for children who sustain a submersion incident is directly related to several variables including length of submersion, initial neurologic evaluation, time to first breath, initial pH, and others. Resuscitation after near-drowning is unsuccessful in terms of death and neurologic deficit in 30% of those children who are treated at our institution. Despite the fact that we have been able to present variables that are somewhat predictive of outcome, it is almost impossible to identify 100% of the time which particular comatose child will survive neurologically intact. Therefore skilled attempts at resuscitation and management are mandatory. The understanding of the sequence of events that occur during the drowning process and the pathophysiologic consequence make it possible for health care personnel to provide aggressive therapeutic interventions that will enhance the likelihood of a normal recovery.