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STUDY OBJECTIVES: Obstructive changes in lung function have been reported with cumulative scuba diving exposure. The aim of this study was to investigate the decline in FEV(1) in scuba divers over time. DESIGN: Prospective controlled cohort study. SETTING: German Naval Medical Institute. PATIENTS: Four hundred sixty-eight healthy, male, military scuba divers and 122 submariners (control subjects) were entered. MEASUREMENTS AND RESULTS: Pulmonary function tests were performed in all subjects on at least three occasions with a minimum interval of 1 year between first and last measurement. The decline in FEV(1) was investigated fitting a general linear model to FEV(1) across time with a factorial main-effects model for slopes and intercepts with respect to the factors group, smoking status, and baseline FEV(1). Mean baseline age of all subjects was 32 years (SD, 9.1), and mean body mass index was 24.7 kg/m(2) (SD, 2.4). Subjects were followed up for 5 years (range, 1 to 9 years) on average. Baseline FEV(1) exceeded the predicted values in both divers and nondiving control subjects. There was no significant difference in the decline of FEV(1) between divers and control subjects. Over time, FEV(1) declined more rapidly in smokers than in nonsmokers (p = 0.0064) and declined more rapidly also in subjects with a baseline FEV(1) above average compared to subjects below average (p < 0.0001). The annual decline of FEV(1) peaked in smoking divers who had a high FEV(1) at baseline. CONCLUSIONS: The data indicate that scuba diving is not associated with an accelerated decline in FEV(1). Combined exposure to diving and smoking contributes to the fall of FEV(1); therefore, smoking cessation is advised for divers. [ABSTRACT FROM AUTHOR]

Background: Psychiatric emergencies pose a special challenge for emergency physicians. It is known from other areas of medicine that the influence of a doctor's gender can have an impact on the type of treatment and quality of patient care. However, this has not yet been investigated in the context of prehospital care in psychiatric emergencies., Objectives: To identify whether the gender of the prehospital emergency physicians has an influence on the "on-scene" time, treatment strategy and on the potential escalation of interventions for patients with a psychiatric diagnosis., Methods: A retrospective cohort analysis of emergency missions with a psychiatric diagnosis was performed between January 1, 2015 and December 31, 2021 at the Department of Emergency Medicine, Department of Anesthesiology and Intensive Care Medicine, University Hospital Ulm, Germany., Results: 2882 emergency missions with a psychiatric indication/prehospital psychiatric diagnosis were studied and divided into: intoxication (n = 1343, 46.6%), suicidal behavior (n = 488, 16.9%), exceptional mental situation (n = 282, 9.8%), agitation (n = 262, 9.1%), anxiety and panic disorders (n = 262, 9.1%) and "psychiatric miscellaneous" (n = 245, 8.5%). Inpatient hospitalization occurred in 67.9% (n = 1958) of emergency missions. Of these, 20.3% (n = 392) were admitted directly to a psychiatric hospital. Male emergency physicians had a slightly longer "on-scene" time for psychiatric emergencies than female emergency physicians (p = 0.024). However, the variance in "on-scene" time for all interventions was significantly greater for female emergency physicians than for male emergency physicians (p = 0.025). Male emergency physicians were significantly more likely than their female counterparts to administer intravenous hypnotics in prehospital psychiatric emergencies (p = 0.001). For psychiatric patients who refused medically indicated inpatient psychiatric admission ("involuntary psychiatric admission"), male and female emergency physicians were equally likely to take the required action (p = 0.522). However, male emergency physicians were significantly more likely to administer an intravenous hypnotic to enforce involuntary admission (p = 0.009)., Conclusions: Similar to other medical specialties where the influence of physician gender on patient care is certainly relevant, the gender of prehospital emergency physicians also appears to influence their prehospital management strategy in psychiatric emergencies. The influence of gender is sometimes subtle and limited to specific aspects, such as the administration of hypnotics. Prospective study designs are needed to thoroughly investigate the influence of the gender of the prehospital emergency physician on the quality of care in psychiatric emergencies., Trial Registration: The study was approved by the ethics committee of the University Ulm, Trial-Code No. 110/22 and was prospectively registered in the German Clinical Trials Register (DRKS-ID: DRKS00031237). Patient information was not required for retrospective data analysis., (© 2024. The Author(s).)

Background: Prehospital care of psychiatric patients often relies on the medical experience of prehospital emergency physicians (PHEPs). The psychiatrists (PSs) involved in the further treatment of psychiatric patients also often rely on their experience. Furthermore, the interaction between PHEPs and PSs is characterized by interaction problems and different approaches in the prehospital care of the psychiatric emergency., Objectives: To analyze the phenomenon of "medical experience" as a cause of possible interaction-related problems and assess its impact on the prehospital decision-making process between prehospital emergency physicians and psychiatrists., Methods: The retrospective data analysis was conducted between November 2022 and March 2023. Medical experience was defined as follows, based on the demographic information collected in the questionnaires: For PHEPs, the period since obtaining the additional qualification in emergency medicine was defined as a surrogate marker of medical experience: (i) inexperienced: < 1 year, (ii) experienced: 1-5 years, (iii) very experienced: > 5 years. For PSs, age in years was used as a surrogate parameter of medical experience: (i) inexperienced: 25-35 years, (ii) experienced: 35-45 years, (iii) very experienced: > 45 years., Results: Inexperienced PSs most frequently expressed anxiety about the psychiatric emergency referred by a PHEP (27.9%). Experienced PHEPs most frequently reported a lack of qualifications in handling the care of psychiatric emergencies (p = 0.002). Very experienced PHEPs were significantly more likely to have a referral refused by the acute psychiatric hospital if an inexperienced PS was on duty (p = 0.01). Experienced PHEPs apply an intravenous hypnotic significantly more often (almost 15%) than PSs of all experience levels (p = 0.001). In addition, very experienced PHEPs sought prehospital phone contact with acute psychiatry significantly more often (p = 0.01)., Conclusion: PHEPs should be aware that the PS on duty may be inexperienced and that treating emergency patients may cause him/her anxiety. On the other hand, PHEPs should be receptive to feedback from PS who have identified a qualification deficiency in them. Jointly developed, individualized emergency plans could lead to better prehospital care for psychiatric emergency patients. Further training in the prehospital management of psychiatric disorders is needed to minimize the existing skills gap among PHEPs in the management of psychiatric disorders., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Consumption of game meat may exert additional lead exposure with potential health risks. The purpose of the present pilot study was to determine blood lead concentration in game meat and no game meat consumers in southern Germany. Concentration of lead in blood (µg·L - 1 ) was significantly higher in game meat consumers (n = 190; 21.3 [20.0; 29.7]) compared to study participants consuming no game meat (n = 74; 20.0 [20.0; 20.0], p < 0.0001). In study participants with no game meat consumption, blood lead concentration was significantly higher in those who perform active hunting (80.3 [50.5; 110.0]) as well as active shooting (80.3 [50.5; 110.0]) than in those with no hunting or shooting activities (20.0 [20.0; 20.0], p < 0.01). In conclusion, game meat consumers as well as active hunters and shooters should take in to account their potential for an increased lead exposure and the corresponding health risks., (© 2022. The Author(s).)

Background: To cope with the COVID-19 outbreak in Germany, the government imposed a lockdown, which led to restrictions and lifestyle changes for the population., Purpose: This study aimed to evaluate the impact of the lockdown on activities causing trauma and the consultation in emergency rooms., Material and Methods: All consecutive trauma patients consulting the Emergency Department of the Marienhospital Stuttgart (MHS), Germany, during the 6 weeks preceding the lockdown, during and after the lockdown were included. The time and type of consultation, treatment received, Manchester triage score, type of trauma, the anatomical region of the injury as well as demographic data were reported and compared., Results: The study included 551 cases during lockdown, 943 cases before and 783 cases after the lockdown. We observed a reduced caseload during the lockdown of 41.6% compared to before and of 29.7% compared to after (p < 0.001). Patients were on average older in the observation group than in both control groups (before : 51.5 years, lockdown: 56.1 years, after: 51.6 years) (p < 0.001). Injuries to the head and neck were constant (25.0%, 25.4%, 25.5%). We noticed lower limb injuries decreasing (26.1%, 22.3%, 22.7%) and upper limb injuries increasing (25.5%, 31.8%, 30.1%). A decrease in sports injuries (11.1%, 5.1%, 9.1%) and work accidents (16.1%, 10.7%, 12.8%) resulted in more domestic accidents (30.4%, 52.5%, 31.8%). Self-referral decreased (67.7%, 53.2%, 60.3%) while referral via paramedics increased (28.3%, 38.7%, 35.6). Blunt trauma was the most common cause of injury (55.6%, 61.0%, 55.3%). Indications for surgery were higher (16.8%, 21.6%, 14.0%)., Conclusion: The lockdown and restrictions in personal life and daily routine had an impact on the frequency, etiology and management of trauma patients in Stuttgart., (© 2021. Springer Medizin Verlag GmbH, ein Teil von Springer Nature.)

Background: Pre-clinical psychiatric emergencies are generally treated by emergency medical staff. The subsequent clinical treatment is often conditioned by interaction problems between emergency medical staff and psychiatric clinical staff., Objectives: To identify problems affecting interaction between emergency medical and psychiatric care of mentally ill patients and pinpoint aspects of optimized emergency care., Methods: To shed light on the interaction problems an anonymous, questionnaire-based, nonrepresentative survey of 98 emergency physicians (EM) and 104 psychiatrists (PS) practicing in acute psychiatry was conducted between March 1, 2021 and October 1, 2021., Results: The chi-square test for multiple response sets revealed consistently significant differences (p < 0.001) between EM and PS with respect to the questions analyzed. Approximately 36% of EM reported not to be adequately qualified to handle psychiatric emergencies (p = 0.0001), while around 50% of respondents were neutral in their assessment in how to deal with psychiatric emergencies. 80% of EM reported a negative interaction (rejection of patients) with PS when referring a psychiatric emergency patient to the acute psychiatric unit. The most common reasons for refusal were intoxication (EM: 78.8%, PS: 88.2%), emergency physician therapy (EM: 53.8%, PS: 63.5%), and not resident in the catchment area of the hospital (EM 68.8%, PS: 48.2%). In the casuistry presented, most respondents would choose "talk down" for de-escalation (EM: 92.1%, PS: 91.3%). With respect to drug therapy, benzodiazepine is the drug of choice (EM: 70.4%, PS: 78.8%). More EM would choose an intravenously (i.v.) or a Mucosal Atomization Device (MAD) administration as an alternative to oral medication (i.v.: EM: 38.8%, PS: 3.8%, p = 0.001, MAD: EM: 36.7%, PS: 10.6%, p = 0.006). Significantly more EM would seek phone contact with the acute psychiatric hospital (EM: 84.7%, PS: 52.9%, p = 0.0107). A psychiatric emergency plan was considered useful in this context by more than 90% of respondents. The need for further training for EM with regard to treating psychiatric clinical syndromes was considered important by all respondents. In particular, the topics of "psychogenic seizure," "intoxication," and "legal aspects of psychiatric emergencies" were considered important (Mann-Whitney U test, p < 0.001)., Conclusion: The interaction-related problems identified in the emergency medical care of pre-clinical psychiatric patients relate to non-modifiable, structural problems, such as insufficient admission capacity and non-existent or inadequate monitoring capabilities in acute psychiatric hospitals. However, factors such as the education and training of EM and communication between EM and PS can be improved. Developing personalized emergency care plans for psychiatric patients could help to optimize their care., (© 2022. The Author(s).)

Purpose: Thermal inhalation injury is a common, life-threatening problem in burned patients. Whether or not this single event of damage to the oral integrity causes long term health problems is yet to be examined., Material and Methods: All consecutive burn patients between 2014 and 2017 of Marienhospital Stuttgart (MHS), Germany, with at least 10% of burned skin surface were included and compared. The Periodontal Screening Index as well as Vitamin D levels were examined. Vitamin D has been suspected to contribute to the genesis of periodontitis. Risk factors and subjective oral life quality were prompted., Results: We included a total of 32 patients, 15 of which had an inhalation injury in their medical history. Risk factors were examined via Renatus' questionnaire. While risk factors were equally distributed in both groups we saw a remarkable difference in periodontal integrity, with the Periodontal Screening Index (PSI) per sextant differing drastically (with inhalation injury: 2.40, without inhalation injury: 1.10, p < 0.001). Patients with an inhalation injury had a mean of 5.2 out of 6 possible sextants with a pathologic PSI (with the median being 6/6), while patients without an inhalation injury had a mean of 1.83 out of 6 (median: 1/6), p < 0.001. The oral health impact profile showed a difference as well, albeit without statistical significance (with inhalation injury: median = 11, without: median = 3.5, p = 0.414). A correlation between Serum Vitamin D levels and periodontal integrity could not be seen in this group., Conclusion: Inhalation injury is a possible cause for periodontitis and hence impacts the quality of life of burned patients., (Copyright © 2021 Elsevier Ltd and ISBI. All rights reserved.)

Introduction: Cardiac arrest is a leading cause of death in industrialised countries. Cardiopulmonary resuscitation (CPR) guidelines follow the principles of closed chest compression as described for the first time in 1960. Mechanical CPR devices are designed to improve chest compression quality, thus considering the improvement of resuscitation outcomes. This protocol outlines a systematic review and meta-analysis methodology to assess trials investigating the therapeutic effect of automated mechanical CPR devices at the rate of return of spontaneous circulation, neurological state and secondary endpoints (including short-term and long-term survival, injuries and surrogate parameters for CPR quality) in comparison with manual chest compressions in adults with cardiac arrest., Methods and Analysis: A sensitive search strategy will be employed in established bibliographic databases from inception until the date of search, followed by forward and backward reference searching. We will include randomised and quasi-randomised trials in qualitative analysis thus comparing mechanical to manual CPR. Studies reporting survival outcomes will be included in quantitative analysis. Two reviewers will assess independently publications using a predefined data collection form. Standardised tools will be used for data extraction, risks of bias and quality of evidence. If enough studies are identified for meta-analysis, the measures of association will be calculated by dint of bivariate random-effects models. Statistical heterogeneity will be evaluated by I 2 -statistics and explored through sensitivity analysis. By comprehensive subgroup analysis we intend to identify subpopulations who may benefit from mechanical or manual CPR techniques. The reporting follows the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement., Ethics and Dissemination: No ethical approval will be needed because data from previous studies will be retrieved and analysed. Most resuscitation studies are conducted under an emergency exception for informed consent. This publication contains data deriving from a dissertation project. We will disseminate the results through publication in a peer-reviewed journal and at scientific conferences., Prospero Registration Number: CRD42017051633., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Decompression sickness and arterial gas embolism, collectively known as decompression illness (DCI), are serious medical conditions that can result from compressed gas diving. DCI can present with a wide range of physiologic and neurologic symptoms. In diving medicine, skin manifestations are usually described in general as cutis marmorata (CM). Mainly in the Anglo-American literature the terms cutis marmorata, livedo reticularis (LR), and livedo racemosa (LRC) are used interchangeably but actually describe pathophysiologically different phenomena. CM is a synonym for LR, which is a physiological and benign, livid circular discoloration with a net-like, symmetric, reversible, and uniform pattern. The decompression-associated skin discolorations, however, correspond to the pathological, irregular, broken netlike pattern of LRC. Unlike in diving medicine, in clinical medicine/dermatology the pathology of livedo racemosa is well described as a thrombotic/embolic occlusion of arteries. This concept of arterial occlusion suggests that the decompression-associated livedo racemosa may be also caused by arterial gas embolism. Recent studies have shown a high correlation of cardiac right/left (R/L) shunts with arterial gas embolism and skin bends in divers with unexplained DCI. To further investigate this hypothesis, a retrospective analysis was undertaken in a population of Austrian, Swiss, and German divers. The R/L shunt screening results of 18 divers who suffered from an unexplained decompression illness (DCI) and presented with livedo racemosa were retrospectively analyzed. All of the divers were diagnosed with a R/L shunt, 83% with a cardiac shunt [patent foramen ovale (PFO)/atrium septum defect (ASD)], and 17% with a non-cardiac shunt. We therefore not only confirm this hypothesis but when using appropriate echocardiographic techniques even found a 100% match between skin lesions and R/L shunt. In conclusion, in diving medicine the term cutis marmorata/livedo reticularis is used incorrectly for describing the actual pathology of livedo racemosa. Moreover, this pathology could be a good explanation for the high correlation of livedo racemosa with cardiac and non-cardiac right/left shunts in divers without omission of decompression procedures., (Copyright © 2020 Hartig, Reider, Sojer, Hammer, Ploner, Muth, Tilg and Köhler.)

Background: Bradykinin-mediated, drug-induced edema like ACE-inhibitor-induced angioedema (ACEi AE) is almost exclusively located in the head and neck region and is potentially life threatening. To date, there are no guidelines or officially-approved treatments available for this pathology., Objectives: We sought to provide a structured therapeutic algorithm for the acute treatment of drug-induced bradykinin-mediated angioedema., Materials and Methods: We analyzed data (especially the course of disease and therapy) of all patients with acute angioedema, who presented to the Department of Otorhinolaryngology, Head and Neck Surgery at the University of Ulm (2010-2015). We also conducted a literature review on PubMed with the terms "acute angioedema", "angioedema emergency", "ACE angioedema", "bradykinin angioedema" and "angioedema therapy". Other fundamental references were the recent German guidelines "hereditary angioedema", "anaphylaxis" and "airway management"., Results: An emergency algorithm was generated as a flowchart for the acute therapy of bradykinin-mediated drug-induced angioedema was generated. We focused on the decision criteria for intubation/airway management and pharmacological therapy: antihistamines and glucocorticoids versus anti-bradykinin treatment. Furthermore, recommendations for inpatient monitoring have been derived., Conclusion/discussion: To date, therapy of drug-induced bradykinin-mediated angioedema is performed according to an "off-label" use and without officially-approved guidelines. The presented emergency algorithm provides a first approach for a structured therapeutic concept for a potentially life-threatening pathology.

Background: Cardiac arrest is an event with a limited prognosis which has not substantially changed since the first description of cardiopulmonary resuscitation (CPR) in 1960. A promising new treatment approach may be mechanical CPR devices (mechanical CPR)., Methods: In a retrospective analysis of the German Resuscitation Registry between 2007-2014, we examined the outcome after using mechanical CPR on return of spontaneous circulation (ROSC) in adults with out-of-hospital cardiac arrest (OHCA). We compared mechanical CPR to manual CPR. According to preclinical risk factors, we calculated the predicted ROSC-after-cardiac-arrest (RACA) score for each group and compared it to the rate of ROSC observed. Using multivariate analysis, we adjusted the influence of the devices' application on ROSC for epidemiological factors and therapeutic measures., Results: We included 19,609 patients in the study. ROSC was achieved in 51.5% of the mechanical CPR group (95%-CI 48.2-54.8%, ROSC expected 42.5%) and in 41.2% in the manual CPR group (95%-CI 40.4-41.9%, ROSC expected 39.2%). After multivariate adjustment, mechanical CPR was found to be an independent predictor of ROSC (OR 1.77; 95%-CI 1.48-2.12). Duration of CPR is a key determinant for achieving ROSC., Conclusions: Mechanical CPR was associated with an increased rate of ROSC and when adjusted for risk factors appeared advantageous over manual CPR. Mechanical CPR devices may increase survival and should be considered in particular circumstances according to a physicians' decision, especially during prolonged resuscitation., Competing Interests: The authors have declared that no competing interests exist.

Background  Psychiatric emergencies (PE) in preclinical emergency medical services are about 5 - 10 % of all emergencies and represent often a source of difficulties in handling for the non-psychiatric professional helpers that deal with them. Studies informing about quantitative and qualitative changes of PEs in preclinical emergency medicine in Germany are scarce. Methods  Therefore, we conducted a retrospective cross-sectional study of PE in a preclinical emergency medical service based on the protocols of the emergency ambulance of the Section for Emergency Medicine at the University Hospital Ulm comparing the years 2000 and 2010. Results  We observed a significant increase of PEs from 8.8 % in the year 2000 (n = 285, from a total of n = 3227) to 10.3 % in 2010 (n = 454, from a total of n = 4425). In both years intoxications were the most common PE [2000: n = 116 (44.4 %); 2010: n = 171 (37.7 %)], followed by suicide-related behavior [2000: n = 59 (22.6 %); 2010: n = 78 (17.2 %)] and acute anxiety disorders [2000: n = 37 (13 %); 2010: n = 105 (23.1 %)]. The mentioned three conditions accounted for about 80 % of all PE. Most frequently PE occurred at the weekend and with the highest density in the evening and at night (18 - 24 h) in both years. Patients with PE were predominantly men, but the rate of women causing PE increased between 2000 and 2010. Discussion/Conclusion  This study provides preliminary data on current trends in PEs in preclinical emergency medicine in Germany and has implications for improving the medical care provided., Competing Interests: Interessenkonflikt: Die Autoren geben an, dass kein Interessenkonflikt besteht., (© Georg Thieme Verlag KG Stuttgart · New York.)

Objective: Cardiac arrest is associated with a poor outcome if cardiopulmonary resuscitation (CPR) is delayed. Nevertheless, CPR performance by laypersons in witnessed cardiac arrest is frequently poor. The present study evaluated the effect of a media campaign on CPR performance., Participants and Methods: CPR performance of 1000 individuals who did not have any medical background was evaluated using a resuscitation manikin. The media campaign consisted of flyers, posters, and electronic advertisement. Five hundred individuals were evaluated before the media campaign and 500 individuals after the media campaign. Age and male/female ratio were comparable within each of the groups. Premedia campaign performance was compared with postmedia campaign performance with respect to chest compressions and ventilation metrics., Results: Chest compression depth and total compression work were significantly higher after the media campaign: median depth 51 mm postcampaign versus 45 mm precampaign (P<0.001), median cumulative compression work postcampaign 4176 versus 2462 mm precampaign (P<0.001). Tidal volumes and ventilation work were significantly lower following the media campaign, but did not differ between participants who had acknowledged exposure to the campaign and those who did not. Ventilation performance was generally poor across the two groups both before and after the media campaign., Conclusion: A simple and cost-efficient media campaign appears to enhance the performance of chest compressions. Ventilation performance and the rate of CPR performance were not increased by the campaign.

Emergency medical service is called by a 54-year-old man bitten by his rattlesnake. Upon initial survey we find the patient in a cardiopulmonary stable condition. He has bite marks and pain on his rapidly swelling middle finger of his right hand. Our initial treatment is immobilization of the patient. The snake raiser has already called the poison control center in Munich. By the help of this institution we bring him to a hospital having the right antivenom on hand., (© Georg Thieme Verlag Stuttgart · New York.)

The diving accident (decompression incident, DCI) occurs in the decompression phase of dives. The DCI can either be caused by an arterial gas embolism (AGE) subsequent to a pulmonary barotrauma or by the formation of inert gas bubbles subsequent to a reduction of ambient pressure during the ascent from depth. In contrast to the traditional assumption that decompression incidents only occur if decompression rules are neglected, recent data indicate that a vast amount of diving accidents occur even though divers adhered to the rules. Hence, there is a large inter- and intraindividual variability in the predisposition for diving accidents. Within the past few years, the molecular understanding of the pathophysiology of diving accidents has improved considerably. It is now well accepted that pro-inflammatory and pro-coagulatory mechanisms play a central role. Moreover, microparticles are increasingly discussed in the pathogenesis of diving accidents. These new molecular findings have not yet resulted in new therapeutic approaches. However, new approaches of preconditioning before the dive have been developed which are intended to reduce the risk of diving accidents. The symptoms of a diving accident show a large variability and range. They reach from pruritus over tension in the female breast, marbled skin and pain in the joints to severe neurological disability like paraplegia or hemiplegia. Furthermore, pulmonary symptoms can be a result of a pulmonary gas embolism and/or a tension pneumothorax. Extreme cases can also manifest as generalized, difficult-to-treat seizures, loss of consciousness or even death. The evidence-based therapy of diving accidents consists of an immediate application of 100% inspiratory O2. This can be performed via a demand valve, face mask with reservoir bag or ventilation bag connected to a reservoir bag. Fluid substitution is performed by i. v. infusion of 500-1000ml/h of cristalloids. If consciousness is not impaired, the diver is positioned in a supine position, in case of impaired or absent consciousness in a lateral recovery position. Especially in severe cases of DCI a fast transfer to a qualified hyperbaric center and the earliest possible hyperbaric O2-therapy is essential., (© Georg Thieme Verlag Stuttgart · New York.)

Background: Drowning is a relevant worldwide cause of severe disability and death. The delay of ventilations and chest compressions is a crucial problem in drowning victims. Hence, a novel helicopter-based ALS rescue concept with in-water ventilation and chest compressions was evaluated., Methods: Cardio pulmonary resuscitation (CPR) and vascular access were performed in a self-inflating Heliboat platform in an indoor wave pool using the Fastrach intubating laryngeal mask, the Oxylator resuscitator, Lund University Cardiopulmonary Assist System (LUCAS) chest compression device and EZ-IO intraosseous power drill. The time requirement and physical exertion on a Visual Analogue Scale (VAS) were compared between a procedure without waves and with moderate swell., Results: Measurement of the elapsed time of the various stages of the procedure did not reveal significant differences between calm water and swell: Ventilation was initiated after 02:48 versus 03:02 and chest compression after 04:20 versus 04:18 min; the intraosseous cannulisation was completed after 05:59 versus 06:30 min after a simulated jump off the helicopter. The attachment of the LUCAS to the mannequin and the intraosseous cannulisation was rated significantly more demanding on the VAS during swell conditions., Conclusions: CPR appears to be possible when performed in a rescue platform with special equipment. The novel helicopter-based strategy appears to enable the rescuers to initiate CPR in an appropriate length of time and with an acceptable amount of physical exertion for the divers. The time for the helicopter to reach the patient will have to be very short to minimise neurological damage in the drowning victim., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Background: In-water resuscitation (IWR) is recommended in the 2010 guidelines of the European Resuscitation Council. As IWR represents a physical challenge to the rescuer, a novel Rescue Tube device with an integrated "Oxylator" resuscitator might facilitate IWR. The aim of the present study was the assessment of IWR using the novel Rescue Tube device., Methods: Tidal and minute volumes were recorded using a modified Laerdal Resusci Anne mannequin. Furthermore, rescue time, water aspiration, submersions, and physical exertion were assessed. In this randomized cross-over trial, 17 lifeguards performed four rescue maneuvers over a 100-m distance in open water in random order: no ventilation (NV), mouth-to-mouth ventilation (MMV), Oxylator-aided mask ventilation (OMV), and Oxylator-aided laryngeal tube ventilation (OLTV)., Results: OLTV resulted in effective ventilation over the entire rescue distance with the highest mean minute volumes (NV 0, MMV 2.9, OMV 4.1, OLTV 7.6 L · min(-1)). NV was the fastest rescue maneuver while IWR prolonged the rescue maneuver independently of the method of ventilation (mean total rescue time: NV 217, MMV 280, OMV 292, OLTV 290 s). Aspiration of substantial amounts of water occurred only during MMV (mean NV 20, MMV 215, OMV 15, OLTV 6 ml). NV and OLTV were rated as moderately challenging by the lifeguards, whereas MMV and OMV were rated as substantially demanding on a 0-10 visual analog scale (NV 5.3, MMV 7.8, OMV 7.6, OLTV 5.9)., Discussion: The device might facilitate IWR by providing effective ventilation with minimal aspiration and by reducing physical effort. Another advantage is the possibility of delivering 100% oxygen.

Introduction: Full-face-masks (FFM) prevent the diver's face from cold and can support nasal breathing underwater. The aim of the study was to evaluate the effect of the use of FFMs on lung function and wellbeing., Methods: Twenty-one, healthy, non-asthmatic divers performed two cold-water dives (4⁰C, 25 min, 10 metres' depth) - one with a FFM and the other with a standard scuba regulator (SSR). Spirometry was performed before and after each dive and well-being and cold sensation were assessed after the dives., Results: Significant decreases in forced vital capacity (FVC), forced expiratory volume in one second (FEV₁) and midexpiratory flow at 75% of FVC (MEF₇₅) occurred after both FFM and SSR dives. Changes in FVC and FEV₁ did not differ significantly between FFM and SSR dives. However, the mid-expiratory flows measured at 50% and 25% of FVC (MEF₅₀ and MEF₂₅) were significantly lower 10 minutes after the FFM dive compared to 10 minutes after the SSR dive. The wellbeing and cold sensation of the divers were significantly improved with FFM dives compared to SSR dives., Conclusions: Cold-water dives during wintertime can be associated with airway narrowing. During cold-water dives, the use of a FFM appears to reduce the cold sensation and enhance the well-being of the divers. However, a FFM does not appear to prevent airway narrowing in healthy, non-asthmatic subjects.

Introduction: Drowning is a common cause of death in young adults. The 2010 guidelines of the European Resuscitation Council call for in-water-resuscitation (IWR). There has been controversy about IWR amongst emergency and diving physicians for decades. The aim of the present study was assessing the efficacy of IWR., Methods: In this randomized cross-over trial, nineteen lifeguards performed a rescue manoeuvre over a 100 m distance in open water. All subjects performed the procedure four times in random order: with no ventilation (NV) and transportation only, mouth-to-mouth ventilation (MMV), bag-mask-ventilation (BMV) and laryngeal tube ventilation (LTV). Tidal volumes, ventilation rate and minute-volumes were recorded using a modified Laerdal Resusci Anne manikin. Furthermore, water aspiration and number of submersions of the test mannequin were assessed, as well as the physical effort of the lifeguard rescuers.One lifeguard subject did not complete MMV due to exhaustion and was excluded from analysis., Results: NV was the fastest rescue manoeuvre (advantage ∼40s). MMV and LTV were evaluated as efficient and relatively easy to perform by the lifeguards. While MMV (mean 199 ml) and BMV (mean 481 ml) were associated with a large amount of aspirated water, aspiration was significantly lower in LTV (mean 118 ml). The efficacy of ventilation was consistently good in LTV (Vt=447 ml), continuously poor in BMV (Vt=197) and declined substantially during MMV (Vt=1,019 ml initially and Vt=786 ml at the end). The physical effort of the lifeguards was remarkably higher when performing IWR: 3.7 in NV, 6.7 in MMV, 6.4 in BMV and 4.8 in LTV as measured on the 0-10 visual analogue scale., Conclusion: IWR in open water is time consuming and physically demanding. The IWR training of lifeguards should put more emphasis on a reduction of aspiration. The use of ventilation adjuncts like the laryngeal tube might ease IWR, reduce aspiration of water and increase the efficacy of ventilation during IWR., (Copyright © 2013. Published by Elsevier Ireland Ltd.)

Introduction: In water resuscitation has been reported to enhance the outcome of drowning victims. Mouth-to-mouth ventilation during swimming is challenging. Therefore, the efficacy of ventilation utilities was evaluated., Methods: Ventilation was assessed with the Oxylator ventilator, as well as the consecutive self-contained underwater breathing apparatus (SCUBA) regulators using an anaesthetic test lung: Poseidon Cyklon 5000, Poseidon XStream, Apeks TX 100, Spiro Arctic, Scubapro Air2 and Buddy AutoAir., Results: Oxylator, Apeks TX 100, Arctic and Buddy AutoAir delivered reliable peak pressures and tidal volumes. In contrast, the ventilation parameters remarkably depended on duration and depth of pressing the purge button in Poseidon Cyklon 5000, Poseidon XStream and Scubapro Air2. Critical peak pressures occurred during ventilation with all these three regulators., Discussion: The use of Poseidon Cyklon 5000, Poseidon XStream and Scubapro Air2 regulators is consequently not recommended for in-water ventilation. With the limitation that the devices were tested with a test lung and not in a human field study, Apeks TX 100, Spiro Arctic and Buddy AutoAir might be used for emergency ventilation and probably ease in-water resuscitation for the dive buddy of the victim. Professional rescue divers could be equipped with the Oxylator and an oxygen tank to achieve an early onset of efficient in-water ventilation in drowning victims.

Objective: Drowning is associated with a high mortality and morbidity and a common cause of death. In-water resuscitation (IWR) in the case of drowning accidents has been recommended by certain resuscitation guidelines in the last several years. IWR has been discussed controversially in the past, especially with regard to the delay of chest compressions, effectiveness of ventilation, and hazard to the rescuer. The aim of the present study was to assess the effectiveness and safety of IWR., Methods: In this crossover manikin study, 21 lifeguards and 21 laypersons performed two rescue procedures in an indoor swimming pool over a 50-meter distance: In random order, one rescue procedure was performed with in-water ventilation and one without. Tidal and minute volumes were recorded using a modified Laerdal Resusci Anne (Laerdal Medical, Stavanger, Norway) and total rescue duration, submersions, water aspiration by the victim, and physical effort were assessed., Results: IWR resulted in significant increases in rescue duration (lifeguards: 106 vs. 82 seconds; laypersons: 133 vs. 106 seconds) and submersions (lifeguards: 3 vs. 1; laypersons: 5 vs. 0). Furthermore, water aspiration (lifeguards: 112 vs. 29 mL; laypersons: 160 vs. 56 mL) and physical effort (lifeguards: visual analog scale [VAS] score 7 vs. 5; laypersons: VAS score 8 vs. 6) increased significantly when IWR was performed. Lifeguards achieved significantly better ventilation characteristics and performed both rescue procedures faster and with lower side effects. IWR performed by laypersons was insufficient with regard to both tidal and minute volumes., Conclusions: In-water resuscitation is associated with a delay of the rescue procedure and a relevant aspiration of water by the victim. IWR appears to be possible when performed over a short distance by well-trained professionals. The training of lifeguards must place particular emphasis on a reduction of submersions and aspiration when IWR is performed. IWR by laypersons is exhausting, time-consuming, and inefficient and should probably not be recommended. Key words: drowning; near-drowning; hypoxia; ventilation, artificial; respiration, artificial; resuscitation, in-water.

Introduction: In-water resuscitation has recently been proposed in the European resuscitation guidelines. Initiation of mechanical ventilation underwater might be considered when an immediate ascent to the surface is impossible or dangerous. The present study evaluated the feasibility of such ventilation underwater., Methods: A resuscitation manikin was ventilated using an Interspiro® MK II full-face mask or with an Oxylator® ventilator via a facemask or a laryngeal tube, or with mouth-to-tube inflation. Tidal volumes achieved by the individual methods of ventilation were assessed. The ventilation tests were performed during dives in the wet compartment of a recompression chamber and in a lake. Ventilation was tested at 40, 30, 20, 12, 9 and 6 metres' depth., Results: Ventilation was impossible with the cuffed mask and only sufficient after laryngeal intubation for a small number of breaths. Laryngeal tube ventilation was associated with the aspiration of large amounts of water and the Oxylator failed during the ascent. Efficient ventilation with the MK II full-face mask was also possible only for a short period. An absolutely horizontal position of the manikin was required for successful ventilation, which is likely to be difficult to achieve in open water. Leakage at the sealing lip of the full-face mask and the cuff of the laryngeal tube led to intrusion of water and resulted in subsequent complete failure of ventilation., Conclusions: The efficacy of underwater ventilation seems to be poor with any of the techniques trialed. Water aspiration frequently makes ventilation impossible and might foster emphysema aquosum-like air trapping and, therefore, increase the risk of pulmonary barotrauma during ascent. Because the limitations of underwater ventilation are substantial even under ideal conditions, it cannot be recommended presently for real diving conditions.

Background: Acute pulmonary embolism (APE) is an important clinical problem in patients after major surgery and often remains a difficult diagnosis because of unspecific clinical symptoms. Therefore, we investigated the role of N-terminal prohormone of brain natriuretic peptide (NT-proBNP) for the detection of APE., Methods: In 44 patients with suspected APE referred to the intensive care unit after major surgery, serum NT-proBNP, troponin-I, and D-dimers were measured according to the standard hospital protocol. To definitively confirm or exclude APE, all patients underwent an angiographic CT scan of the thorax., Results: APE was confirmed in 28 and excluded in 16 patients by CT scan. NT-proBNP was significantly (P<0.01) higher in patients with APE [4425 (sd 8826; range 63-35 000) pg ml(-1)] compared with those without [283 (sd 327; range 13-1133) pg ml(-1)]. The sensitivity of the NT-proBNP screening was 93%, specificity 63%, positive predictive value 81%, and negative predictive value 83%. There were no significant (P = 0.96) differences in D-dimers between subjects with and without APE [confirmed APE: 511 (sd 207; range 83-750) μg litre(-1); excluded APE: 509 (sd 170; range 230-750) μg litre(-1)]. Troponin-I levels were not elevated in 32% of the patients with APE., Conclusions: D-dimer levels are frequently elevated in post-surgical patients and not applicable for confirmation or exclusion of APE. In contrast, NT-proBNP appears to be a useful biomarker for APE diagnosis in the postoperative setting. In the case of NT-proBNP levels below the upper reference limit, haemodynamically relevant APE is unlikely. Troponin-I in contrast is not considered to be helpful.

Recompression during decompression has been suggested to possibly reduce the risk of decompression sickness (DCS). The main objective of the current study was to investigate the effects of FLIRT (First Line Intermittent Recompression Technique) on bubble detection in man. 29 divers underwent 2 simulated dives in a dry recompression chamber to a depth of 40 msw (500 kPa ambient pressure) in random order. A Buehlmann-based decompression profile served as control and was compared to an experimental profile with intermittent recompression during decompression (FLIRT). Circulating bubbles in the right ventricular outflow tract (RVOT) were monitored by Doppler ultrasound and quantified using the Spencer scoring algorithm. Heat shock protein 70 (HSP70), thrombocytes, D-Dimers and serum osmolarity were analyzed before and 120 min after the dive. Both dive profiles elicited bubbles in most subjects (range Spencer 0-4). However, no statistically significant difference was found in bubble scores between the control and the experimental dive procedure. There was no significant change in either HSP70, thrombocytes, and D-Dimers. None of the divers had clinical signs or symptoms suggestive of DCS. We conclude that FLIRT did not significantly alter the number of microbubbles and thus may not be considered superior to classical decompression in regards of preventing DCS., (© Georg Thieme Verlag KG Stuttgart · New York.)

Unlabelled: Diving with self-contained underwater breathing apparatus (SCUBA) has become a popular recreational activity in children and adolescents. This article provides an extensive review of the current literature., Conclusions: Medical contraindications to SCUBA diving for adults apply to children and adolescents, too, but must be adapted. Additional restrictions to the fitness to dive must apply to both, children and adolescents. Children should always be accompanied by a trained adult when diving., (© 2011 The Author(s)/Acta Paediatrica © 2011 Foundation Acta Paediatrica.)

The purpose of this study was to monitor heart rate (HR) and rhythm during open water SCUBA dives. Nine children performed 25-min open water SCUBA dives to 8 m depth. Before, during and after these dives, ECG was recorded. Compared with predive heart rate, heart rate declined by -24 ± 8% (range -36%; -15%) during the dive. In some children a further decline in HR was observed within the last minutes of the dive. Older and taller subjects and those with a high initial HR showed a more pronounced decline in HR. Furthermore singular supraventricular and ventricular extrasystoles were observed in some children. Immersion as well as facial and skin cooling presumably account for the initial decline in heart rate. A further drop in HR within the last minutes of the dive might be related to mild hypothermia. Single supraventricular and ventricular extrasystoles might occur in healthy children during dives.

An increasing number of children and adolescents is diving with Self-Contained Underwater Breathing Apparatus (SCUBA). SCUBA diving is associated with health risks such as pulmonary barotrauma, especially in children and in individuals with airflow limitation. As no data has been published on the effects of open-water diving on pulmonary function in children, the objective of this study was to evaluate the effects of SCUBA dives on airflow in children. 16 healthy children aged 10-13 years underwent spirometry and a cycle-exercise challenge while breathing cold air. They subsequently performed dives to 1-m and 8-m depth in random order. Pulmonary function was measured before and after the exercise challenge and the dives. There were statistically significant decreases in FEV1, FVC, FEV1/FVC, MEF25 and MEF50 after the cold-air exercise challenge and the dives. Changes in lung function following the exercise challenge did not predict the responses to SCUBA diving. In 3 children the post-dive decrements in FEV1 exceeded 10%. These children had a lower body weight and BMI percentile. SCUBA diving in healthy children may be associated with relevant airflow limitation. A low body mass might contribute to diving-associated bronchoconstriction. In the majority of subjects, no clinically relevant airway obstruction could be observed., (© Georg Thieme Verlag KG Stuttgart · New York.)

The incidence and nature of cardiac arrhythmias during static apnea were studied by monitoring the electrocardiogram (ECG) and oxygen saturation (SaO(2)) of 16 recreational breath-hold divers. All subjects completed a maximal apnea with a mean (+/-SD) breath-hold duration of 281 (+/-73) s without clinical complications. Both heart rate (HR) and SaO(2) decreased significantly with breath-hold duration. The decline in SaO(2) was inversely related to the decline in HR (r = -0.55, P < 0.05). Cardiac arrhythmias (supraventricular and ventricular premature complexes, right bundle branch block) occurred in 12/16 (77%) subjects and were related to breath-hold duration. Subjects with atrial premature complexes (n = 9) had a reduced BMI (P = 0.016) and a higher decline of the terminal SaO(2) (P = 0.01). In conclusion, ectopic arrhythmias were common during maximal static apneas for training purposes. The results indicate that the occurrence of ectopic beats is associated with individual factors such as the tolerable SaO(2) decrease.

A single exposure to hyperbaric oxygen (HBO), i.e., pure oxygen breathing at supra-atmospheric pressures, causes oxidative DNA damage in humans in vivo as well as in isolated lymphocytes of human volunteers. These DNA lesions, however, are rapidly repaired, and an adaptive protection is triggered against further oxidative stress caused by HBO exposure. Therefore, we tested the hypothesis that long-term repetitive exposure to HBO would modify the degree of DNA damage. Combat swimmers and underwater demolition team divers were investigated because their diving practice comprises repetitive long-term exposure to HBO over years. Nondiving volunteers with and without endurance training served as controls. In addition to the measurement of DNA damage in peripheral blood (comet assay), blood antioxidant enzyme activities, and the ratio of oxidized and reduced glutathione content, we assessed the DNA damage and superoxide anion radical (O(2)(*-)) production induced by a single ex vivo HBO exposure of isolated lymphocytes. All parameters of oxidative stress and antioxidative capacity in vivo were comparable in the four different groups. Exposure to HBO increased both the level of DNA damage and O(2)(*-) production in lymphocytes, and this response was significantly more pronounced in the cells obtained from the combat swimmers than in all the other groups. However, in all groups, DNA damage was completely removed within 1 h. We conclude that, at least in healthy volunteers with endurance training, long-term repetitive exposure to HBO does not modify the basal blood antioxidant capacity or the basal level of DNA strand breaks. The increased ex vivo HBO-related DNA damage in isolated lymphocytes from these subjects, however, may reflect enhanced susceptibility to oxidative DNA damage.

Hyperbaric oxygen (HBO) therapy is used for the treatment of a variety of diseases, but also leads to oxidative stress as a result of increased formation of reactive oxygen species. The consequences may be damage to the lung, the central nervous system and the genome. The oxidative attack on DNA causes, among other damage, single and double strand breaks. Using the comet assay, a well-established genotoxicity test, it was possible to show that a single HBO exposure leads to increased levels of DNA strand breaks in a close dose-effect relationship. On the other hand, it was possible to demonstrate that these strand breaks are repaired rapidly and that, in repeated HBO exposures, DNA strand breaks occur only after the first treatment, not subsequent ones, indicating an induction of protective mechanisms. In healthy organisms, DNA repair and antioxidant mechanisms maintain a steady-state level of damage with minimal risk to the cell or the whole organism, but it cannot be excluded that HBO might lead to a significant mutational burden in situations where antioxidant defence is deficient or overwhelmed. The administration of antioxidants draws an ambivalent picture; Vitamin C, E or even N-acetylcysteine seems to be ineffective to prevent HBO-induced genotoxicity, whereas the orally effective vegetal superoxide dismutase (SOD, Glisodin®) is effective, and, thus, may play a role in the prevention of oxidative DNA damage.

Breath-hold divers employ glossopharyngeal insufflation (GI) in order to prevent the lungs from compressing at great depth and to increase intrapulmonary oxygen stores, thus increasing breath-hold time. The presented case study shows the physiological data and dynamic magnetic resonance imaging (dMRI) findings of acute hyperinflation, deliberately induced by GI, in a breath-hold diver and discusses the current state of knowledge regarding the associated hazards of this unique competitive sport. Static and dynamic lung volumes and expiratory flows were within the normal range, with vital capacity and peak expiratory flow being higher than the predicted values. Airway resistance and diffusing capacity of the lung for carbon monoxide were normal. Static compliance was normal and increased five-fold with hyperinflation. dMRI revealed a preserved shape of the thorax and diaphragm with hyperinflation. A herniation of the lung beneath the sternum and enlargement of the costodiaphragmatic angle were additional findings during the GI manoeuvre. After expiration, complete resolution to baseline was demonstrated. Hyperinflation can be physiological and even protective under abnormal physical conditions in the sense of acute adaptation to deep breath-hold diving. Dynamic magnetic resonance imaging is adequate for visualisation of the sequence of the glossopharyngeal insufflation manoeuvre and the complete reversibility of deliberate hyperinflation.

Competitive breath-hold divers (BHD) employ glossopharyngeal insufflation (GI) to increase intrapulmonary oxygen stores and prevent the lungs from dangerous compressions at great depths. Glossopharyngeal insufflation is associated with inflation of the lungs beyond total lung capacity (TLC). It is currently unknown whether GI transiently over-distends the lungs or adversely affects lung elastic properties in the long-term. Resting lung function, ventilatory drive, muscle strength, and lung compliance were measured in eight BHD who performed GI since 5.5 (range 2-6) years on average, eight scuba divers, and eight control subjects. In five BHD subsequent measures of static lung compliance (Cstat) were obtained after 1 and 3 min following GI. Breath-hold divers had higher than predicted ventilatory flows and volumes and did not differ from control groups with regard to gas transfer, inspiratory muscle strength, and lung compliance. A blunted response to CO2 was obtained in BHD as compared to control groups. Upon GI there was an increase in mean vital capacity (VCGI) by 1.75 +/- 0.85 (SD) L compared to baseline (p < 0.001). In five BHD Cstat raised from 3.7 (range 2.9-6.8) L/kPa at baseline to 8.1 (range 3.4-21.2) L/kPa after maximal GI and thereafter gradually decreased to 5.6 (range 3.3-8.1) L/kPa after 1 min and 4.2 (range 2.7-6.6) L/kPa after 3 min (p < 0.01). We conclude that in experienced BHD there is a transient alteration in lung elastic recoil. Resting lung function did not reveal a pattern indicative of altered lung ventilatory or muscle function.

About 10% of all sport scuba divers are children and adolescents. Little is known about the particular risks and consequences of this sport on a child's health. Due to the peculiarities of childhood anatomy and physiology, certain restrictions apply to the diving fitness of children and adolescents. Before starting scuba training, the presence of particular cognitive abilities must be demonstrated and eustachian tube dysfunction must be ruled out by a specialist. Medical contra-indications to scuba diving for adults apply to children too but must be adapted. Relative risks for adults may translate to absolute contra-indications in children and adolescents. When planning dives, there should be rigorous limitations as to depth and time. Experienced adult divers must always assist with dive planning and accompany children and adolescents when scuba diving.

In diving mammals splenic contraction increases circulating red cell volume, whereas in humans increased haemoglobin concentrations have been reported. It is unknown, however, whether repetitive apnea diving also comprises an adaptive increase in total red cell volume as reported in endurance athletes. The first aim of the study therefore was to investigate the effect of repeated apnea dives on splenic size and putative red cell release in trained apnea divers (n = 10) and control subjects (SCUBA divers performing apneas without long-term apnea training, n = 7). Long-term effects of repetitive apnea diving may elevate the oxygen transport capacity by an adaptive increase in total haemoglobin mass as reported in endurance athletes. The second goal, therefore, was to compare the trained apnea divers' and the control divers' total haemoglobin mass (tHb-mass) with that of endurance-trained (n = 9) and untrained (n = 10) non-divers. Before and immediately after a series of five dives to a depth of 4 m in a heated pool, spleen volume was assessed with ultrasound tomography. tHb-mass and plasma volume were measured using the CO-rebreathing method. In the trained apnea divers, repeated apnea dives resulted in a 25% reduction of spleen size (P < 0.001), whereas no significant effect was observed in the control subjects. While tHb-mass did not differ between trained apnea divers, untrained SCUBA divers performing apneas and untrained non-divers, it was 30% lower than in endurance-trained non-divers. We conclude that prolonged apnea training causes marked apnea-induced splenic contraction. In contrast to athletes in endurance sports, the trained apnea divers did not present with increased total haemoglobin mass and, hence, no increase in blood oxygen stores.

Emergencies on or in water are relatively rare in the rescue service. For this reason, water accident treatment and management does not receive much attention in the training of emergency medicine physicians. Consequently doctors working in emergency medicine often have minimal knowledge in this area. On the other hand, the number of fatal accidents on and in water has increased in recent years. In Germany the number of non-swimmers is also increasing, so it can be assumed that the number of water-related accidents will continue to rise. Drowning accidents and near drowning are important in this context and will be discussed in detail in this review as well as hypothermia (a frequent problem), accompanying injuries and diving accidents.