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Contents lists available at ScienceDirect

Resuscitation
journal homepage: www.elsevier.com/locate/resuscitation

Editorial

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Drowning resuscitation requires another state of mind

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This issue of resuscitation includes a large prognostic Utsteinbased drowning resuscitation study from Osaka, Japan, which at rst glance reports very disappointing outcomes. Of the 1737 drowning victims who were in a cardiac arrest at arrival of emergency medical services (EMS), only 0.8% were alive with normal neurological function after one month.1 The study is consistent with another Japanese cohort study,2 but contrasts with case reports where more optimistic outcomes have been reported.3,4 A conclusion of the current publication could be that resuscitation of drowning victims is useless and that we should perhaps return to the 17th century when the laws in many European countries required that drowning victims remain untouched with at least their feet hanging in the water so as to allow police to determine the cause of death.5 The work of Nitta et al.1 emphasises the reality of the down-side of resuscitation efforts and the importance of effective drowning prevention strategies.68 At the same time, the study allows us to learn more about some key elements of drowning resuscitation and drowning resuscitation research. In drowning victims, important predictors for survival are water temperature,3,9 submersion time,9,10 adequacy of bystander cardiopulmonary resuscitation (CPR),2,11 and EMS response time.12,13 Nitta et al.1 correctly mention that their study has been based on Utstein template of data collection for cardiac arrest,14 and not on the Utstein template for drowning.15 Their study, therefore, could not provide data on these predictors in valuable detail. The reported average EMS response time of 7 min however provides an estimate of the out-of-water anoxic interval. The total (under-water plus out-of-water) anoxic interval must have been substantial. Notably, almost 60% of the victims did not receive any bystander CPR and an additional 20% received compression-only CPR. Also the time to install the automated external debrillator (AED), ultimately superuous as reported in many drowning studies,2,12,13,16,17 may have to be added to the total anoxic period. Taking these factors into account, it is not surprising that the EMS providers could not achieve restoration of spontaneous circulation (ROSC) in 84% of overall study population.1 It is a reasonable nding that severe anoxic brain damage occurred in many of the remaining victims. Nitta et al.1 do provide important new data regarding effects of victim age on resuscitation success. ROSC was restored by the EMS in 53% (19/36) of 04 year old children, in 28% (9/32) of 517 year olds. This markedly contrasts with a rate of 12.5% (208/1669) in those older than 17 years. Interestingly, this study does not identify any patient in which ROSC was achieved after arrival in the hospital.4,13,18,19 For those in whom ROSC was achieved, survival after 1 month in 04 year olds was 53% (10/19), 33% (3/9) in 517

year olds, and 14% (28/208) in those >17 years of age. The frequency of neurologically intact survival, assessed at 1 month, showed an opposite age-related trend: 20% (2/10) of 04 year olds, 33% (1/3) of 517 year olds and 39% (11/208) of those above 17 years of age. This does not necessarily predict long-term functional recovery. Several case reports of drowning resuscitation have observed improvement of neurological function after the rst post-resuscitation month as a result of neuro-rehabilitation.20,21 On the other hand, more detailed neurological and neurophysiological investigations after months or years show complications that had before gone unnoticed.6,22 A further remark needs to be made. This regards the complex relationship between outcome, drowning mechanisms, and drowning populations.23 Notably the large number of elderly victims included in the Nitta el al.1 study population (mean age 77 years; interquartile range 6784) is remarkable and indicates further investigation of the drowning mechanisms.24 It may be that particular mechanisms or populations have a poorer prognosis per se. Taking these factors in to consideration, let us go back to the physiology of drowning and again look at the data of Nitta et al.1 to better understand why the outcome in their study was so tragically low. First, it is essential to understand that cardiac arrest in drowning is not like the onoff physiological mechanism occurring in most out-of-hospital cardiac arrests (OHCA). In drowning, cardiac function gradually deteriorates over several minutes as a result of progressive hypoxia. Drowning physiology implicates that early ventilation and oxygenation are essential for survival. It is also known that airway resistance may be extremely high in drowning victims. This can prevent effective ventilation in the pre-hospital setting and during transportation.4,25,26 In other situations, where rescue and resuscitation have been performed by the same person, extremely large tidal volumes are often inated which result in outow limitations of the right ventricle and lower perfusion pressures during cardiac compressions.27,28 The ventilatory component of treatment is not only relevant during resuscitation but also during in-hospital treatment. A number of drowning victims will die during the rst week as a result of adult respiratory distress syndrome and pneumonia.29 These respiratory aspects may have contributed to the high number of patients who died in hospital after ROSC. Children are an important proportion of drowning victims. Bystanders, EMS and physicians are less competent in airway management in children.30,31 Previous studies have expressed concerns that regional differences in paediatric OHCA in Japan may be attributed to an EMS system that is yet

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0300-9572/$ see front matter 2013 Published by Elsevier Ireland Ltd. http://dx.doi.org/10.1016/j.resuscitation.2013.09.005

Please cite this article in press as: Bierens JJLM, Warner DS. Drowning resuscitation requires another state of mind. Resuscitation (2013), http://dx.doi.org/10.1016/j.resuscitation.2013.09.005

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insufciently trained to handle paediatric OHCA and that the transfer of OHCA children is mainly to adult ICUs or hospitals with low resuscitation volume.32 This is likely true of many other countries as well. Clinical treatment in hospitals with more experience in post-resuscitation care is benecial to outcome.33 This includes the possibilities of using extracorporeal membrane oxygenation (ECMO) and cardiopulmonary bypass (CPB). None of the patients in Nitta et al.1 were reported to have been placed on CPB or ECMO. There also was no report of use of post-ROSC therapeutic hypothermia, which has been reported to be benecial in aqua-related cardiac arrest events.4,18,20,34 This study elegantly demonstrates the complexity of drowning resuscitation.1 The data suggest that in children, the hypoxic heart is capable of restoring function but that the brain, being more vulnerable to hypoxia, has already sustained severe damage. This contrasts with adults in which the hypoxic heart often could not be re-started and hence there were fewer survivors with brain damage. Most young drowning victims will have had a healthy heart until the hypoxia generated arrest, while many older OHCA victims will have pre-existing cardiac disease.16 What does this new data mean for optimal drowning resuscitation? The study further supports that the contention that ventilation is essential in drowning resuscitation, i.e., chest compressions should be combined with ventilation.2,35,36 As quickly as possible, the EMS should be alerted and arrive with the highest qualied persons available to optimise early ventilation and oxygenation.12,30 Drowning victims with OHCA, notably children who have submerged in ice-cold water, should be transported to paediatric intensive care facilities.34 When in cardiac arrest, protocols and regional organisation should include the option to transfer the drowning victim to a facility with ECMO and CPB.20 The role of early debrillation seems to be less important. In contrast to speculation that ventricular brillation (VF) would have been more often detected had more drowning victims received bystander CPR and EMS response time decreased,13 it may also be speculated that cardiac compressions on a nonarrested acidotic, hypoxic or hypothermic heart may have induced VF. To summarise: based on physiological mechanisms, and only partly on scientic evidence, the poor neurological outcome after one month in this study raises concerns as to whether the conventional OHCA CPR guidelines can be copy-pasted to resuscitation guidelines in drowning situations. The drowning victim poses many other challenges. Most of all it seems important to teach dedicated drowning resuscitation techniques to those who are likely to witness drowning, such as pool and surf lifesavers, lifeboat crews, and those professionals and laypersons frequently present in the aquatic environment.2 Such training may involve more than emphasis on conventional CPR. This is an educational and training challenge for the stakeholders who are active in the eld of drowning prevention, rescue and resuscitation, such as the International Lifesaving Federation, International Maritime Rescue Federation, International Federation of Red Cross and Red Crescent Societies, and the Divers Alert Network. This will most notably be true for low and middle-income countries, where drowning fatalities are amongst the most frequent causes of death.8 These organisations include millions of dedicated members. For researchers, the challenges will be to collect coherent data on drowning resuscitation in prospective multicentred studies, to dene the indicators for futility, to identify drowning mechanisms and populations with better or poorer survival chances, and to further explore optimal resuscitation techniques and early neuroprotective strategies in experimental studies.

Conict of interest statement Neither Dr. Bierens nor Dr. Warner have a conict or potential conict of interest to disclose.

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REFERENCES
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27. Aufderheide TP, Sigurdsson G, Pirrallo RG, et al. Hyperventilationinduced hypotension during cardiopulmonary resuscitation. Circulation 2004;109:19605. 28. Barcala-Furelos R, Abelairas-Gomez C, Romo-Perez V, Palacios-Aguilar J. Effect of physical fatigue on the quality CPR: a water rescue study of lifeguards: physical fatigue and quality CPR in a water rescue. Am J Emerg Med 2013;31:4737. 29. van Berkel M, Bierens JJ, Lie RL, et al. Pulmonary oedema, pneumonia and mortality in submersion victims; a retrospective study in 125 patients. Intens Care Med 1996;22:1017. 30. Gerritse BM, Draaisma JM, Schalkwijk A, van Grunsven PM, Scheffer GJ. Should EMS-paramedics perform paediatric tracheal intubation in the eld? Resuscitation 2008;79:2259. 31. Lammers R, Byrwa M, Fales W. Root causes of errors in a simulated prehospital pediatric emergency. Acad Emerg Med 2012;19:3747. 32. Okamoto Y, Iwami T, Kitamura T, et al. Regional variation in survival following pediatric out-of-hospital cardiac arrest. Circ J 2013. 33. Ro YS, Shin SD, Song KJ, et al. A comparison of outcomes of out-of-hospital cardiac arrest with non-cardiac etiology between emergency departments with lowand high-resuscitation case volume. Resuscitation 2012;83:85561. 34. Topjian AA, Berg RA, Bierens JJ, et al. Brain resuscitation in the drowning victim. Neurocrit Care 2012. 35. Handley AJ. Compression-only CPR-to teach or not to teach? Resuscitation 2009;80:7524.

Joost J.L.M. Bierens (MD, PhD) Q1 Maatschappij tot Redding van Drenkelingen (Society to Rescue People from Drowning), Rokin 114 B, 1012 LB Amsterdam, The Netherlands David S. Warner Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA author. Fax: +1 919 684 6692. E-mail addresses: jbierens@euronet.nl (J.J.L.M. Bierens), david.warner@duke.edu (D.S. Warner) 3 September 2013 Available online xxx
Corresponding

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Please cite this article in press as: Bierens JJLM, Warner DS. Drowning resuscitation requires another state of mind. Resuscitation (2013), http://dx.doi.org/10.1016/j.resuscitation.2013.09.005