今日の臨床サポート

溺水

著者: 加藤之紀 医療法人EMS 植田救急クリニック

監修: 林寛之 福井大学医学部附属病院

著者校正/監修レビュー済:2021/04/07
参考ガイドライン:
患者向け説明資料

概要・推奨   

  1. 溺水とは沈水、浸水に由来する呼吸障害から発生する一連の過程と定義される[1][2]
  1. 不整脈等による二次性の溺水も注意が必要だが、溺水自体による身体への影響は主に低酸素によるものであり、低酸素脳症を始めとした各臓器障害の原因となる。
病院前対応での対応・推奨
  1. 溺水患者に対する現場からの早期の換気は強く推奨される(推奨度1)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
加藤之紀 : 特に申告事項無し[2021年]
監修:林寛之 : 講演料(メディカ出版),原稿料(羊土社)[2021年]

改訂のポイント
  1. 文献の定期レビューを行い、ガイドラインに沿った記載とした。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 溺水とは、液体への沈水、浸水に由来する呼吸障害から発生する一連の過程と定義される[1][2]
  1. 全世界では溺水によって年間50万人の死者が発生しているといわれており、その分布は地域によっても異なる[2]
  1. 2019年に日本で発生した水難事故は1,298件で、1,538人の水難者が発生したが、うち死亡した人数、行方不明の人数は695人と非常に多いものとなっている。また家庭内での不慮の事故による溺水においても年間4,000人近い死者が発生している[3][4]
  1. 年齢別で考えると、アメリカでは溺水による死亡は1~4歳、10~14歳の死因として交通事故に次ぎ2番目に多く報告されている[2]
  1. 気道に水が浸入した際の咳反射や呼吸苦による喘ぎなどによる誤嚥、窒息や喉頭けいれんによる低酸素、脳虚血によって溺水患者は速やかに意識消失、無呼吸、次いで心肺停止に陥る。
  1. 溺水患者の予後改善には、気道、呼吸を優先した現場での蘇生処置が重要となるが、講習による意識啓蒙など予防に向けた活動、対応も重要となる。
 

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文献 

著者: E F van Beeck, C M Branche, D Szpilman, J H Modell, J J L M Bierens
雑誌名: Bull World Health Organ. 2005 Nov;83(11):853-6. doi: /S0042-96862005001100015. Epub 2005 Nov 10.
Abstract/Text Drowning is a major global public health problem. Effective prevention of drowning requires programmes and policies that address known risk factors throughout the world. Surveillance, however, has been hampered by the lack of a uniform and internationally accepted definition that permits all relevant cases to be counted. To develop a new definition, an international consensus procedure was conducted. Experts in clinical medicine, injury epidemiology, prevention and rescue from all over the world participated in a series of "electronic" discussions and face-to-face workshops. The suitability of previous definitions and the major requirements of a new definition were intensely debated. The consensus was that the new definition should include both cases of fatal and nonfatal drowning. After considerable dialogue and debate, the following definition was adopted: "Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid." Drowning outcomes should be classified as: death, morbidity, and no morbidity. There was also consensus that the terms wet, dry, active, passive, silent, and secondary drowning should no longer be used. Thus a simple, comprehensive, and internationally accepted definition of drowning has been developed. Its use should support future activities in drowning surveillance worldwide, and lead to more reliable and comprehensive epidemiological information on this global, and frequently preventable, public health problem.

PMID 16302042  Bull World Health Organ. 2005 Nov;83(11):853-6. doi: /S・・・
著者: Ashish R Panchal, Jason A Bartos, José G Cabañas, Michael W Donnino, Ian R Drennan, Karen G Hirsch, Peter J Kudenchuk, Michael C Kurz, Eric J Lavonas, Peter T Morley, Brian J O'Neil, Mary Ann Peberdy, Jon C Rittenberger, Amber J Rodriguez, Kelly N Sawyer, Katherine M Berg, Adult Basic and Advanced Life Support Writing Group
雑誌名: Circulation. 2020 Oct 20;142(16_suppl_2):S366-S468. doi: 10.1161/CIR.0000000000000916. Epub 2020 Oct 21.
Abstract/Text
PMID 33081529  Circulation. 2020 Oct 20;142(16_suppl_2):S366-S468. doi・・・
著者: R S Watson, P Cummings, L Quan, S Bratton, N S Weiss
雑誌名: J Trauma. 2001 Oct;51(4):658-62.
Abstract/Text BACKGROUND: Submersion victims are frequently considered at high risk for cervical spine (C-spine) injury regardless of whether they sustain a traumatic injury. We hypothesized that C-spine injury is unlikely in submersion victims who do not sustain high-impact injuries.
METHODS: The study was a cohort study of all people who submerged between January 1974 and July 1996 and received medical care or were seen by the medical examiner in King, Pierce, and Snohomish counties in Washington State.
RESULTS: Eleven (0.5%) of 2,244 submersion victims had C-spine injuries. All 11 had submerged in open bodies of water; had clinical signs of serious injury; and had a history of diving, motorized vehicle crash, or fall from height. No C-spine injuries occurred in 880 low-impact submersions.
CONCLUSION: Submersion victims are at risk for C-spine injury only if they have also sustained a traumatic injury. Routine C-spine immobilization does not appear to be warranted solely on the basis of a history of submersion.

PMID 11586155  J Trauma. 2001 Oct;51(4):658-62.
著者: Vivian Hwang, Frances S Shofer, Dennis R Durbin, Jill M Baren
雑誌名: Arch Pediatr Adolesc Med. 2003 Jan;157(1):50-3.
Abstract/Text OBJECTIVE: To determine the prevalence of traumatic injuries in children involved in drowning and near-drowning accidents.
DESIGN/METHODS: Ten-year retrospective medical chart review of patients at an urban tertiary care pediatric facility. Included patients had International Classification of Diseases, Ninth Revision, Clinical Modification codes for fatal/nonfatal drowning or E codes for fall into water, accidental drowning, and submersion. We recorded demographics, event characteristics, diagnostics, and outcome data. We used the chi(2) or the Fisher exact test to compare patients with and without injuries.
RESULTS: One hundred forty-three patients met inclusion criteria. Of these, 95 (66.4%) were male. Median age was 3.8 years, and 30 (23.4%) of 128 had preexisting conditions. Site of drowning was the pool (70.6%), the bathtub (19.0%), or natural water (10.4%). The prevalence of traumatic injury was 4.9% (95% confidence interval, 0%-28%). The predominant mechanism of injury was diving, and all injuries were to the cervical spine. Patients with injury were more likely to be older (mean age, 13.5 vs 5.1 years; P<.001) and to have a history of diving (85.7% vs 2.2%; P<.001). The presence of injury was not associated with sex, preexisting condition, or site of drowning (P>.05).
CONCLUSIONS: The prevalence of traumatic injury in drowning and near drowning is low. We identified only cervical spine injuries, and all but 1 patient had a clear history of diving. Use of specialized trauma evaluations may not be warranted for patients in drowning and near-drowning accidents without a clear history of traumatic mechanism.

PMID 12517194  Arch Pediatr Adolesc Med. 2003 Jan;157(1):50-3.
著者: K J Griest, R E Zumwalt
雑誌名: Pediatrics. 1989 Jan;83(1):41-6.
Abstract/Text Drowning as a form of subtle fatal child abuse is difficult to distinguish from accidental immersion or from sudden unexpected natural death when the circumstances of immersion are concealed. Homicidal drownings are unwitnessed, usually occurring in the home, and the victims are young, either infants or toddlers. Accidental drownings are more likely to involve toddlers or older children in public areas such as swimming pools, drainage ditches, lakes, and rivers. This is especially true in rural areas. In cities, bathtubs remain a major site of accidental childhood drownings. Perpetrators of deliberate drownings often fit the sociopathologic profile of a child abuser. Because there is often a survival interval between immersion and death, pathologic findings consistent with postimmersion syndrome suggest the cause of death. Foreign material in the lungs, if immersion was other than in clear tap water, and injuries of the face are other positive correlating factors. A thorough investigation of the circumstances and cooperation between the investigating agency and the pathologist are essential to determine the correct manner of death in these cases.

PMID 2909975  Pediatrics. 1989 Jan;83(1):41-6.
著者: D N Kyriacou, E L Arcinue, C Peek, J F Kraus
雑誌名: Pediatrics. 1994 Aug;94(2 Pt 1):137-42.
Abstract/Text STUDY OBJECTIVE: To determine the effect of immediate resuscitative efforts on the neurological outcome of children with submersion injury.
DESIGN: A case-control study was designed to determine if immediate resuscitation by rescuers or bystanders reduces the frequency of severe neurological damage or death in children with a documented submersion event. Logistic regression was used calculate an adjusted odds ratio.
PARTICIPANTS: The study group consisted of 166 children, aged zero to 14 years, having a submersion event during May 1984 through August 1992, and admitted through various emergency departments to Huntington Memorial Hospital in Pasadena, California.
MEASUREMENTS AND MAIN RESULTS: All study subjects had an observed and documented episode of apnea at the time of submersion. Outcomes were evaluated on the basis of neurological impairment or death. Exposure was verified from historical accounts of postsubmersion events provided by family, friends, and/or paramedical personnel. The study factors included age and gender, duration of submersion, hypothermia, presence of apnea, resuscitative efforts, and clinical outcome. Children with a good outcome were 4.75 (adjusted odds ratio (OR)) times more likely to have a history of immediate resuscitation than children with poor outcome (95% confidence interval: 3.44 < OR < 6.06, P = .0001). Various types of resuscitative efforts and potential confounding factors were also evaluated. CPR and mouth-to-mouth resuscitation were the most effective types for the prevention of death or severe anoxic encephalopathy.
CONCLUSION: Immediate resuscitation before the arrival of paramedical personnel is associated with a significantly better neurological outcome in children with submersion injury.

PMID 8036063  Pediatrics. 1994 Aug;94(2 Pt 1):137-42.
著者: Terry L Vanden Hoek, Laurie J Morrison, Michael Shuster, Michael Donnino, Elizabeth Sinz, Eric J Lavonas, Farida M Jeejeebhoy, Andrea Gabrielli
雑誌名: Circulation. 2010 Nov 2;122(18 Suppl 3):S829-61. doi: 10.1161/CIRCULATIONAHA.110.971069.
Abstract/Text
PMID 20956228  Circulation. 2010 Nov 2;122(18 Suppl 3):S829-61. doi: 1・・・
著者: David Szpilman, Márcio Soares
雑誌名: Resuscitation. 2004 Oct;63(1):25-31. doi: 10.1016/j.resuscitation.2004.03.017.
Abstract/Text OBJECTIVES: At present, there is no reliable information indicating the best option of rescuing a non-breathing drowning victim in the water. Our objectives were to compare the outcomes of performing immediate in-water resuscitation (IWR) or delaying resuscitation until the victim is brought to shore.
MATERIAL AND METHODS: A retrospective data analysis was conducted of non-breathing drowning victims rescued by lifeguards in the coastal area of Rio de Janeiro, Brazil. Patients were coded as IWR and no-IWR (NIWR) cases based on the lifeguard's decision whether to perform IWR. Death and development of severe neurological damage (SND) were considered poor outcome.
RESULTS: Forty-six patients were studied. Their median age was 17 (9-31) years. Nineteen (41.3%) patients received IWR and 27 (58.7%) did not. The mortality rate was lower for IWR cases (15.8% versus 85.2%, P < 0.001). However, among surviving IWR cases, 6 (31.6%) developed SND. In multivariate analysis, higher age [odds ratio (OR) = 1.12 (95% confidence interval (CI) = 1.01-1.24), P = 0.038] was associated with death, while IWR [ OR = 0.05 (95% CI = 0.01-0.50), P = 0.011] was protective. When death or the development of SND was set as the dependent variable, longer cardiopulmonary arrest (CPA) duration was the unique variable selected (OR = 1.77 (95% CI = 1.13-2.79), P = 0.013]. Every patient with CPA duration higher than 14 min had a poor outcome.
CONCLUSIONS: Delaying resuscitation efforts were associated with a worse outcome for non-breathing drowning victims. In the cases studied, IWR was associated with improvement of the likelihood of survival. An algorithm was developed for its indications and to avoid unnecessary risks to both victim and rescuer.

PMID 15451583  Resuscitation. 2004 Oct;63(1):25-31. doi: 10.1016/j.res・・・
著者: Bernd E Winkler, Anna Magdalena Eff, Sebastian Eff, Ulrich Ehrmann, Andreas Koch, Wataru Kähler, Claus-Martin Muth
雑誌名: Resuscitation. 2013 Aug;84(8):1137-42. doi: 10.1016/j.resuscitation.2013.02.006. Epub 2013 Feb 19.
Abstract/Text 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.
PMID 23435218  Resuscitation. 2013 Aug;84(8):1137-42. doi: 10.1016/j.r・・・
著者: Yannick P Lungwitz, Benedikt L Nussbaum, Klaus Paulat, Claus-Martin Muth, Peter Kranke, Bernd E Winkler
雑誌名: Aerosp Med Hum Perform. 2015 Apr;86(4):379-85. doi: 10.3357/AMHP.4133.2015.
Abstract/Text 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.

PMID 25945555  Aerosp Med Hum Perform. 2015 Apr;86(4):379-85. doi: 10.・・・
著者: P Suominen, C Baillie, R Korpela, S Rautanen, S Ranta, K T Olkkola
雑誌名: Resuscitation. 2002 Mar;52(3):247-54.
Abstract/Text BACKGROUND: Because children have less subcutaneous fat, and a higher surface area to body weight ratio than adults, it has been suggested that children cool more rapidly during submersion, and therefore have a better outcome following near-drowning incidents.
AIM OF THE STUDY: To study the impact of age, submersion time, water temperature and rectal temperature in the emergency room on outcome in near-drowning.
MATERIAL AND METHODS: This retrospective study included all near-drowning victims admitted to the intensive care units of Helsinki University Central Hospital after successful cardiopulmonary resuscitation between 1985 and 1997.
RESULTS: There were 61 near-drowning victims (age range: 0.5-60 years, median 29 years). Males were in the majority (40), and 26 were children (<16 years). The median water temperature was 17 degrees C (range: 0-33 degrees C). The median submersion time for the 43 survivors (70%) was 10 min (range: 1-38 min). Intact survivors and those with mild neurological disability (n=26, 43%) had a median submersion time of 5 min (range: 1-21 min). In non-survivors the median submersion time was 16 min (range: 2-75 min). Submersion time was the only independent predictor of survival in linear regression analysis (P<0.01). Patient age, water temperature and rectal temperature in the emergency room were not significant predictors of survival.
CONCLUSIONS: Although submersion time is usually an estimate, it is the best prognostic factor after a near drowning incident. Children did not have a better outcome than adults.

PMID 11886729  Resuscitation. 2002 Mar;52(3):247-54.
著者: D M Habib, F W Tecklenburg, S A Webb, N G Anas, R M Perkin
雑誌名: Pediatr Emerg Care. 1996 Aug;12(4):255-8.
Abstract/Text OBJECTIVES: (a) Evaluate the presenting hemodynamic status and neurologic function of a series of warm water submersion injuries. (b) To ascertain the importance of the timing of the neurologic examination. (c) To identify risk factors that predict which patients will not return to presubmersion status.
DESIGN: Retrospective review of all patients with a diagnosis of drowning/near-drowning responded to by the Children's Hospital pediatric transport service. Data were collected over a 24-month period regarding patient characteristics, submersion medium, rescue efforts, time out of sight, elapsed times to emergency department (ED) and pediatric intensive care unit (PICU) arrival, neurologic and hemodynamic status on arrival at the ED and PICU, reconstructed Conn-Modell category, and neurologic outcome.
SETTING: EDs of the referring hospitals and PICU of the Children's Hospital of Orange County (CHOC), California.
PATIENTS: Ninety-three submersion victims at an average age of 31 months. All patients were provided intensive care support.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: Twenty-three percent (21/ 93) of patients died or survived vegetative. No patient arriving comatose and asystolic in the ED survived neurologically intact (n = 21, three patients expired in the ED). This group of patients had a mean duration of documented asystole = 41 minutes, range of 18 to 107 minutes, and time to ED arrival = 21 minutes. All patients with a detectable pulse and blood pressure (n = 72) on arrival to the ED, regardless of their neurologic status, recovered to their presubmersion status. Patients arriving comatose (decorticate, decerebrate, or flaccid posture) in the PICU (n = 18, mean arrival = 192 minutes) all died or were vegetative. All patients with non-coma (n = 72, Conn-Modell category A or B) on arrival to the PICU recovered normally.
CONCLUSIONS: Hemodynamic status in the ED and neurologic status in the PICU are highly predictive of outcome. On arrival to the ED, the cardiovascular status is more predictive of abnormal outcome than neurologic status. Poor neurologic outcome appears inevitable for warm water submersion victims who are asystolic at ED arrival and remain comatose for more than 200 minutes.

PMID 8858647  Pediatr Emerg Care. 1996 Aug;12(4):255-8.
著者: S L Bratton, D S Jardine, J P Morray
雑誌名: Arch Pediatr Adolesc Med. 1994 Feb;148(2):167-70.
Abstract/Text OBJECTIVE: We evaluated serial neurologic examinations after warm water near drowning to determine how rapidly survivors with poor neurologic outcome could be identified.
RESEARCH DESIGN: Retrospective chart review.
SETTING: University-affiliated pediatric hospital.
PATIENTS: Forty-four children admitted to the pediatric intensive care unit with an abnormal mental status after near drowning during a 5-year period. Follow-up was a minimum of 6 months.
INTERVENTIONS: None.
MEASUREMENTS: A 14-point coma scale was used to evaluate both cortical and brain-stem function at the time of hospital admission and then daily afterward. The Mann-Whitney U Test was used to compare patients grouped as having satisfactory outcomes (those who returned to their presubmersion baseline or had very mild deficits) and unsatisfactory outcomes (total custodial care or death). Significance was defined as P < .05.
CONCLUSION: All satisfactory survivors were sufficiently awake to have spontaneous, purposeful movements 24 hours after near drowning and had normal brain-stem function. All children without spontaneous, purposeful movements and normal brain-stem function 24 hours after near drowning suffered severe neurologic deficits or death. In this retrospective investigation of 44 children, the cortical examination 24 hours after warm water near drowning distinguished satisfactory survivors from children who required total custodial care or died.

PMID 8118534  Arch Pediatr Adolesc Med. 1994 Feb;148(2):167-70.
著者: Michael J Tipton, Frank St C Golden
雑誌名: Resuscitation. 2011 Jul;82(7):819-24. doi: 10.1016/j.resuscitation.2011.02.021. Epub 2011 Apr 1.
Abstract/Text 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.
PMID 21458133  Resuscitation. 2011 Jul;82(7):819-24. doi: 10.1016/j.re・・・
著者: S J Jacinto, M Gieron-Korthals, J A Ferreira
雑誌名: Pediatr Clin North Am. 2001 Jun;48(3):647-60.
Abstract/Text Predicting the neurologic outcome of children after a hypoxic-ischemic event continues to be a challenge for intensivists and pediatric neurologists. Nevertheless, with accurate history taking, serial neurologic examination, and some ancillary studies, the clinician can predict accurately whether a child will die or have profound neurologic damage. Aggressive resuscitation should be offered to all children when found in CPA. A simple ingestion might have led to this clinical scenario, and complete neurologic recovery may be possible if effective resuscitation is implemented. In cases of drowning, several factors, if present, are consistent with profound neurologic sequelae or death. These include prolonged submersions with asystole, delayed onset of CPR, no spontaneous respirations on arrival to the emergency department, and low initial pH value. The options of withdrawal of life support or a DNR status should be offered to families of children who have survived a devastating hypoxic-ischemic event but who are in a PVS. If brain-death criteria have been fulfilled, the patient must then be disconnected from life support after organ donation has been discussed with the family.

PMID 11411298  Pediatr Clin North Am. 2001 Jun;48(3):647-60.
著者: J H Modell, S A Graves, E J Kuck
雑誌名: Can Anaesth Soc J. 1980 May;27(3):211-5.
Abstract/Text This paper reports a retrospective review of 121 cases of near-drowning treated at university hospitals in Miami and Gainesville. The series included 57 adults and 64 children who were classified into three categories, Category A (Awake), Category B (Blunted) and Category C (Comatose), based on their level of consciousness on arrival at the primary hospital. Results based on the total 121 patients showed 87 per cent survived with apparently normal brain function, two per cent survived with impaired brain function and 11 per cent died. The survival rate of all patients who were awake when they entered the hospital was significantly greater than that of both those who were admitted and blunted consciousness (p = 0.05) and those who were comatose when admitted (p less then 0.0001). Further, the group whose members had blunted consciousness had a significantly greater number of normal survivors than the group whose members were comatose on admission (p less than 0.002). All treated adults survived without permanent neurological damage and only three surviving children in the series suffered residual brain damage. Whether the course of the seven patients, three adults and four children, who died without return of brain function, would have been altered by deliberate attempts to preserve the brain is a matter of speculation.

PMID 7378863  Can Anaesth Soc J. 1980 May;27(3):211-5.
著者: J P Orlowski
雑誌名: JACEP. 1979 May;8(5):176-9.
Abstract/Text Ninety-three cases of drowning or near-drowning in the pediatric age group between 1972 and 1976 were reviewed. A scoring system for prognostic factors was developed using one point for each of five unfavorable factors involved in the drowning or near-drowning of each patient. The prognostic factors were 1) age less than three years; 2) maximum submersion time estimated longer than five minutes; 3) resuscitation not attempted for at least ten minutes after rescue; 4) patient in coma on admission to hospital, and 5) arterial blood pH of less than or equal to 7.10. This scoring system significantly predicted the eventual outcome of patients who had experienced the postsubmersion syndrome. Patients with scores of less than or equal to 2 had a 90% chance of full recovery; those with scores of greater than or equal to 3 had only a 5% probability of survival. The early institution of resuscitative efforts was the single most important factor influencing survival.

PMID 35635  JACEP. 1979 May;8(5):176-9.
著者: Anjan S Batra, Michael J Silka
雑誌名: J Pediatr. 2002 Aug;141(2):283-4. doi: 10.1067/mpd.2002.126924.
Abstract/Text We describe the abrupt sequence of events resulting in cardiac arrest while swimming in a 12-year-old with long QT syndrome. Diving into cold water resulted in an irregular cardiac rhythm and further prolongation of the QT interval, followed by a premature ventricular complex, which initiated pulseless ventricular tachycardia (rate >300/minute). The transition from sinus rhythm to ventricular tachycardia occurred in <5 seconds and was followed by a successful implantable cardioverter-defibrillator rescue shock.

PMID 12183730  J Pediatr. 2002 Aug;141(2):283-4. doi: 10.1067/mpd.2002・・・
著者: David J Tester, Laura J Kopplin, Wendy Creighton, Allen P Burke, Michael J Ackerman
雑誌名: Mayo Clin Proc. 2005 May;80(5):596-600. doi: 10.4065/80.5.596.
Abstract/Text OBJECTIVE: To perform a molecular autopsy involving the RyR2-encoded cardiac ryanodine receptor/calcium release channel to determine whether mutations responsible for catecholaminergic polymorphic ventricular tachycardia (CPVT) represent a novel pathogenic basis for unexplained drownings.
METHODS: A cardiac channel molecular autopsy was performed on 2 individuals who died of unexplained drowning and whose cases were referred to the Sudden Death Genomics Laboratory at the Mayo Clinic in Rochester, Minn. Comprehensive mutational analysis of all 60 protein-encoded exons of the 5 long QT syndrome-causing cardiac channel genes and a targeted analysis of 18 RyR2 exons known to host RyR2-mediated CPVT-causing mutations (CPVT1) was performed using polymerase chain reaction, denaturing high-performance liquid chromatography, and DNA sequencing.
RESULTS: Both individuals harbored novel mutations in RyR2. Postmortem mutational analysis revealed a familial missense mutation in exon 14, R414C, in a 16-year-old girl. A 9-year-old boy possessed a sporadic missense mutation in exon 49, V2475F. Both amino acid positions involve highly conserved residues that localize to critical functional domains in the calcium release channel. Neither substitution was present in 1000 reference alleles.
CONCLUSIONS: This molecular autopsy study provides proof of principle that RyR2 mutations can underlie some unexplained drownings. A population-based genetic epidemiology study that involves molecular autopsies of individuals who die of unexplained drowning is needed to determine the prevalence and spectrum of KCNQ1 and now RyR2 mutations as potential pathogenic mechanisms for drowning.

PMID 15887426  Mayo Clin Proc. 2005 May;80(5):596-600. doi: 10.4065/80・・・
著者: G S Smith, P M Keyl, J A Hadley, C L Bartley, R D Foss, W G Tolbert, J McKnight
雑誌名: JAMA. 2001 Dec 19;286(23):2974-80.
Abstract/Text CONTEXT: Alcohol is increasingly recognized as a factor in many boating fatalities, but the association between alcohol consumption and mortality among boaters has not been well quantified.
OBJECTIVES: To determine the association of alcohol use with passengers' and operators' estimated relative risk (RR) of dying while boating.
DESIGN, SETTING, AND PARTICIPANTS: Case-control study of recreational boating deaths among persons aged 18 years or older from 1990-1998 in Maryland and North Carolina (n = 221), compared with control interviews obtained from a multistage probability sample of boaters in each state from 1997-1999 (n = 3943).
MAIN OUTCOME MEASURE: Estimated RR of fatality associated with different levels of blood alcohol concentration (BAC) among boaters.
RESULTS: Compared with the referent of a BAC of 0, the estimated RR of death increased even with a BAC of 10 mg/dL (odds ratio [OR], 1.3; 95% confidence interval [CI], 1.2-1.4). The OR was 52.4 (95% CI, 25.9-106.1) at a BAC of 250 mg/dL. The estimated RR associated with alcohol use was similar for passengers and operators and did not vary by boat type or whether the boat was moving or stationary.
CONCLUSIONS: Drinking increases the RR of dying while boating, which becomes apparent at low levels of BAC and increases as BAC increases. Prevention efforts targeted only at those operating a boat are ignoring many boaters at high risk. Countermeasures that reduce drinking by all boat occupants are therefore more likely to effectively reduce boating fatalities.

PMID 11743838  JAMA. 2001 Dec 19;286(23):2974-80.
著者: P Cummings, L Quan
雑誌名: JAMA. 1999 Jun 16;281(23):2198-202.
Abstract/Text CONTEXT: During the last few decades, mortality from drowning has decreased in the United States for unknown reasons. It has been hypothesized that this decline may be due to decreased use of alcohol in and around water or improved medical treatment after a submersion.
OBJECTIVES: To estimate changes in unintentional mortality due to submersion, estimate trends in drownings attributable to alcohol use, and assess the role of medical care in these mortality trends.
DESIGN: A 21-year longitudinal study of case findings, from January 1, 1975, through December 31,1995.
SETTING AND PARTICIPANTS: All residents of King County, Washington, who died unintentionally from submersion and 284 persons hospitalized for submersion who survived.
MAIN OUTCOME MEASURES: Changes in submersion-related mortality incidence over time, proportion of this mortality that could be attributed to alcohol use, changes over time in the case-fatality rate of treated patients, and estimate of deaths prevented in 1995 compared with projected estimates had there been no change in incidence since 1975.
RESULTS: There were 539 deaths due to drowning in King County during 21 years. Mortality rates during this period declined by 59% (95% confidence interval [CI], -70% to -46%). The incidence of death attributable to alcohol use decreased by 81% (95% CI, -91% to -57%); this could account for 51% of deaths prevented in 1995. Among 249 comatose patients who received prehospital care, 205 died; the odds of survival decreased 40% over 21 years (P = .40). Among 101 comatose patients who were hospitalized, 63 died; the odds of survival decreased 29% (P = .75). The incidence of survival of comatose hospital patients decreased by 29% from 1975 to 1995 (95% CI, -78% to +125%). We found no evidence that trends in medical treatment prevented any deaths due to drowning in 1995.
CONCLUSIONS: Drowning incidence in King County, Washington, declined because of a decrease in severe submersion episodes rather than an increase in success of medical interventions. Our data support the theory that less use of alcohol around water prevents some deaths. About half of the decrease was unexplained.

PMID 10376572  JAMA. 1999 Jun 16;281(23):2198-202.
著者: G S Bell, A Gaitatzis, C L Bell, A L Johnson, J W Sander
雑誌名: Neurology. 2008 Aug 19;71(8):578-82. doi: 10.1212/01.wnl.0000323813.36193.4d.
Abstract/Text BACKGROUND: People with epilepsy are known to be at increased risk of death by drowning but there are few data available regarding the size of the risk. We aimed to quantify the risk using meta-analysis.
METHODS: A literature search identified 51 cohorts of people with epilepsy in whom the number of deaths by drowning in people with epilepsy and the number of person-years at risk could be estimated. Population data were taken from the WHO Statistical Information Service or from the UK Office for National Statistics where available. Standardized mortality ratios (SMRs) with 95% CIs were calculated for each cohort, for groups of cohorts, and for the total population. Additionally, an SMR for drowning in people with epilepsy in England and Wales (1999-2000) was calculated using National Registries.
RESULTS: Eighty-eight drowning deaths were observed compared with 4.70 expected, giving an SMR of 18.7 (95% CI 15.0 to 23.1). Compared with community-based incident studies (SMR 5.4), the SMR was significantly raised in prevalent epilepsy (SMR 18.0), in people with epilepsy and learning disability (SMR 25.7), in those in institutional care (SMR 96.9), and in those who had a temporal lobe excision (SMR 41.1). The SMR for people with epilepsy in England and Wales was 15.3.
CONCLUSION: The risk of drowning in people with epilepsy is raised 15- to 19-fold compared with people in the general population. It is important that people with epilepsy and their carers be informed of these risks so that deaths can be prevented.

PMID 18711111  Neurology. 2008 Aug 19;71(8):578-82. doi: 10.1212/01.wn・・・
著者: Mariana Penteado Nucci-da-Silva, Edson Amaro
雑誌名: Brain Inj. 2009 Aug;23(9):707-14. doi: 10.1080/02699050903123351.
Abstract/Text PRIMARY OBJECTIVE: To report Magnetic Resonance Imaging (MRI) and/or Magnetic Resonance Spectroscopy (MRS) findings in subjects with hypoxic encephalopathy caused by drowning in recent literature and to compare them with non-specific hypoxic encephalopathy.
METHOD: Systematic review of the Medline Database for bibliographic citations from 1996 to 2008.
RESULTS: The studies included in this review described a total of 68 victims of drowning. From those, 58 performed MRS with a decrease of N-Acetyl-Aspartate/Creatine ratio in 75.86% (n = 44), and presence of lactate in 65.52% (n = 38) of the cases. MRI data was available in 46 cases. The main finding was brain edema in 78.26% (n = 36) and abnormalities of MRI signal in basal ganglia in 75% (n = 27) of the cases. Worse clinical outcomes were reported in conjunction with degree of MRI and MRS alterations. The findings were more consistent in the latter. Comparing these results with literature from non-specific hypoxic brain injury, the drowning process is apparently more variable.
CONCLUSIONS: We found a trend to a more variable pattern of brain injury as seen by MRI/MRS in victims of drowning, which may reflect the nature of the aggression. Possibly there are different mechanisms involved in aquatic submersion, such as temperature, not present in pure hypoxic injury.

PMID 19636995  Brain Inj. 2009 Aug;23(9):707-14. doi: 10.1080/02699050・・・
著者: J Howland, R Hingson
雑誌名: Accid Anal Prev. 1988 Feb;20(1):19-25.
Abstract/Text We identified 36 English language studies (1950-1985) on alcohol and drownings. The majority of these were descriptive, reporting on the percent of drowning victims positive for alcohol upon autopsy. Most studies fell into one of three categories: Type A--complete ascertainment, duration of submergence specified; Type B--complete ascertainment, duration of submergence unspecified; Type C--partial ascertainment. Among Type A studies, percent of positives for alcohol ranged from 29% to 47%. Among Type B studies, percents ranged from 15% to 69%. Among Type C studies, percents ranged from 18% to 86%. We conclude that (1) between 25% and 50% of adult drowning victims have been exposed to alcohol and that (2) without data on the frequency of alcohol consumption among non-victims engaged in aquatic activities, the causal role of alcohol in drownings is uncertain. Suggestions for further research are offered.

PMID 3276341  Accid Anal Prev. 1988 Feb;20(1):19-25.
著者: J H Modell
雑誌名: JAMA. 1985 Jan 25;253(4):557.
Abstract/Text
PMID 3968790  JAMA. 1985 Jan 25;253(4):557.
著者: J H Modell, F Moya
雑誌名: Anesthesiology. 1966 Sep-Oct;27(5):662-72.
Abstract/Text
PMID 5919007  Anesthesiology. 1966 Sep-Oct;27(5):662-72.
著者: Y Yagil, R Stalnikowicz, J Michaeli, P Mogle
雑誌名: Arch Intern Med. 1985 Jan;145(1):50-3.
Abstract/Text Unusual serum electrolyte abnormalities developed in eight patients who nearly drowned (ND) in the Dead Sea. Elevations in serum calcium and magnesium levels in particular required specific therapeutic intervention. The Dead Sea has a uniquely high concentration of calcium, magnesium, sodium, potassium, and chloride. The unusual serum electrolyte elevation that was observed in the ND victims in the Dead Sea apparently reflected the large solute load to which they were exposed. Four patients died subsequent to ND. Near drowning in the Dead Sea therefore represents a clinical entity that is associated with a high fatality rate and in which unrecognized major electrolyte abnormalities, in addition to the known respiratory complications, may influence the outcome.

PMID 3970646  Arch Intern Med. 1985 Jan;145(1):50-3.
著者: J H Modell, S A Graves, A Ketover
雑誌名: Chest. 1976 Aug;70(2):231-8.
Abstract/Text Hospital records of 91 consecutive near-drowning victims were studied retrospectively. Eight-one (89 percent) of these patients survived. Patients who were alert on arrival at the emergency room survived, but those who were comatose and had fixed dilated pupils died. Other states of consciousness were unreliable predictors of survival. All patients with a normal chest roentgenogram on admission survived; however, values for arterial oxygen tension (PaO2) did not necessarily correlate with the chest roentgenograms. Values for arterial blood gas tensions and pH varied widely, as follows; PaO2, 25 to 465 mm Hg; arterial carbon dioxide tension (PaCO2), 17 to 100 mm Hg; pH, 6.77 to 7.50; and arterial bicarbonate level, 6.6 to 29.7 mEq/L. The ratio of PaO2 to the fractional concentration of oxygen in the inspired gas (FIo2), which was calculated to standardize PaO2 data for varying concentrations of inspired oxygen, ranged from 30 to 585 mm Hg. Only one patient with a ratio of PaO2/FIo2 greater than 150 mm Hg on admission subsequently died; this was a neurologic rather than a pulmonary death. Serum electrolytic concentrations and values for hemoglobin level and hematocrit reading neither predicted survival nor indicated that a threat to life existed. Steroid and prophylactic antibiotic therapy did not appear to increase the chance of survival. Observations on these patients are discussed in light of previous experiments in animals, and an approach to therapy is suggested.

PMID 780069  Chest. 1976 Aug;70(2):231-8.
著者: M G Harries
雑誌名: Crit Care Med. 1981 May;9(5):407-8.
Abstract/Text
PMID 7214975  Crit Care Med. 1981 May;9(5):407-8.
著者: Manfred Oehmichen, Renate Hennig, Christoph Meissner
雑誌名: Leg Med (Tokyo). 2008 Jan;10(1):1-5. doi: 10.1016/j.legalmed.2007.05.007. Epub 2007 Jul 6.
Abstract/Text Opposite to clinical laboratory findings in experimental drowning of animals (erythrocytic lysis, hyperkalemia, and final cardial fibrillation) are the observations in drowned humans (increase of pCO2, hypoxic encephalopathy), which leads to a different pathophysiological interpretation of the drowning process. This process, however, is recently discussed again, therefore an additional study seemed to be recommended. In a retrospective study, 31 cases of near-drowning (23 cases: fresh water; 8 cases: brackish water) clinical laboratory data were analysed. While 21 of the cases were fatal with a delay of up to 180 days, 10 individuals survived the accident, four cases with severe neurological deficits. Data of pH, potassium, sodium, chloride, hemoglobin and total protein were collected during the very early post-drowning period. Nearly all cases (96%) revealed a reduction of pH due to hypoxic acidosis, and only two cases (6.5%) exhibited a slight hyperkalemia. The hemoglobin level was normal in most of the cases (83%) and slightly reduced in the others (17%) while the protein level was slightly reduced in most of the fatalities (80%). As a result of our investigation we have to state the lack of hyperkalemia as well as of an increase of the hemoglobin level indicate that there is no distinct intravascular red cell lysis due to influx of water into the vascular compartment. Therefore the death by drowning in humans in most cases is the result of a hypoxic cerebral process. A comparison with animal experiments obviously is not helpful because the drowning process in humans leads to an aspiration of only 2-4 ml water/kg, while in animal experiments more than 10 ml water/kg will be artificially aspirated leading to red cell lysis as well as to electrolyte disturbances and cardial fibrillation.

PMID 17618158  Leg Med (Tokyo). 2008 Jan;10(1):1-5. doi: 10.1016/j.leg・・・
著者: D Szpilman
雑誌名: Chest. 1997 Sep;112(3):660-5.
Abstract/Text STUDY OBJECTIVE: To establish an updated classification for near-drowning and drowning (ND/D) according to severity, based on mortality rate of the subgroups.
MATERIALS AND METHODS: We reviewed 41,279 cases of predominantly sea water rescues from the coastal area of Rio de Janeiro City, Brazil, from 1972 to 1991. Of this total, 2,304 cases (5.5%) were referred to the Near-Drowning Recuperation Center, and this group was used as the study database. At the accident site, the following clinical parameters were recorded: presence of breathing, arterial pulse, pulmonary auscultation, and arterial BP. Cases lacking records of clinical parameters were not studied. The ND/D were classified in six subgroups: grade 1--normal pulmonary auscultation with coughing; grade 2--abnormal pulmonary auscultation with rales in some pulmonary fields; grade 3--pulmonary auscultation of acute pulmonary edema without arterial hypotension; grade 4--pulmonary auscultation of acute pulmonary edema with arterial hypotension; grade 5--isolated respiratory arrest; and grade 6--cardiopulmonary arrest.
RESULTS: From 2,304 cases in the database, 1,831 cases presented all clinical parameters recorded and were selected for classification. From these 1,831 cases, 1,189 (65%) were classified as grade 1 (mortality=0%); 338 (18.4%) as grade 2 (mortality=0.6%); 58 (3.2%) as grade 3 (mortality=5.2%); 36 (2%) as grade 4 (mortality=19.4%); 25 (1.4%) as grade 5 (mortality=44%); and 185 (10%) as grade 6 (mortality=93%) (p<0.000001).
CONCLUSION: The study revealed that it is possible to establish six subgroups based on mortality rate by applying clinical criteria obtained from first-aid observations. These subgroups constitute the basis of a new classification.

PMID 9315798  Chest. 1997 Sep;112(3):660-5.
著者: Linda Quan, Christopher D Mack, Melissa A Schiff
雑誌名: Resuscitation. 2014 Jun;85(6):790-4. doi: 10.1016/j.resuscitation.2014.02.024. Epub 2014 Mar 4.
Abstract/Text AIM: Evaluate the roles of water temperature and submersion duration in the outcome of drowning victims.
METHODS: Subjects were those who drowned in open water (lakes, rivers, and ocean) in three counties in Washington State between 1975 and 1996. We performed a case control study to assess the association between age, reported submersion duration, and estimated water temperature and drowning outcomes. Cases were victims with good outcomes (survival with normal or mild/moderate neurologic sequelae). Controls were victims with bad outcomes (death or severe neurologic sequelae or persistent vegetative state). We used Poisson regression to estimate odds ratios (OR) and 95% confidence intervals (CI).
RESULTS: Of the total 1094 open water drowning victims, most were male (85%),white (84%), and with a mean age of 27 years. Most drownings occurred in lakes (51%) and in cold (≥6-16 °C (44%)) or very cold waters (<6 °C (34%)). Most (78%) had bad outcomes (74% died; 4% survived with severe neurologic sequelae. Of those with good outcomes, 88.2% were submerged <6 min, 7.4% 6-10 min and 4.3% for 11-60 min. Victims with good outcomes were 61% (95% CI 0.23-0.65) less likely to be submerged for 6 to 10 min and 98% (95% CI 0.01-0.04) less likely to be submerged for 11 or more minutes. Water temperature was not associated with outcome.
CONCLUSIONS: A protective effect of cold water for drowning victims was not found; estimated submersion duration was the most powerful predictor of outcome. Recommendations for initiation of rescue and resuscitation efforts should be revised to reflect the very low likelihood of good outcome following submersion greater than 10 min.

Copyright © 2014 Elsevier Ireland Ltd. All rights reserved.
PMID 24607870  Resuscitation. 2014 Jun;85(6):790-4. doi: 10.1016/j.res・・・
著者: David Szpilman, Joost J L M Bierens, Anthony J Handley, James P Orlowski
雑誌名: N Engl J Med. 2012 May 31;366(22):2102-10. doi: 10.1056/NEJMra1013317.
Abstract/Text
PMID 22646632  N Engl J Med. 2012 May 31;366(22):2102-10. doi: 10.1056・・・
著者: J K Kieboom, H J Verkade, J G Burgerhof, J J Bierens, P F van Rheenen, M C Kneyber, M J Albers
雑誌名: BMJ. 2015 Feb 10;350:h418. Epub 2015 Feb 10.
Abstract/Text OBJECTIVES: To evaluate the outcome of drowned children with cardiac arrest and hypothermia, and to determine distinct criteria for termination of cardiopulmonary resuscitation in drowned children with hypothermia and absence of spontaneous circulation.
DESIGN: Nationwide retrospective cohort study.
SETTING: Emergency departments and paediatric intensive care units of the eight university medical centres in the Netherlands.
PARTICIPANTS: Children aged up to 16 with cardiac arrest and hypothermia after drowning, who presented at emergency departments and/or were admitted to intensive care.
MAIN OUTCOME MEASURE: Survival and neurological outcome one year after the drowning incident. Poor outcome was defined as death or survival in a vegetative state or with severe neurological disability (paediatric cerebral performance category (PCPC) ≥ 4).
RESULTS: From 1993 to 2012, 160 children presented with cardiac arrest and hypothermia after drowning. In 98 (61%) of these children resuscitation was performed for more than 30 minutes (98/160, median duration 60 minutes), of whom 87 (89%) died (95% confidence interval 83% to 95%; 87/98). Eleven of the 98 children survived (11%, 5% to 17%), but all had a PCPC score ≥ 4. In the 62 (39%) children who did not require prolonged resuscitation, 17 (27%, 16% to 38%) survived with a PCPC score ≤ 3 after one year: 10 (6%) had a good neurological outcome (score 1), five (3%) had mild neurological disability (score 2), and two (1%) had moderate neurological disability (score 3). From the original 160 children, only 44 were alive at one year with any outcome.
CONCLUSIONS: Drowned children in whom return of spontaneous circulation is not achieved within 30 minutes of advanced life support have an extremely poor outcome. Good neurological outcome is more likely when spontaneous circulation returns within 30 minutes of advanced life support, especially when the drowning incident occurs in winter. These findings question the therapeutic value of resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia.

© Kieboom et al 2015.
PMID 25670715  BMJ. 2015 Feb 10;350:h418. Epub 2015 Feb 10.
著者: B A Foex, R Boyd
雑誌名: Emerg Med J. 2001 Nov;18(6):465-6.
Abstract/Text
PMID 11696502  Emerg Med J. 2001 Nov;18(6):465-6.
著者: P T Ender, M J Dolan
雑誌名: Clin Infect Dis. 1997 Oct;25(4):896-907.
Abstract/Text Drowning and near-drowning can abruptly devastate the lives of both the affected victims and their families. In addition to the complications directly caused by the submersion, several indirect causes of morbidity exist. Infection is one of the complications associated with near-drowning, and pneumonia is the most severe of these infectious complications. The risk factors, microbiological causes, diagnostic approach, and appropriate therapy for pneumonia associated with near-drowning are not well described in the literature. Herein, we review the epidemiology and pathophysiology associated with near-drowning, discuss the potential mechanisms of infection, and describe the likely risk factors for pneumonia related to near-drowning. We also detail the microbiological causes of this entity and provide important clinical and epidemiological information associated with specific pathogens. Finally, we summarize an appropriate diagnostic and therapeutic approach to pneumonia associated with near-drowning.

PMID 9356805  Clin Infect Dis. 1997 Oct;25(4):896-907.
著者: D D Oakes, J P Sherck, J R Maloney, A C Charters
雑誌名: J Trauma. 1982 Jul;22(7):544-9.
Abstract/Text Between 1972 and 1981 40 victims of near-drowning were admitted to the Santa Clara Valley Medical Center. Hospital records were reviewed with regard to: 1) the circumstances of submersion and rescue; 2) the patient's condition upon arrival at the emergency room; 3) treatment, hospital course, and ultimate outcome. There were ten hospital deaths, 23 patients recovered completely, and seven were discharged with incapacitating neurologic disability. Three of the neurologically impaired patients died between 1 and 13 months after discharge. All patients who arrived with a beating heart were eventually discharged neurologically intact. Of the 21 patients who required in-hospital cardiopulmonary resuscitation, ten died, seven remained comatose, and four recovered without serious neurologic deficits. The use of hypothermia, steroids, and barbiturate coma was not randomized, but did not appear to influence ultimate outcome. Intracranial pressure was monitored in five patients and was never elevated during the first 24 hours. The complete recovery of nearly 20% of apparently lifeless individuals justifies aggressive resuscitation and support of all victims of near-drowning.

PMID 7097814  J Trauma. 1982 Jul;22(7):544-9.
著者: M van Berkel, J J Bierens, R L Lie, T P de Rooy, L J Kool, E A van de Velde, A E Meinders
雑誌名: Intensive Care Med. 1996 Feb;22(2):101-7.
Abstract/Text OBJECTIVE: The identification of risk factors contributing to the development of pulmonary oedema, pneumonia and late mortality in submersion victims.
DESIGN: A retrospective study of 125 submersion victims.
SETTING: The medical intensive care unit in a university hospital.
METHODS: Baseline examination on admission consisted of history, physical examination, arterial blood gas analysis and a chest radiograph. Patients were then classified into four groups: class I, baseline examination negative; class II, baseline examination positive, but mechanical ventilation not needed on admission; class III, mechanical ventilation required on admission; class IV, patients suffering from cardiopulmonary arrest. All patients who were not successfully resuscitated or who had expired within 24 h after admission were excluded for determination of the risk of pulmonary oedema and pneumonia.
RESULTS: Class I patients did not develop pulmonary complications; neither pulmonary oedema nor pneumonia occurred in this group. In the remaining classes the incidence of pulmonary oedema was 72% and that of pneumonia, 14.7%. Stepwise logistic regression showed that pulmonary oedema was related to the type of water (seawater, ditch water, swimming pool) victims were submerged in and to the neurological state both at the time of rescue and on admission. The development of pneumonia was related to the use of mechanical ventilation (the risk was 52%). Pneumonia was not related to neurological state at the time of rescue or on admission, to body temperature on admission, to the prophylactic administration of antibiotics or to the use of corticosteroids. Mortality was high in class IV patients, but low in all other patients. Early mortality was 18.4% while late mortality was 5.6%.
CONCLUSIONS: There is no need to hospitalise submersion victims when there are no signs or symptoms of aspiration upon arrival in the emergency room. All other patients should be admitted to an intensive care unit. The risk of pneumonia is high when mechanical ventilation is necessary. Mortality is high in patients with circulatory arrest on admission, but low in all other patients.

PMID 8857116  Intensive Care Med. 1996 Feb;22(2):101-7.
著者: D O Corbin, H S Fraser
雑誌名: West Indian Med J. 1981 Mar;30(1):22-9.
Abstract/Text
PMID 7269548  West Indian Med J. 1981 Mar;30(1):22-9.
著者: Chris Wood
雑誌名: Emerg Med J. 2010 May;27(5):393-4. doi: 10.1136/emj.2010.094888.
Abstract/Text
PMID 20442174  Emerg Med J. 2010 May;27(5):393-4. doi: 10.1136/emj.201・・・
著者: J M Tadié, N Heming, E Serve, N Weiss, N Day, A Imbert, G Ducharne, C Faisy, J L Diehl, D Safran, J Y Fagon, E Guérot
雑誌名: Resuscitation. 2012 Mar;83(3):399-401. doi: 10.1016/j.resuscitation.2011.08.023. Epub 2011 Sep 10.
Abstract/Text PURPOSE: Pneumonia is the most common infectious complication of drowning. Pneumonia is potentially life threatening and should be treated by effective antibiotic therapy. However the risk factors, microbiological causes, diagnostic approach and appropriate therapy for pneumonia associated with drowning are not well described. The microbiological ecology of the body of water where immersion occurred could be of import. The aim of this study was to report on microorganisms involved in pneumonia associated with drowning and out of hospital cardiac arrest after successful cardiopulmonary resuscitation. Additionally, we retrieved and undertook microbiological analysis on samples of water from our local river.
METHODS: This retrospective study included all patients having suffered an out of hospital cardiac arrest due to drowning and admitted to our tertiary care academic hospital between 2002 and 2010. Data concerning bacteriological lung samples (tracheal aspirate or bronchoalveolar lavage) at admission were reported and compared to bacteriological samples obtained from our local river (the river Seine).
RESULTS: A total of thirty-seven patients were included in the study. Lung samples were obtained for twenty-one of these patients. Lung samples were positive in nineteen cases, with a high frequency of multi-drug resistant bacteria. Samples from the Seine River found microorganisms similar to those found in drowning associated pneumonia.
CONCLUSIONS: Drowning associated pneumonia can be due to multi drug resistant bacteria. When treating drowning associated pneumonia, antibiotics should be effective against bacteria similar to those found in the body of water where immersion occurred.

Copyright © 2011 Elsevier Ireland Ltd. All rights reserved.
PMID 21907690  Resuscitation. 2012 Mar;83(3):399-401. doi: 10.1016/j.r・・・
著者: D J Dubowitz, S Bluml, E Arcinue, R B Dietrich
雑誌名: AJNR Am J Neuroradiol. 1998 Oct;19(9):1617-27.
Abstract/Text BACKGROUND AND PURPOSE: Quantitative MR spectroscopy has a proved role in the investigation of hypoxia caused by near drowning. To date, no studies have addressed the MR imaging changes that may also accompany this condition. The purpose of this study was to describe the MR imaging findings in children with hypoxic encephalopathy caused by near drowning and to compare these findings with the results of qualitative and quantitative proton MR spectroscopy and clinical outcome.
METHODS: Twenty-two children (6 months to 11 years old) admitted to the pediatric intensive care unit after near drowning incidents underwent cerebral MR imaging and quantitative proton MR spectroscopy. Clinical and imaging studies were reviewed retrospectively, and subjects were grouped according to outcome: good result, persistent vegetative state, and death. Images were scored for edema, basal ganglia changes, and cortical changes, and were compared with MR spectra and outcome at days 1 to 2, 3 to 4, and 5 or more.
RESULTS: Six patients had a good outcome, four remained in a persistent vegetative state, and 12 died. Generalized/occipital edema correlated with poor outcome. Indistinct lentiform nuclei margins on T1-weighted images were a frequent finding (78%). Basal ganglia T2 hyperintensity correlated with poor outcome, progressing from a patchy/peripheral distribution to diffuse high intensity. Patchy high T2 signal in the cortex or subcortical lines were specific but insensitive for poor outcome, as were brain stem infarcts.
CONCLUSION: MR images in children with hypoxic encephalopathy after near drowning show a spectrum of changes. The most sensitive prognostic result may be achieved by combining MR imaging with qualitative and quantitative MR spectroscopic data.

PMID 9802481  AJNR Am J Neuroradiol. 1998 Oct;19(9):1617-27.
著者: Karim T Rafaat, Robert M Spear, Cynthia Kuelbs, Kourosh Parsapour, Bradley Peterson
雑誌名: Pediatr Crit Care Med. 2008 Nov;9(6):567-72. doi: 10.1097/PCC.0b013e31818c8955.
Abstract/Text OBJECTIVES: The primary aim of this study is to better define both the type and incidence of cranial computed tomography (CT) abnormalities in children following submersion injury.
DESIGN: This is a retrospective chart review; patients were selected from a drowning registry that extends from January 1989 to April 2006.
SETTING: Children's Hospital, San Diego.
PATIENTS: Patients were included if they were admitted to the hospital with a diagnosis of drowning and had a cranial CT within 24 hrs of submersion. Of 961 patients in the registry, 156 were included.
INTERVENTIONS: None.
MEASUREMENTS AND MAIN RESULTS: Eighteen percent (28 of 156) of children had an abnormal initial head CT, 82% (128 of 156) had a normal CT. Fifteen percent (24 of 156) of patients initially had a normal head CT and later had an abnormal CT. Abnormal CT findings were remarkable for diffuse loss of gray-white differentiation (75% on presentation) and bilateral basal ganglia edema/infarct (50% on presentation). There was no evidence of intra- or extra-axial blood nor were there any unilateral findings in any of the abnormal CTs. Presenting Glasgow Coma Scale was significantly lower in those who presented with an abnormal versus a normal head CT (p < 0.001). All patients with an abnormal initial CT presented with a Glasgow Coma Scale of 3, and all eventually died. Outcome was also very poor in those with a normal first CT and an abnormal second CT; 54% died and 42% remained in a persistent vegetative state.
CONCLUSIONS: These data from the largest study of CT findings in pediatric drowning clearly illustrate that following submersion injury, intra- or extra-axial bleeding is not seen on cranial CT. Furthermore, an abnormal CT scan at any time was associated with a poor outcome (death or persistent vegetative state). The CT findings and the presenting Glasgow Coma Scale of patients with drowning differ from those of patients who have suffered abusive head trauma.

PMID 18838936  Pediatr Crit Care Med. 2008 Nov;9(6):567-72. doi: 10.10・・・
著者: C Romano, T Brown, T C Frewen
雑誌名: Pediatr Radiol. 1993;23(4):261-3.
Abstract/Text Previous studies have suggested that CT examinations of the brain in children soon after near-drowning incidents are not helpful in predicting clinical outcome and are not necessary. The clinical and CT findings of 19 pediatric near-drowning victims were reviewed for correlation with clinical and neurologic outcome. As expected, a normal initial CT scan was poorly predictive of outcome, whereas an abnormal CT scan in the initial 36 h following an immersion incident was associated with a dismal prognosis. Three children with abnormal initial CT examinations were identified and all died within 3 days of admission. A CT scan performed in the immediate near-drowning period, therefore, may be helpful in identifying some patients who have sustained severe neurologic injury.

PMID 8414750  Pediatr Radiol. 1993;23(4):261-3.
著者: Ruben Peralta, Daniel P Ryan, Alexander Iribrane, Michael G Fitzsimons
雑誌名: J Extra Corpor Technol. 2005 Mar;37(1):71-4.
Abstract/Text Near drowning is a common event among otherwise healthy young people. The development of ARDS in the setting may significantly increase mortality. The traditional means of ventilation may lead to barotrauma. Extracorporeal membrane oxygenation (ECMO) is an effective means to improve oxygenation and remove carbon dioxide, while allowing the lungs to recover from the acute insult. It may be especially successful in those victims with single organ injury. We report the use of ECMO in a young adult with ARDS and pneumonia after near drowning.

PMID 15804162  J Extra Corpor Technol. 2005 Mar;37(1):71-4.
著者: Christoph Eich, Anselm Bräuer, Dietrich Kettler
雑誌名: Resuscitation. 2005 Oct;67(1):145-8. doi: 10.1016/j.resuscitation.2005.05.002.
Abstract/Text Drowning is a leading cause of death in children worldwide. However, there is uncertainty about the initiation and the extent of adequate therapeutic interventions after drowning accidents. As prediction of outcome in drowned children remains difficult, initial maximum life support appears to be generally justified. We present the case of a 3-year-old drowned girl in refractory cardiorespiratory arrest who was resuscitated successfully with cardiopulmonary bypass (CPB) followed by extracorporeal membrane oxygenation (ECMO) for 4 days. After a prolonged period in a vegetative state eventually she made an almost complete neurological recovery. We do not have knowledge of any case of drowning reported with a favourable neurological outcome after such a prolonged period of ECMO.

PMID 16129537  Resuscitation. 2005 Oct;67(1):145-8. doi: 10.1016/j.res・・・
著者: M Thalmann, E Trampitsch, N Haberfellner, E Eisendle, R Kraschl, G Kobinia
雑誌名: Ann Thorac Surg. 2001 Aug;72(2):607-8.
Abstract/Text We report a case of near drowning of a 3-year-old girl, who was admitted to our emergency room with a core temperature of 18.4 degrees C. After rewarming on cardiopulmonary bypass and restitution of her circulation, respiratory failure resistant to conventional respiratory therapy prohibited weaning from cardiopulmonary bypass. Therefore, we instituted extracorporeal membrane oxygenation (ECMO). Fifteen hours later, she could be weaned from ECMO but required assisted ventilation for another 12 days. Twenty months later there are no neurologic deficits.

PMID 11515909  Ann Thorac Surg. 2001 Aug;72(2):607-8.
著者: P K Suominen, N H Vallila, L M Hartikainen, H I Sairanen, R E Korpela
雑誌名: Acta Anaesthesiol Scand. 2010 Nov;54(10):1276-81. doi: 10.1111/j.1399-6576.2010.02307.x. Epub 2010 Sep 14.
Abstract/Text BACKGROUND: There is a lack of data on the outcome of cardiopulmonary bypass (CPB) rewarming of hypothermic children with cardiac arrest following drowning.
AIM OF THE STUDY: To retrospectively analyze single-center outcome of drowning victims treated with CPB.
MATERIALS AND METHODS: This retrospective study included all hypothermic drowning victims admitted to the Hospital for Children and Adolescents with attempted resuscitation on CPB between 1994 and 2008 inclusive. Median sternotomy and cannulation of the ascending aorta and the right atrium for CPB were performed on all victims.
RESULTS: Nine hypothermic drowning victims, comprising five boys and four girls, with a median age of 3.8 years (range, 1.5-10 years). The median submersion time was 38 min (range, 5-75 min) and the median water temperature was 6.5 °C (range, 0.2-16.5 °C). The median core temperature was 21.9 °C (range 17.7-32.8 °C) at arrival to the hospital. All nine children were able to be weaned from CPB. Only one child, with mild to moderate neurological deficit, became a long-term survivor. She was slowly rewarmed up to 33 °C with CPB and kept in mild hypothermia for 48 h.
CONCLUSIONS: Large numbers of submerged children can be primarily resuscitated with CPB. Unfortunately, many of them will decease from severe hypoxic brain injury. Slow rewarming with CPB may improve the likelihood of a better neurological outcome.

© 2010 The Authors. Journal compilation © 2010 The Acta Anaesthesiologica Scandinavica Foundation.
PMID 20840512  Acta Anaesthesiol Scand. 2010 Nov;54(10):1276-81. doi: ・・・
著者: Kasim Oguz Coskun, Aron Frederik Popov, Jan Dieter Schmitto, José Hinz, Thomas Kriebel, Friedrich Albert Schoendube, Wolfgang Ruschewski, Theodor Tirilomis
雑誌名: Artif Organs. 2010 Nov;34(11):1026-30. doi: 10.1111/j.1525-1594.2010.01156.x.
Abstract/Text 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.

PMID 21134219  Artif Organs. 2010 Nov;34(11):1026-30. doi: 10.1111/j.1・・・
著者: Kun Il Kim, Won Yong Lee, Hyoung Soo Kim, Jae Han Jeong, Ho Hyun Ko
雑誌名: Scand J Trauma Resusc Emerg Med. 2014 Dec 12;22:77. doi: 10.1186/s13049-014-0077-8. Epub 2014 Dec 12.
Abstract/Text BACKGROUND: The aim of this study was to determine the early outcomes of using extracorporeal membrane oxygenation (ECMO) in near-drowning patients with cardiac or pulmonary failure.
METHODS: This study was based on data from 9 patients including 2 children (mean age 33; 8 males, 1 female) who received ECMO after near-drowning between 2008 and 2013. Veno-arterial or veno-arteriovenous ECMO was used in 2 patients with sustained cardiac arrest and veno-venous ECMO was used in 7 patients with severe acute respiratory distress syndrome (ARDS). The means of the partial arterial oxygen pressure (PaO2), Murray score, sequential organ failure assessment (SOFA) score, and simplified acute physiology score II (SAPS-II) prior to ECMO were 59.7 ± 9.9 mmHg on 100% oxygen, 3.5 ± 0.6, 11.4 ± 1.9, and 73.0 ± 9.2, respectively.
RESULTS: The PaO2 mean improved to 182 ± 152 mmHg within 2 h post-ECMO. The mean of SOFA score and SAPS-II decreased significantly to 8.6 ± 3.2 (p = 0.013) and 46.4 ± 5.1 (p = 0.008), respectively, at 24 h post-ECMO with mean flow rate of 3.9 ± 0.8 l/min. ECMO was weaned at a mean duration of 188 (range, 43-672) h in all patients. Seven patients were discharged home without neurological sequelae, while 2 patients who had hypoxic brain damage died after further referral. The overall survival with favourable neurological outcomes at 3 months was 77.8%. There were no complications related to ECMO.
CONCLUSIONS: ECMO was safe and effective for patients with ongoing cardiac arrest or ARDS after a near-drowning incident and can be used as a resuscitative strategy in near-drowning patients with cardiac or pulmonary failure resistant to conventional ventilator therapy.

PMID 25496812  Scand J Trauma Resusc Emerg Med. 2014 Dec 12;22:77. doi・・・
著者: D J Waters, M Belz, D Lawse, D Ulstad
雑誌名: Ann Thorac Surg. 1994 Apr;57(4):1018-9.
Abstract/Text Accidental hypothermia associated with near-drowning and cardiac arrest has a high mortality, especially in the adult. We report the resuscitation of a 31-year-old man who suffered extended ice-water submersion, severe hypothermia (23 degrees C), and prolonged (> or = 78 minutes) cardiac asystole. A modified portable cardiopulmonary bypass system and femoral-femoral cannulation in the Emergency Department permitted the rapid institution of core rewarming, oxygenation, and controlled reperfusion, with a successful outcome. Rapid initiation of cardiopulmonary bypass outside the operating room can be an initial treatment option in this unique clinical situation.

PMID 8166500  Ann Thorac Surg. 1994 Apr;57(4):1018-9.
著者: D J Bohn, W D Biggar, C R Smith, A W Conn, G A Barker
雑誌名: Crit Care Med. 1986 Jun;14(6):529-34.
Abstract/Text We retrospectively evaluated the clinical and pathologic effects of hypothermia and high-dose barbiturate therapy on hypoxic/ischemic cerebral injury after near-drowning in children. Of 40 near-drowned patients admitted to the ICU, 13 died, seven had permanent cerebral damage, and 20 survived. Twenty-four patients (group 1) were treated with a regime of hyperventilation, hypothermia, and high-dose phenobarbitone while intracranial pressure (ICP) was continuously monitored. Of ten who died in this group, three were diagnosed as having cerebral death shortly after admission; autopsy revealed severe cerebral edema with herniation. The remaining seven nonsurvivors had severe cerebral hypoxia without raised ICP and had the features of severe adult respiratory distress syndrome and hypoxic/ischemic damage to other organs. Six of these seven patients developed septicemia which was invariably associated with a profound neutropenia. Sixteen patients (group 2) were treated with a similar protocol but without hypothermia. Three of these patients died but only one developed septicemia. Neutropenia after resuscitation from near-drowning seemed to indicate a poor prognosis; the mean polymorphonuclear leukocyte count in nonsurvivors (1.9 +/- 0.5 X 10(9) cell/L) was significantly (p less than .01) lower than that in survivors (6.4 +/- 1.1 X 10(9) cell/L). Hypothermia was associated with a decreased number of circulating PMNs but did not increase the number of neurologically intact survivors. Similarly, although barbiturates may control ICP, their use did not improve outcome. Because severe cerebral edema and herniation after near-drowning is usually associated with irreversible brain damage, measures to control brain swelling such as hypothermia and barbiturates will be of little benefit.(ABSTRACT TRUNCATED AT 250 WORDS)

PMID 3709193  Crit Care Med. 1986 Jun;14(6):529-34.
著者: E Nussbaum, J C Maggi
雑誌名: Pediatrics. 1988 May;81(5):630-4.
Abstract/Text The effect of pentobarbital therapy was studied prospectively in 31 nearly drowned children in a flaccid state of coma. Each child was assigned to one of two sequential treatment groups. Group A: 16 children were treated with hypothermia and IV pentobarbital, achieving serum levels greater than 25 mu/mL within 48 hours of admission. Group B: 15 children were treated with hypothermia but no pentobarbital. All patients received "conventional therapy" (ie, PaCO2 20 to 25 mm Hg, PaO2 90 to 100 mm Hg, fluid restriction, pancuronium bromide, and furosemide or mannitol). Analysis of variance failed to detect differences for age, estimated time of submersion, arterial pH, core temperature, and mean intracranial pressure between the patients prior to treatment with pentobarbital. In Group A, six patients (37%) recovered completely and were neurologically intact, six patients (37%) had severe brain damage and four patients (26%) died. In Group B, six patients (40%) recovered completely, six patients (40%) survived with brain damage, and three patients (20%) died. There were no statistical differences between the two groups (P greater than .05, chi 2 analysis) for the mortality rate, survival with brain damage, and complete recovery. The results suggest that: (1) pentobarbital therapy does not improve neurologic outcome for nearly drowned, flaccid-comatose children; (2) previous claims implying better outcome with hypothermia combined with pentobarbital therapy may be attributed to the effect of hypothermia alone; and (3) pentobarbital therapy may not be justified in nearly drowned, flaccid-comatose victims.

PMID 3357724  Pediatrics. 1988 May;81(5):630-4.
著者: Ortrud Vargas Hein, Andreas Triltsch, Christoph von Buch, Wolfgang J Kox, Claudia Spies
雑誌名: Crit Care. 2004 Oct;8(5):R353-7. doi: 10.1186/cc2926. Epub 2004 Sep 2.
Abstract/Text 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.

PMID 15469580  Crit Care. 2004 Oct;8(5):R353-7. doi: 10.1186/cc2926. E・・・
著者: S P Choi, C S Youn, K N Park, J H Wee, J H Park, S H Oh, S H Kim, J Y Kim
雑誌名: Acta Anaesthesiol Scand. 2012 Jan;56(1):116-23. doi: 10.1111/j.1399-6576.2011.02562.x. Epub 2011 Oct 19.
Abstract/Text BACKGROUND: Therapeutic hypothermia in adult victims who suffer cardiac arrest following drowning has been applied in only a small number of cases. In the last 4 years, we have employed therapeutic hypothermia to decrease hypoxia-induced brain injury in these patients. The purpose of the present study was to report the results of the treatment of these patients.
METHODS: This study investigated the utilisation of therapeutic hypothermia on consecutive patients with cardiac arrest because of drowning between 2005 and 2008. The study was conducted retrospectively, collecting data by reviewing medical records. Hypothermia, with a target temperature of 32-34°C, was induced for 24 h. Neurological outcomes were classified using the cerebral performance categories (CPCs). The primary outcome was neurological function at discharge.
RESULTS: Twenty patients were treated with therapeutic hypothermia. Four patients (20%) exhibited a favourable neurological outcome (CPC 1-2). Two patients (10%) remained in a vegetative state at discharge (CPC 4), and 14 patients (70%) died (CPC 5). The most common complications during therapeutic hypothermia were pancreatitis and rhabdomyolysis. A longer duration of advanced cardiac life support (P = 0.035), an absence of motor response to pain after 3 days (P = 0.003), an abnormal brain imaging (P = 0.005) and a lack of cortical response to somatosensory evoked potential (P = 0.008) were related to an unfavourable outcome (CPC 3-5).
CONCLUSION: The present study did not demonstrate an advantage of therapeutic hypothermia in adult cardiac arrest after drowning compared with previous studies treated with conventional therapy. Further prospective studies are needed to evaluate the effects of therapeutic hypothermia.

© 2011 The Authors Acta Anaesthesiologica Scandinavica © 2011 The Acta Anaesthesiologica Scandinavica Foundation.
PMID 22091986  Acta Anaesthesiol Scand. 2012 Jan;56(1):116-23. doi: 10・・・
著者: Alexis A Topjian, Robert A Berg, Joost J L M Bierens, Christine M Branche, Robert S Clark, Hans Friberg, Cornelia W E Hoedemaekers, Michael Holzer, Laurence M Katz, Johannes T A Knape, Patrick M Kochanek, Vinay Nadkarni, Johannes G van der Hoeven, David S Warner
雑誌名: Neurocrit Care. 2012 Dec;17(3):441-67. doi: 10.1007/s12028-012-9747-4.
Abstract/Text Drowning is a leading cause of accidental death. Survivors may sustain severe neurologic morbidity. There is negligible research specific to brain injury in drowning making current clinical management non-specific to this disorder. This review represents an evidence-based consensus effort to provide recommendations for management and investigation of the drowning victim. Epidemiology, brain-oriented prehospital and intensive care, therapeutic hypothermia, neuroimaging/monitoring, biomarkers, and neuroresuscitative pharmacology are addressed. When cardiac arrest is present, chest compressions with rescue breathing are recommended due to the asphyxial insult. In the comatose patient with restoration of spontaneous circulation, hypoxemia and hyperoxemia should be avoided, hyperthermia treated, and induced hypothermia (32-34 °C) considered. Arterial hypotension/hypertension should be recognized and treated. Prevent hypoglycemia and treat hyperglycemia. Treat clinical seizures and consider treating non-convulsive status epilepticus. Serial neurologic examinations should be provided. Brain imaging and serial biomarker measurement may aid prognostication. Continuous electroencephalography and N20 somatosensory evoked potential monitoring may be considered. Serial biomarker measurement (e.g., neuron specific enolase) may aid prognostication. There is insufficient evidence to recommend use of any specific brain-oriented neuroresuscitative pharmacologic therapy other than that required to restore and maintain normal physiology. Following initial stabilization, victims should be transferred to centers with expertise in age-specific post-resuscitation neurocritical care. Care should be documented, reviewed, and quality improvement assessment performed. Preclinical research should focus on models of asphyxial cardiac arrest. Clinical research should focus on improved cardiopulmonary resuscitation, re-oxygenation/reperfusion strategies, therapeutic hypothermia, neuroprotection, neurorehabilitation, and consideration of drowning in advances made in treatment of other central nervous system disorders.

PMID 22956050  Neurocrit Care. 2012 Dec;17(3):441-67. doi: 10.1007/s12・・・
著者: F D Pratt, B E Haynes
雑誌名: Ann Emerg Med. 1986 Sep;15(9):1084-7.
Abstract/Text Most authorities recommend admission of all near-drowning victims out of fear of "secondary drowning." Identifying victims at risk could promote vigorous evaluation and reduce unnecessary hospitalization. We prospectively studied 52 swimmers with symptoms of respiratory distress after submersion. Thirty-one (60%) were released on the beach, and none of 26 followed up by telephone sought medical care or exhibited symptoms of respiratory distress as many as five days later. Twenty-one patients (40%) were transported to a hospital for further evaluation. All who required admission displayed signs of respiratory distress within four hours. No patient developed "secondary drowning" after an asymptomatic interval, indicating that emergency department observation for four to six hours could effectively screen for those patients requiring inpatient therapy. We question the existence of "secondary drowning" as anything other than established, detectable respiratory insufficiency.

PMID 3740598  Ann Emerg Med. 1986 Sep;15(9):1084-7.

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