Drowning a Cry for Help

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Anesthesiology 2009; 110:1211–3 Copyright © 2009, the American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.

Drowning

A Cry for Help

IN this issue of A NESTHESIOLOGY , Layon and Modell re-

view current evidenced-based management of drown-

ing victims who reach medical care.1 Modern resusci-tation research of the drowning victim now spans

decades. This review article expertly and comprehen-

sively evaluates information resulting from that inves-tigation; perhaps as important as that which is said, is

that which is not said.

Throughout the 1960s and 1970s, Dr. Model and hiscolleagues provided groundbreaking research describing

principally pulmonary and blood electrolyte responsesto drowning and the effects of the liquid medium on

these responses ( e.g., fresh water vs. salt water).2–5 That

era can now be considered as the golden age of drown-

ing research. Preclinical models were developed andexploited. Clinical case series and experimental inter-

ventions were reported that harnessed simultaneous ad-

vances in critical care.5–7 However, the work did notprogress to the level of randomized intervention trials,

and the science did not keep pace with that of brain

resuscitation research. This is particularly crucial be-cause asphyxial brain injury is often the terminal event

or persistent debilitating factor in those resuscitatedfrom cardiac arrest caused by drowning. A review of the

PubMed database reveals negligible current effort tobetter define drowning pathophysiology or clinical man-

agement of its victims. Indeed, the majority of paperscited by Layon and Modell1 were published before 1990.

Is this subject of concern to anesthesiologists? Drown-

ing victims are typically treated first at the site of rescue,later in the emergency department, and unless death or

hospital discharge ensues, are transferred to medicalintensive care units. Although trauma may accompany

drowning, this infrequently results in a call for periop-erative management. Yet, anesthesiologists pride them-

selves on their expertise in resuscitation medicine and

this offers great opportunity to participate in revitaliza-tion of the endeavor to improve management of drown-

ing victims.

Drowning is a major public health problem. In the

United States, it is a leading cause of accidental death

through the first 5 decades of life, with peak incidencesoccurring during early childhood and adolescence.#

Estimates vary but suggest that at least 150,000 to

800,000 people die worldwide from accidental drown-

ing each year,8 with untold numbers sustaining perma-

nent neurocognitive deficits.9 Despite the prevalence of

this disorder, novel information applicable to medical

management has been scant over the past 2 decades.

This is held in contrast to major advances in both

cardiopulmonary and cerebral resuscitation. Most nota-

bly, it has been proved that induced mild/moderate

hypothermia initiated after restoration of spontaneous

circulation for out-of-hospital ventricular fibrillation car-

diac arrest reduces both mortality and neurologic mor-

bidity.10,11 This success was predicated on extensive

preclinical research. Preclinical models of ischemic and

anoxic cerebral injury have dramatically improved, par-

ticularly those that allow analysis of long-term outcome.

Understanding the immediate and delayed cellular re-

sponses to ischemia has radically altered how we think

about the response of brain to energy deprivation and

reperfusion injury. Knowledge of ischemia and reperfu-

sion injury is highly relevant to drowning and can allow

a platform for rational investigation of novel interven-tion. Yet, little research is performed, and modern, val-

idated, and clinically relevant preclinical models are not

available to examine these complex pathologic condi-

tions in the specific context of drowning. It cannot be

assumed that simple major cerebral vessel occlusion in

laboratory animals will mimic interactions among tissue

energy deprivation, temperature shifts, electrolyte ab-

normalities, and pulmonary injury often associated with

immersion in various fluids.

Similarly, there is need for clinical research. The earlier

the intervention takes place, the larger the effect on a

positive outcome.12–14

What interventions, achievable inthe field, can be implemented to improve functional

outcome? Is hyperoxia adverse?15 Should efforts be

made to sustain hypothermia?10,11 At either preclinical

or clinical levels, both are known to substantively alter

outcome from cardiac arrest, but no work has focused

on drowning. Within the hospital, little data define the

role of intracranial pressure management or electro-

physiologic monitoring, cerebral microdialysis, neuro-

chemical markers, tissue oxygen management, pharma-

cologic intervention, glucose control, rewarming strategies

(cold drowning), temperature management, or influence of

respiratory care on brain outcome specific to drowning

This Editorial View accompanies the following article: Layon

AJ, Modell JH. Drowning: Update 2009. A NESTHESIOLOGY

2009;110:1390–401

Accepted for publication February 27, 2009. The authors are not supportedby, nor maintain any financial interest in, any commercial activity that may beassociated with the topic of this article.

PubMed (search term “drowning). Available at: http://www.ncbi.nlm.nih.gov/pubmed/. Accessed February 23, 2009.

# Centers for Disease Control and Prevention. Water-related injuries: Factsheet. Available at: http://www.cdc.gov/HomeandRecreationalSafety/Water-Safety/waterinjuries-factsheet.htm. Accessed February 23, 2009.

Anesthesiology, V 110, No 6, Jun 2009 1211



patients.16 These all are factors for which anesthesiologistsoffer major expertise.

There are more reasons for the anesthesiologist to

become interested in the issue of drowning. Case reportshave shown that, during drowning, combinations of theextremes in hypoxemia and hypothermia have led to

survival, where the individual pathologic processes ini-tiated by either alone would have been lethal. It may be

enlightening to understand why survival may occur after submersion times of more than 1 h, resuscitation timesof more than 2 h, extremes in temperature (13.7°C) in

the absence of cardiopulmonary bypass, and profoundderangements in acid-base status.17–19 A better observa-

tion, registration, and understanding of these accidentalevents and mechanisms associated with survival may identify new paradigms in treatment of hypoxic and

hypothermic insults. Another issue that needs urgent attention, and where

anesthesiologists can show leadership, has to do with the trend that compression-only cardiopulmonary resus-citation is likely to become the standard for layperson

Basic Life Support in witnessed sudden cardiac arrest.20

Before cardiopulmonary resuscitation without ventila-tion can be proposed in drowning victims, important

questions need to be answered. What happens to amarginally active globally hypoxic and/or hypothermic

myocardium, as in the case of drowning, when compres-sion-only cardiopulmonary resuscitation is applied? Con-sidering that hypoxia-induced bradycardia leading toeventual arrest is likely in most drowning victims, the

response to ventilation may be quite different from thatof focal myocardial ischemia.**

Drowning is a major public health issue calling for

worldwide attention. While the US drowning rate isdecreasing, drowning is the most common cause of childmortality in seven Asian nations. Drowning rates in

lower and middle income countries are six times higher than in high-income nations, but less adaptive popula-tions in high-income nations also have high drowningrates.21–23 There is no effort to resuscitate in most

drowning events in much of the world. Anesthesiolo-gists can show the social commitment of their specialty

by developing and teaching the most appropriate resus-citation techniques. It is also important to answer ques-tions such as should the Sellick maneuver be appliedduring Basic Life Support when mouth-to-mouth ventila-

tion is impeded due to low lung compliance, which drowning victims benefit from oxygen therapy, what isthe value of prehospital pulse oximetry, which victimsneed to be admitted to hospital, when is discharge indi-

cated, and what are the early predictors of permanentneurologic damage. There are no standardized scoring

systems with reasonable accuracy to provide a prognosis

after drowning. The most efficacious rewarming meth-

ods and optimum rewarming speed in hypothermic

drowning victims still need to be determined. Answers

to these questions will be helpful in the case of an

individual victim but will have enormous impact when,

due to floods or boat accidents, large numbers of drown-ing victims have to be treated, resources are scarce, and

triage is needed.23 The 2002 World Congress on Drown-

ing identified over 200 research needs in the prevention,

rescue, and treatment of drowning.24

Conduct of randomized clinical trials is necessary to

better define intervention efficacy. A multicenter clin-

ical trial involving major medical centers may be the

final arbiter of post-drowning care, but many victims

are first delivered to local hospitals when interven-

tions are likely to have the greatest impact on out-

come, so these first contact hospitals must also be

included in randomized management protocols. Data-

bases have been proposed to better define outcome

responses to various interventions. Detailed recom-

mendations regarding the kind of data that should be

collected have been published and tested.24,25 How-

ever, to our knowledge, no databases other than mor-

tality and incident reports collected by the Centers for

Disease Control are actively collecting information

that could transform practice. Coordinated data col-

lection at the local, state, and federal level will be

needed to positively affect outcomes from drowning.

Drowning is a prevalent disease that will requiresophisticated resuscitation science to substantively ad-

vance patient care. There is need for basic scientists,

clinicians at major centers, local medical doctors, and

emergency personnel to support this effort. What can

anesthesiology contribute? Resuscitation is yeoman’s

work in our specialty, and indeed anesthesiologists

such as Dr. Modell were at the forefront of drowning

research in its golden age. Anesthesiology meetings

are replete with innovations in resuscitation science.

Interactions between anesthesiologists/intensivists

and emergency physicians will be necessary to gener-

ate and implement clinically important advances. Inmany countries, these entities are comprised within

the same specialty. The challenge is to begin a new

age of drowning research, incorporating the vast

amount of new knowledge obtained in diseases famil-

iar to us ( e.g., anoxia, cardiac arrest, ischemia) that

can be evaluated in the context of and uniquely ap-

plied to care of the drowning victim. Drowning vic-

tims are often from the most vulnerable population

with the greatest chance of full recovery and oppor-

tunity to contribute to society, but we must move

forward now with new research initiatives so we can

save patients with brains and hearts too good to die.26

** Clarification Statement on Cardiopulmonary Resuscitation for Drowning. Available at: http://www.watersafe.org.nz/attachments/ils-clarification-statement-on-cardiopulmonary.pdf. Accessed February 23, 2009.

1212 EDITORIAL VIEWS

Anesthesiology, V 110, No 6, Jun 2009



David S. Warner, M.D.,* Joost J. L. M. Bierens, M.D., Ph.D.,M.C.D.M.,† Stephen B. Beerman, M.D., C.C.F.P., F.C.F.P.,†Laurence M. Katz, M.D.§ *Departments of Anesthesiology, Neuro-biology, and Surgery, Duke University Medical Center; †Department of

Anesthesiology, VU University Hospital, Amsterdam, The Netherlands;†Department of Family Practice, University of British Columbia,International Lifesaving Federation; §Department of Emergency Medicine, University of North Carolina at Chapel Hill, Chapel Hill,

North Carolina. [email protected]

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1213EDITORIAL VIEWS

Anesthesiology, V 110, No 6, Jun 2009

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Drowning a Cry for Help