Cold water drowning/nonfatal submersion

[Roheline]

Somewhere during my EMS training I remember reading or perhaps learning in a CE lecture that victims of cold water drowning tended to respond better to resuscitation attempts than "traditional" cardiac arrest patients (the saying "you're not dead until you're warm and dead" springs to mind), but I can't seem to find any statistics to back this up. Anyone seen a published study about this? Anyone have personal experience responding to a drowning call?

Part of why I'm asking is simply curiosity and a desire to understand the phenomenon better but I guess I should admit that I'm personally involved with this topic. Last January I lost a close friend whom I've known since I was 15 in a freak drowning accident (she fell through an uncovered manhole that was apparently hidden by a layer of snow) and I've had this horrible suspicion plaguing me that maybe she would have survived if it had happened in a country with a better medical system or more advanced protocols (this occurred in Estonia).

I know this is the worst kind of "Monday morning quarterbacking" and probably highly unfair to the EMS providers who responded; I wasn't there to see what actually happened/don't know what kind of trauma and other complications were present and my feeling probably indicates that I'm still somewhere between denial and anger in the stages of grief and am therefore being somewhat (very?) irrational about this. I also realize that news reporting isn't perfectly accurate, but it really bothers me that she was reported to have been pronounced dead in the ambulance and I keep wondering, did that mean they just stopped CPR and gave up on her? It doesn't help that I stumbled across an Estonian EMS forum and people were commenting that the rescue seemed very poorly done. I have no way of knowing how much/how little they knew of the situation and on what basis they made that judgement, but it hasn't helped the nagging feeling that someone F*ed up.

Here's the original news article if anyone's interested:
http://www.parnupostimees.ee/378219/parnus-hukkus-kaevu-kukkunud-noor-naine/

It's in Estonian but there are pictures of the rescue in progress. I don't recommend the automatic translation feature offered by Google Chrome. You could get the gist of it, I suppose, but you'll have to overlook the ridiculous mistranslations such as "cannabis users were unable to save her life." <---WTF, Google?

*sigh* I don't know how I've derailed my post so much already... What do you know about cold water drownings? Have you ever responded to one? Ever had a save from this situation? How long would you continue CPR? Have you seen any evidence in the literature or from personal experience that the ridiculous "Grey's Anatomy" save after hours and hours of asystole EVER actually happens?

 

[medicnick83]

I haven't responded to a drowning of any sort YET so I have no experience or bits of advice for you... YET

I do know that they need to be taken to hospital for observation even if they refuse - you must insist they go.

 

[Handsome Robb]

Your talking about the mammalian diving reflex. Down and dirty its a self defense mechanism when your face is submerged in cold water. HR slows, peripheral vasculature constricts shunting blood to the core and vital organs and in extreme cases fluid shifting from intravascular to the extravascular space to protect your lungs and thoracic cavity from being crushed in high pressure (read: deep water) environments.

The shunting of oxygenated blood to end organs along with decreased myocardial o2 demand secondary to the bradycardia allows the oxygen already bound to hemoglobin to be used to support cellular function in these organs for an extended amount of time.

Like you said, they aren't dead until they're warm and dead. The only change in treatment I'm aware of is no drugs if their core temp is less than 86* F or 30* C but I'm not sure if it's widely recognized and will be protocol specific.

Never seen an arrest from a drowning but I have seen my fair share of unconscious near-drowning patients.

 

[mycrofft]

Empiric Sidebar

Mojave desert medical folks have long noted the occasional incidents of people diving into unheated pools and simply shutting down "from the shock", i.e., going from say 100F to 70F in nothing flat with a nice deep lung of air and attendant Valsalva going on. No bottom impact until they glide down to it, per some witnesses.

Plus some tachycardias respond temporarily to the "head in a bucket" routine.

Google for studies:

http://scholar.google.com/scholar?q=NIH+mammalian+diving+reflex+resuscitation&hl=en&as_sdt=0&as_vis=1&oi=scholart

 

[AK_SAR]

The long survival times of some cold water near drowning victims may be related to becoming severely hypothermic before drowning. Anna Bågenholm survived 80 minutes submerged in ice water, but apparently had an air pocket for at least the first 40 minutes. For a discussion of her case, and references see http://en.wikipedia.org/wiki/Anna_Bågenholm

For a current disussion of treatment you might want to check the Alaska "Cold Injuries Guidelines" section on cold water near drowning. See http://www.ems.alaska.gov/EMS/documents/AKColdInj2005.pdf

 

[icefog]

Here's a pretty exhaustive article on drowning, it's got everything from pathophysiology to prehospital and hospital treatment:

http://journals.lww.com/anesthesiology/Fulltext/2009/06000/Drowning__Update_2009.30.aspx
Very cold water may result in rapid hypothermia, which decreases the victim’s requirement for oxygen, thereby prolonging the period of time they may be submerged and still completely recover.22,23 On the other hand, significant hypothermia may also lead to severe delays in myocardial conduction, dysrhythmias, and cardiac arrest. In addition, immersion in cold (0° to 15°C) water increases minute ventilation and decreases maximal duration of breath holding. This may decrease the effectiveness of the “diving reflex” and increase the likelihood of drowning.​

And here's an interesting case report from Florida:

http://chestjournal.chestpubs.org/content/125/5/1948.long​

And an old study from 1997 on the effect of water temperature on nearly drowned children:

http://www.resuscitationjournal.com/article/S0300-9572(97)00036-1/abstract
In conclusion the effect of a potentially beneficial rapid development of hypothermia by cold water on the outcome of nearly drowned children could not be proved.​

Another study from 2002 confirming several factors' lack of relevance:

http://www.sciencedirect.com/science/article/pii/S0300957201004786
Patient age, water temperature and rectal temperature in the emergency room were not significant predictors of survival.​

Basically, you've got a cerebral protection due to hypothermia, but not many conclusive studies actually proving it.

 

[mycrofft]

I hate studies that preface their conclusions with "may".

We need lots of cadaver studies just to establish thermodynamics of heat loss to immersion. Then a lot of really hard up volunteers!

Dang, I just remembered, this includes the field of study the Nazis used concentration camp prisoners for and were later declared tainted due to humanitarian concerns. h34r:

 

[icefog]

Well, you know, a healthy "may" a day keeps the lawyers away...

Those Nazi experiments were actually used by researchers in Canada working on the development of cold water survival suits. They said such data will never again surface in an ethical world, and not using it would be just as bad - they tried to get something constructive out of it. Whether that's right or wrong is another discussion. However, the main scientific concern with that data is that it relied on weak, malnourished and often sick subjects, and is therefore not at all representative for the general population.

 

[Roheline]

Thanks for all your responses, guys, especially the links to the studies. So much to learn, never enough time...

 

[Veneficus]

Well, you know, a healthy "may" a day keeps the lawyers away...

Those Nazi experiments were actually used by researchers in Canada working on the development of cold water survival suits. They said such data will never again surface in an ethical world, and not using it would be just as bad - they tried to get something constructive out of it. Whether that's right or wrong is another discussion. However, the main scientific concern with that data is that it relied on weak, malnourished and often sick subjects, and is therefore not at all representative for the general population.

There are a lot of studies that were carried out that will (rightfully) never be done again, especially for things like hypothermia and burns.

Most studeies have to be prefaced with "may" not only for lawyers but for scientific integrity.

It is very hard to draw actual conclusions from any given study. You try to reduce as many confounding factors as possible, but it cannot always be done. There also so me things we don't know, so stating things as fact when there are pieces of your puzzle missing cries out to have your credibility debinked.

I always love to see when somebody cites 1 study and claims its value in dictating or changing practice. Especially if they just use the abstract.

Take a look at the Cochrane Reviews and the amount of citations and exploration they do before drawing a conclusion on any given practice.

It is the sum total of evidence over time that determines the validity of individual studies and conclusions.

Do to the nature of medicine, large scale trials will never be 100% applicable to all patients.

Becuase of morals, some topics will never be effectively studied.

Sometimes expert opinion is the best you can get. My pet peeve is when the opinions of antiquitated experts who gave said conclusions is taken as higher value than more modern experts or the burdon of proof demanded on modern experts is higher than that of the original.

 

[icefog]

OK, I'm a bit puzzled here... Where did this come from, what on Earth did I say? :blink: Since you quoted my last post, I'm assuming your criticism was directed at my posts, therefore...

Most studeies have to be prefaced with "may" not only for lawyers but for scientific integrity.

The "may" thing was a joke playing on mycrofft's headline, and I don't think he meant it as an appeal to disregard scientific integrity, but rather as an opportunity to voice the irritation (which I think a lot of us feel) with not being able to say "we know this for certain" more often.

I always love to see when somebody cites 1 study and claims its value in dictating or changing practice. Especially if they just use the abstract.
Take a look at the Cochrane Reviews and the amount of citations and exploration they do before drawing a conclusion on any given practice.

I listed 3 studies that I found on the issue and cited the abstract for each one for easier reference. I'll be sure to cite the entire study in full next time, and make good use of "may" for securing scientific integrity. I wasn't aware forum posts had to meet Cochrane methodological quality standards, but that's still irrelevant since I haven't drawn any conclusions. What I've said is: there are no results that are widely accepted as conclusive on the issue. Or, at least, I haven't found any - if you disagree, please point to a source tipping the balance one way or the other, it would be more constructive to the issue at hand.

Do to the nature of medicine, large scale trials will never be 100% applicable to all patients.

Alright, now you're just twisting my words for the sake of criticizing. Whoever said anything about 100% applicability? I just said others raised a criticism regarding the increased "sampling error". Personally, I understand the problem, while at the same time I can see how a bit of extrapolated data is better than no data whatsoever. I don't see where the problem is.

 

[mycrofft]

Give me a good old fashioned "Often" or "Frequently".

Good thread, sparked wide ranging discussion. Dropping body temp is being tried and used for other medical conditions as well, such as cardiac arrest.

 

[AK_SAR]

We need lots of cadaver studies just to establish thermodynamics of heat loss to immersion. Then a lot of really hard up volunteers!

Actually, Gordon Geisbrecht at University of Manitoba (aka "Professor Popsicle") has done lots of studies. I think he refers to them as graduate students, rather than "really hard up volunteers".

I hear he has some openings in his program, if you want to go to grad school!

See:
http://www.umanitoba.ca/faculties/kinrec/about/giesbrecht.html

For a list of his publications see:
http://www.umanitoba.ca/faculties/kinrec/media/Cold_Related_Publications_Selected.pdf

 

[mycrofft]

Some people refer to grad students

as galley slaves.

 

[AK_SAR]

Some people refer to grad students as galley slaves.

I know.....Been there, done that......To old for that $h*t now.