A Case of Severe Acute Kidney Injury by Near-Drowning

Acute kidney injury (AKI) secondary to near-drowning is rarely described and poorly understood. Only few cases of severe isolated AKI resulting from near-drowning exist in the literature. We report a case of near-drowning who developed to isolated AKI due to acute tubular necrosis (ATN) requiring dialysis. A 21-yr-old man who recovered from near-drowning in freshwater 3 days earlier was admitted to our hospital with anuria and elevated level of serum creatinine. He needed five sessions of hemodialysis and then renal function recovered spontaneously. Renal biopsy confirmed ATN. We review the existing literature on near-drowning-induced AKI and discuss the possible pathogenesis.

A Case of Scedosporium Apiospermum Pneumonia in an Immunocompetent Patient / 대한내과학회지

Scedosporium apiospermum, an asexual form of Pseudallescheria boydii, is a saprophytic mold with a worldwide distribution. It may cause severe pulmonary or disseminated infections in immunocompromised patients who have undergone organ transplantation, have hematological malignancies, or have received corticosteroid therapy. However, in immunocompetent patients, it usually produces localized infection and has been reported to cause pneumonia after near-drowning in polluted water. We present here the case of an immunocompetent 72-year-old woman with pneumonia caused by S. apiospermum.

Successful Recovery after Drowning by Early Prone Ventilatory Positioning and Use of Nitric Oxide Gas: A Case Report / 대한구급학회지

Drowning is the third leading cause of unintentional accidental death globally. The most serious pathophysiologic consequence of drowning is hypoxemia from acute respiratory distress syndrome. Herein, we report a drowning victim who presented with hypothermia and cardiac arrest, followed by acute respiratory distress syndrome, rhabdomyolysis (with acute kidney injury), and disseminated intravascular coagulopathy. Aided by advanced cardiac life support and mechanical ventilation in a prone position, the patient fully recovered after two days of hospitalization. Recovery was largely attributed to early prone ventilatory positioning and use of nitric oxide gas.

Veno-Venous Extracorporeal Membrane Oxygenation of Acute Respiratory Failure due to Near-drowning: 2 case reports / 대한흉부외과학회지

Extracorporeal membrane oxygenation (ECMO) during acute respiratory failure due to any cause aids in the recovery of respiratory function. The use of ECMO for acute respiratory failure due to near drowning was reported to be a successful therapeutic option in those patients who do not respond to optimal conventional therapies. We performed veno-venous ECMO for 2 acute respiratory failures due to near-drownings. All cannulations were performed percutaneously via both femoral veins. The 2 patients were successfully weaned off ECMO, but one patient experienced diffuse hypoxic brain damage and a subarachnoid hemorrhage.

Disseminated Scedosporium apiospermum Infection Induced from Aspiration Pneumonia after Near-Drowning / 결핵및호흡기질환

Scedosporium apiospermum, the anamorph of Pseudallescheria boydii, is a ubiquitous saprophytic fungus. S. apiospermum can cause life-threatening infections usually in immunocompromised patients or after near-drowning incidents. Here, we report the first case of disseminated infection caused by S. apiospermum after near-drowning in Korea. A 44-year-old healthy man developed aspiration pneumonia, followed by multiple brain abscesses, and endopthalmitis, after a near-drowning incident in a septic tank. S. apiospermum infection was diagnosed on the 33rd day after the incident had occurred. The patient died from the progressive renal failure 255 days after incident, although he had been treated with voriconazole.

Acute Respiratory Failure Treated with Veno-venous Extracorporeal Membrane Oxygenation / 결핵및호흡기질환

BACKGROUND: Extracorporeal membrane oxygenation (ECMO) during severe acute respiratory failure helps to recover the pulmonary function. This study evaluated our experience with veno-venous ECMO in adult patients with acute respiratory failure. METHODS: From January 2007 to July 2009, ECMO was used on 54 patients. Of these 54 patients, 7 were placed on veno-venous ECMO for acute respiratory failure. The indications of ECMO were based on the lung dysfunction measured as a PaO2/FiO2 ratio <100 mm Hg on FiO2 of 1.0, or an arterial blood gas pH <7.25 due to hypercapnia despite the optimal treatment. EBS(R), Bio-pump(R), and Centrifugal Rotaflow pump(R) were used and all cannulations were performed percutaneously via both femoral veins. When the lung function was improved, an attempt was made to wean on ECMO at moderate ventilator settings followed by decannulation. RESULTS: Five of the 7 patients were male and the mean age was 46.3+/-18.3. The causes of acute respiratory failure were 3 cases of pneumonia, 2 near-drownings, 1 pulmonary hemorrhage due to acute hepatic failure and 1 mercury vapor poisoning. The mean support time of ECMO was 17.3+/-13.7 days. Of the 7 patients implanted with ECMO, 5 patients (71%) were weaned off ECMO and 3 patients (43%) survived to hospital discharge after a mean 89.6 hospital days. CONCLUSION: The early use of ECMO for acute respiratory failure in adults due to any cause is a good therapeutic option for those unresponsive to the optimal conventional treatments.

A Case of Acute Kidney injury After Seawater Immersion / 대한신장학회지

Acute renal failure (ARF) secondary to immersion and near-drowning has rarely been described and it is poorly understood. ARF associated with immersion and near-drowning might be involved with systemic tissue hypoxia, hypovolemia and hypothermia. Some reports have shown that rhabdomyolysis could be involved. We report here on a 52 year old seaman who developed ARF after cold sea-water immersion. He had been swimming for one hour in cold sea-water because his ship became stuck on a rock. After 2 days, his serum creatinine level was increased to 7.8 mg/dL, and pulmonary edema was developed. The serum myoglobin level was 495.1 ng/mL. He was diagnosed as oliguric ARF and treated with hemodialysis. Thereafter, renal function was gradually recovered. We presumed that hypothermia-induced vasoconstriction, hypovolemia and rhabdomyolysis were involved in ARF in the patient. It should be considered that cold sea-water immersion for a long time could evoke ARF in healthy men.

Casi ahogamiento en pediatría: epidemiología y factores pronósticos / Near drowning in a pediatric population: epidemiology and prognosis

Introducción. El ahogamiento por sumersión es un cuadro con alta morbimortalidad; es la tercera causa accidental de muerte en la población infantil. El objetivo fue analizar y describir factores de riesgo, pronóstico y supervivencia de las víctimas por casi ahogamiento, admitidas en un hospital universitario de alta complejidad. Población, material y métodos. Estudio retrospectivo, observacional, analítico. Se estudiaron los pacientes admitidos en una Unidad de Cuidados Intensivos Pediátricos, entre junio del año 2000 y enero de 2008. Se analizaron múltiples variables. Resultados. Ingresaron 30 pacientes, cuya mediana de edad fue 25 meses (intervalo: 11-144 meses), predominio masculino. El 41,3 por ciento de los episodios ocurrieron en verano, 60 por ciento de los niños estaba bajo supervisión de los padres. El tiempo medio de sumersión fue > 10 minutos en el 3,4 por ciento, tuvieron apnea al ingreso 26 por ciento y el Puntaje de Glasgow fue < 5 en 19,99 por ciento. El ácido láctico fue mayor a 3 mmol/l en 10 pacientes. Se asociaron con mal pronóstico, quienes al ingreso tuvieron glucemia ≥ 300 mg por ciento (OR: 3,325), apnea (OR: 2,752), bradicardia (OR: 4,74), Glasgow < 5 (OR: 3,550) y tiempo de sumersión > a 10 minutos (OR: 5,12). Murieron 2/30 pacientes. Conclusión. En nuestra población, la presencia de apneas, bradicardia, glucemia ≥ 300 mg por ciento, Puntaje de Glasgow < 5 y sumersión mayor a 10minutos, se asociaron a mal pronóstico. La elevación de ácido láctico > 6 mmol/l al ingreso y a las 24 h fue marcador de lesión grave.

Drowning in concentrated syrup.

Drowning is one of the two leading causes of accidental death in children. Most of the cases can be attributed to fresh or salt water drowning. We report an unusual case of acute respiratory distress syndrome in a one year old child following drowning in concentrated sugar syrup, in whom timely intervention and early supportive therapy resulted in a favorable outcome.

Prognostic value of proton magnetic resonance spectroscopy findings in near drowning patients: reversibility of the early metabolite abnormalities relates with a good outcome / Valor prognóstico da espectroscopia de prótons em vítimas de quase-afogamento: reversibilidade das anormalidades metabólicas precoces relacionou-se com bom prognóstico

In two children with near drowning hypoxic encephalopathy and normal-appearing structural MRI, acute proton magnetic resonance spectroscopy (¹H MRS) showed biochemical alterations that correctly indicated prognosis and helped to guide management decisions. Elevation of the lipid-lactate and glutamine-glutamate peaks, on the early (72 hour) ¹H MRS, predicts a poor prognosis. Absence of lipid-lactate and glutamine-glutamate peaks on the early ¹H MRS and reversibility of early mild metabolite abnormalities on follow up examination relates with good outcome.

Em duas criancas vítimas de quase-afogamento com encefalopatia hipóxico-isquêmica, que apresentaram ressonância magnética por imagem normal, a espectroscopia de prótons por ressonância magnética (¹H MRS) na fase aguda mostrou alterações bioquímicas que corretamente indicaram o prognóstico e ajudaram a guiar o manejo terapêutico. Elevação dos picos de lipídeo-lactato e glutamina-glutamato na ¹H MRS precoce realizada com 72 horas previu um mau prognóstico. Relacionaram-se com bom prognóstico; a ausência dos picos de lipídeo-lactato e glutamina-glutamato na ¹H MRS precoce, e a reversibilidade no exame de controle (3 meses) das discretas anormalidades metabólicas encontradas no primeiro exame.

The Characteristics of Childhood Injuries Compared to Adult Injuries

Children are in their course of growth and development, and this is the most important feature in understanding childhood injuries, which is somewhat different from those in adults. Injury is different from accident in that the latter cannot be expected and prevented, and also different from trauma that means the external forces on the body and the response against the force. Injury can be expected scientifically and prevented. The risk of injuries in children is closely related to the age, sex, socio-economical status, and environment. Injuries are always the most common cause of death in children throughout the world, and traffic accident is the most common cause of childhood injuries. Burn, near drowning, and fall down occupy most of the causes of injuries in infancy, and pedestrian injuries and traffic accidents are the major causes of injuries in pre-school ages. Suicide becomes an important cause of injuries in adolescents. Sexual abuse should be considered seriously in children with perineal injuries without definite causes. All of these childhood injuries are closely related to the status of growth and development of children.

Profile of near drowning victims in a coastal region of Karnataka.

BACKGROUND: Drowning and near drowning are serious public health problems and an important cause of morbidity and mortality worldwide. Present study is done to understand the pattern of near drowning cases in this coastal region of Karnataka. METHODS: This hospital based retrospective research was conducted at Kasturba Hospital, Manipal in Southern India from January 1993 to December 2003. A detailed victimologic profile was made. RESULTS: Study included a total of 58 cases of near drowning. Males were predominantly affected (84.5%). Majority of the victims were aged below 10 years (39.7%). Manner was accidental in maximum (82.3%) reported cases. Incidence of fresh water drowning was more than sea water drowning. Fatal outcome was reported in 12.1% cases with maximum fatalities occurring within one to three days of hospitalization. Most of the victims witnessed respiratory complications (55.2%). CONCLUSION: Males in the first decade are at increased risk of accidental drowning. Swimming under adult supervision, immediate resuscitative measures and early medical aid is proposed.

Respiratory complication of tsunami diaster victims in Vachira Phuket Hospital.

There were 958 patients who suffered from the tsunami diaster on 26 December 2004, and came to Vachira Phuket Hospital. 326 cases were admitted with severe respiratory complications. 42 cases had sputum culture, and 20 of them grew gram negative microorganism. The authors present 3 cases.

A Case of Multiple Gastric Mucosa Lacerations in Near Drowning

The causes of complicated upper gastrointestinal bleeding in near-drowning have been known to be stress-induced gastritis, gastric ulcer, Mallory-Weiss syndrome, or Boerhaave syndrome. However, gastric mucosa laceration has often been observed in a drowned body's autopsy. Gastric fundus is the most common site of gastric mucosa lacerations, and the number of lacerations is almost always less than three. Reflex gasping in drowning leads to passive vigorous vomiting, the mechanical force of which causes gastric mucosa laceration. Gastric mucosa laceration is an important forensic clue in autopsy because it means that the victim was drowned alive or was abandoned after being murdered. However, gastric mucosa laceration has rarely been observed in a drowning survivor. We report a neardrowning case of a 9-year-old boy, who had multiple gastric mucosa lacerations treated by endoscopic hemostatic procedure. In our case, we suspect abdominal blunt trauma also to be another cause of gastric mucosa laceration because of uncommon site of the laceration and the large number of lesions. We also present a literature review.

Near-drowning in Pediatric Respiratory Intensive Care Unit, Siriraj Hospital.

OBJECTIVES: To study characteristics, treatment and outcome of near-drowning patients in Pediatric Respiratory Care Unit (P-RCU), Siriraj Hospital MATERIAL AND METHOD: We retrospectively reviewed hospital records of 31 near-drowning patients admitted at P-RCU Siriraj Hospital during 1990-2002. RESULTS: The average age of admitted patients was 4 years (ranged from 6 months to 13 years). Seventy percent of the patients were under 5 years of age. Male : female ratio was 2.1 : 1. Sixty-two percents of the patients were left alone when near-drowning occurred. The sites of occurrence were around their houses in 60% of cases. Bystander resuscitation was documented in 35%. Common complications were pneumonia (74.2%) and seizure (58%). Patients with poor outcome were children without spontaneous purposeful movement within 24 hours after submersion. Neurological sequelae was found in 35.5% of the cases and the mortality rate was 25.8% (3 due to severe pneumonia from prolonged intubation and aspiration, 2 due to severe brain hypoxia, 2 due to severe adult respiratory distress syndrome (ARDS) and 1 due to intracerebral hemorrhage) CONCLUSION: Due to poor outcome observed in this study, prevention of submersion injury is the most important and cost-effective measure. However, if near-drowning happens, effective immediate resuscitation is crucial for the best outcome.

Cause and Prognosis of Pediatric Acute Respiratory Failure by Intrapulmonary Lesion / 소아과

PURPOSE: Respiratory failure arises from derangements in pulmonary gas exchange. The causes may be classified as due to either lung disease or respiratory pump dysfunction. Problems with lung mechanics is an important cause of acute respiratory failure in children clinically. The aims of this study were to survey the cause and prognosis of children diagnosed with acute respiratory failure by intrapulmonary lesion. METHODS: We performed a retrospective study of 52 children(M:F=31:21) diagnosed with acute respiratory failure by intrapulmonary lesion in Gyeongsang National University Hospital from January, 1989 to July, 2003. The age distribution was from 0.1 to 12 years old(2.6+/-3.3 yr). RESULTS: The causes of acute respiratory failure were bronchiolitis and infectious pneumonia(24 cases, 46.1%), acute respiratory distress syndrome(14 cases, 26.9%), near drowning(seven cases, 13.5%), aspiration pneumonia(three cases, 5.8%), sepsis with intrapulmonary lesion(three cases, 5.8%) and croup(one case, 1.9%). The underlying diseases of acute respiratory distress syndrome were aspiration pneumonia(four cases, 28.6%), near drowning(three cases, 21.4%), pneumonia(three cases, 21.4%), sepsis with pneumonia(two cases, 14.3%), and shock(two cases, 14.3%). The survival rate of all subjects was 67.3%. The survival rate of underlying diseases were:83.3% in cases of bronchiolitis and infectious pneumonia, 57.1% in near drowning, 42.8% in acute respiratory distress syndrome, 33.3% in sepsis, and 100% in aspiration pneumonia and croup. CONCLUSION: The major cause of acute respiratory failure by intrapulmonary lesion in children was respiratory infection. And acute respiratory distress syndrome and sepsis with intrapulmonary lesion had relatively poor prognoses, thus active and prompt intervention is important in these conditions.

Predicting outcome in pediatric near-drowning.

BACKGROUND: Near-drowning is common in children and has a high mortality rate. Some survivors remain in a vegetative state after the accident and are a great burden to their family and society. OBJECTIVES: To find out whether outcomes on near drowning can be reliably identified early in the course of illness. METHOD: Medical records of 72 children admitted to Queen Sirikit National Institute of Child Health, Bangkok, Thailand, for treatment of near drowning from January 1993 to December 2001 were retrospectively studied. Stepwise multivariate discriminant analysis was used to identify the power of variables achieving highest overall accuracy in minimizing errors for predicting poor outcome in intact survivors. RESULTS: The patients were identified into three groups: functionally intact, vegetative and dead groups, it was found that a combination of physical examination in the emergency department (ED), the need for cardiopulmonary (CPR) in the ED, amount of adrenaline given during CPR, and high blood sugar achieved an overall accuracy of 83 per cent. When categorizing patients into good outcome versus poor outcome (the combination of the vegetative and dead group were the poor outcome group). The variables mentioned above achieved an overall accuracy of 98 per cent. Good outcome survivors could be correctly predicted with no error, but error occurred when poor outcome survivors were predicted to be good outcome in 3 per cent. Glasgow coma score > or = 5, the need for CPR in the ED and blood sugar > 300 mg/dl were selected clinical variables found to have optimum predictive abilities with an overall accuracy of 96 per cent, but showed an error of 6 per cent in predicting poor outcome from functional intact survivors (unpredicted good outcome). CONCLUSION: From the present study discrimination analysis cannot accurately separate all intact survivors from the vegetative groups, but can prospectively differentiate unpredicted good outcome from vegetative or dead groups. When using only simple clinical classification systems, unpredicted good outcome patients are detected. Since outcome cannot be accurately predicted in the ED, all near drowning victims should receive vigorous and aggressive treatment in the early course of illness and need close monitoring for respiratory complications and neurological signs.

Acute renal failure secondary to rhabdomyolysis following near-drowning in sea water.

We report here a rare case of acute renal failure following near-drowning in sea water. A 21-year old college student presented in acute renal failure 48 hours after a near-drowning event. Investigations revealed rhabdomyolysis to be the cause of renal failure.

Clinical Feature of Submersion Injury in Adults / 결핵

BACKGROUND: Drowning represents the third most common cause of all accidental deaths worldwide. Although few studies of submersion injury were done in Korea, the subjects were mainly pediatric patients. The purpose of this study is to describe the clinical feature of submersion injury in adults. METHODS: The medical records of 31 patients with submersion injury who were >15 years of age and admitted to Kyungpook National University Hospital from July 1990 to March 2003 were retrospectively examined. RESULTS: The most common age-group, cause, and site of submersion accidents in adults were 15-24 years of age, inability to swim, and river followed by more than 65 years of age, drinking, and public bath respectively. The initial chest radiographs showed bilaterally and centrally predominant distribution of pulmonary edema at lung base in about 90% of patients with pulmonary edema represented by submersion injury but at only upper lung zone in 10%. Eventually, 25 patients (80.6%) survived without any neurologic deficit and 2 patients (6.5%) with significant neurologic deficit, and 4 patients (12.9%) died. Age, arterial gas oxygenation, and mental status among baseline variables showed significant difference for prognosis. CONCLUSIONS: More than 65 years of age, drinking, and occurrence in public bath were relatively important in submersion injury of adults, and the successful survival of 80.6% of patients suggests that cardiopulmonary resuscitation should be intensively done in even adults.