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• W4252054284 abstract "HomeCirculationVol. 102, No. suppl_1Part 8: Advanced Challenges in Resuscitation Free AccessOtherDownload EPUBAboutView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessOtherDownload EPUBPart 8: Advanced Challenges in Resuscitation Section 3: Special Challenges in ECC Originally published22 Aug 2000https://doi.org/10.1161/circ.102.suppl_1.I-229Circulation. 2000;102:I-229–I-252HypothermiaDefinition/BackgroundSevere hypothermia (body temperature below 30°C [86°F]) is associated with marked depression of cerebral blood flow and oxygen requirement, reduced cardiac output, and decreased arterial pressure.1A Victims can appear to be clinically dead because of marked depression of brain function.1A2AHypothermia may exert a protective effect on the brain and organs in cardiac arrest.3A4A If the victim cools rapidly without hypoxemia, decreased oxygen consumption and metabolism may precede the arrest and reduce organ ischemia.5A Although rare, full resuscitation with intact neurological recovery may be possible after hypothermic cardiac arrest.1A6AThe victim’s pulses and respiratory efforts may be difficult to detect, but do not withhold lifesaving procedures on the basis of clinical presentation.1A Transport victims as soon as possible to a center where monitored rewarming is possible.Severe unintentional hypothermia is a serious and preventable health problem. Hypothermia in inner-city areas has a high association with mental illness, poverty, and use of drugs and alcohol.7A8A In some rural areas >90% of hypothermic deaths are associated with elevated blood alcohol levels.9A Successful treatment of hypothermia requires optimal training of emergency personnel and appropriate resuscitation methods at each institution.The Figure presents a recommended hypothermia treatment algorithm with recommended actions that should be taken for all possible victims of hypothermia.Prevention of Arrest in Victims of Hypothermia: General Care for All Victims of HypothermiaWhen the victim is extremely cold but has maintained a perfusing rhythm, interventions focus on prevention of further heat loss, careful transport, and rewarming: Prevent additional evaporative heat loss by removing wet garments, insulating the victim, and shielding the victim from wind.Carefully transport the victim to the hospital, taking care to avoid rough movement and activity, because these can precipitate VF.Monitor core temperature and cardiac rhythm. If the victim’s skin is extremely cold, it may not be possible to obtain an ECG or monitor cardiac rhythm by use of adhesive electrodes. If necessary, needle electrodes may be used.Do not delay urgently needed procedures such as intubation or insertion of vascular catheters, but perform them gently and monitor cardiac rhythm closely.Rewarm patients with a core temperature of <34°C (<93°F). Passive rewarming can be achieved with blankets and a warm room. This form of rewarming will not be effective for a patient in cardiopulmonary arrest or with severe hypothermia.5AActive external rewarming uses heating devices (radiant heat, forced hot air, or warm bath water) or heated devices (warm packs). These devices require careful monitoring of patient and device and should be used with caution, if at all. Some researchers think that active external rewarming contributes to “afterdrop” (continued drop in core temperature when cold blood from the periphery is mobilized). In addition, topical application of warm devices may result in tissue injury. If they are used, heated packs should be applied and only to truncal areas (neck, armpits, or groin).Active internal rewarming techniques typically are reserved for patients with a core body temperature <30°C (86°F). They may include the administration of warmed (42°C to 46°C [108°F to 115°F]) humidified oxygen, use of extracorporeal membrane oxygenators, peritoneal lavage, intravenous administration of warmed (42°C to 44°C [108°F to 111°F]) saline, and esophageal rewarming tubes. No randomized, controlled clinical trials have been reported comparing the efficacy of these methods.5AModifications of BLS for HypothermiaWhen the victim is hypothermic, pulse and respiratory rates will be slow, breathing will be shallow, and peripheral vasoconstriction will make pulses difficult to feel. For these reasons the BLS rescuer should assess breathing and, later, pulse for a period of 30 to 45 seconds to confirm respiratory arrest, pulseless cardiac arrest, or bradycardia profound enough to require CPR.2A If the victim is not breathing, initiate rescue breathing immediately. If possible, administer warmed (42°C to 46°C [108°F to 115°F]) humidified oxygen during bag-mask ventilation. If the victim is pulseless with no detectable signs of circulation, start chest compressions immediately. Do not withhold BLS until the victim is rewarmed.To prevent further core heat loss from the victim, remove wet garments from the victim; insulate or shield the victim from wind, heat, or cold; and if possible ventilate with warm, humidified oxygen.1A2A10A Avoid rough movement and do not apply external rewarming devices in the field. As soon as possible, carefully prepare the patient for transport to a hospital. All other field interventions require ACLS capability.Treatment of severe hypothermia (temperature <30°C [86°F]) in the field remains controversial. Many providers do not have the equipment or time to assess core body temperature adequately or to institute rewarming with warm, humidified oxygen or warm fluids, although these methods should be initiated when available to help prevent temperature afterdrop.1A10A11A12A We recommend core temperature determinations in the field with either tympanic membrane sensors or rectal probes (for EMS systems so equipped), but these should not delay transfer. To prevent VF, avoid rough movement and excess activity. Transport the patient in the horizontal position to avoid aggravating hypotension.If the hypothermic victim is in cardiac arrest, the general approach to BLS management still targets airway, breathing, and circulation, but some modifications in approach are required. If VT or VF is present, attempt defibrillation. Automated external defibrillators (AEDs) should be available on virtually all BLS rescue units, and if VF is detected, emergency personnel should be allowed to deliver up to 3 shocks to determine fibrillation responsiveness.2A If VF persists after 3 shocks, further defibrillation attempts should be deferred. Emergency personnel should immediately begin CPR and rewarming (administer warmed, humidified oxygen and warmed intravenous saline) and attempt to stabilize the victim for transportation. If core temperature is <30°C (86°F), successful conversion to normal sinus rhythm may not be possible until rewarming is accomplished.13ASome clinicians believe that patients who appear dead after prolonged exposure to cold temperatures should not be considered dead until they are near normal core temperature and are still unresponsive to CPR.2A13A Hypothermia may exert a protective effect on the brain and organs if the hypothermia develops rapidly in victims of cardiac arrest. When a victim of hypothermia is discovered, however, it may be impossible to separate primary from secondary hypothermia. If the victim is found in arrest in an extremely cold environment and the event was unwitnessed, emergency personnel and hospital providers will not know whether the arrest was due to hypothermia or whether hypothermia was a sequel to a normothermic arrest (eg, a man experiencing cardiac arrest while shoveling snow will develop hypothermia only after the arrest). In addition, the patient may have sustained additional organ insult. For example, successful resuscitation may be more difficult if drowning preceded hypothermia. When it is clinically impossible to know whether the arrest or the hypothermia occurred first, rescuers should attempt to stabilize the patient with CPR. If hypothermia is documented, initiate basic maneuvers to limit heat loss and begin rewarming. Physicians in the hospital should use their clinical judgment to decide when resuscitative efforts should cease in a hypothermic arrest victim.Modifications of ACLS for HypothermiaIf the hypothermic victim has not yet developed cardiac arrest, focus attention on assessment and support of oxygenation and ventilation, assessment and support of circulation, warming, and prevention of further heat loss. Handle the victim gently for all procedures; many physical manipulations (including endotracheal or nasogastric intubation, temporary pacing, or insertion of a pulmonary artery catheter) have been reported to precipitate VF.1A12A When specifically and urgently indicated, however, do not withhold such procedures. In a prospective multicenter study of hypothermia victims, careful endotracheal intubation did not result in a single incident of VF.14A In fact, the fear of precipitating VF during endotracheal intubation may be exaggerated,5A and it should not prevent or delay performance of careful intubation.Endotracheal intubation is required if the hypothermic victim is unconscious or if ventilation is inadequate. The intubation will serve 2 purposes: it will enable provision of effective ventilation with warm, humidified oxygen, and it can isolate the airway to reduce the likelihood of aspiration. We recommend ventilation with 100% oxygen via bag-mask before any intubation attempt.Conscious victims who are cold with only mild symptoms of hypothermia may be rewarmed with external active and passive rewarming techniques (eg, warm packs, warmed sleeping bags, and warm baths).ACLS management of cardiac arrest due to hypothermia is quite different from management of normothermic arrest. Active core rewarming techniques are the primary therapeutic modality in hypothermic victims in cardiac arrest or unconscious with a slow heart rate. The hypothermic heart may be unresponsive to cardioactive drugs, pacemaker stimulation, and defibrillation,12A and drug metabolism is reduced. Although administration of epinephrine and vasopressin has been shown to improve coronary artery perfusion pressure in animals,15A there is concern that administered medications, including epinephrine, lidocaine, and procainamide, can accumulate to toxic levels in the peripheral circulation if they are administered repeatedly in the severely hypothermic victim. For these reasons intravenous drugs are often withheld if the victim’s core body temperature is <30°C (86°F). If the victim’s core body temperature is >30°C (86°F), intravenous medications may be administered but with increased intervals between doses.The temperature at which defibrillation should first be attempted and how often it should be tried in the severely hypothermic patient have not been firmly established. In general, an attempt at defibrillation is appropriate if VT/VF is present. If the patient fails to respond to 3 initial defibrillation attempts or initial drug therapy, subsequent defibrillation attempts or additional boluses of medication should be deferred until the core temperature rises above 30°C (86°F).16A Bradycardia may be physiological in severe hypothermia, and cardiac pacing is usually not indicated unless bradycardia persists after rewarming.Treatment of severely hypothermic victims (core temperature <30°C [86°F]) in cardiac arrest in the hospital should be directed at rapid core rewarming. Techniques that can be used for in-hospital controlled rewarming include Administration of warmed, humidified oxygen (42°C to 46°C [108°F to 115°F])Administration of warmed intravenous fluids (normal saline) at 43°C (109°F) infused centrally at rates of approximately 150 to 200 mL/h (to avoid overhydration)Peritoneal lavage with warmed (43°C [109°F]) potassium-free fluid administered 2 L at a timeNote the following: Extracorporeal blood warming with partial bypass is the preferred method of active internal rewarming because it ensures adequate support of oxygenation and ventilation while the core body temperature is gradually rewarmed.1A10A12A17A18AThe use of esophageal rewarming tubes in the United States has not been reported, although they have been used extensively and successfully in Europe.19APleural lavage with warm saline instilled through a chest tube has also been used successfully.14ADuring rewarming, patients who have been hypothermic for >45 to 60 minutes are likely to require volume administration because their vascular space expands with vasodilation. Careful monitoring of heart rate and hemodynamic monitoring are important at this time. The routine administration of steroids, barbiturates, or antibiotics has not been documented to help increase survival or decrease postresuscitative damage.20A21ADuring rewarming, significant hyperkalemia may develop. Extreme hyperkalemia has been reported in avalanche victims who sustained crushing injuries and hypothermia.5A Severe hyperkalemia has also been reported among hypothermic patients in North America who did not sustain crushing injuries.22A In fact, severity of hyperkalemia has been linked with mortality. Management of hyperkalemia should include the traditional ACLS approach, with administration of calcium chloride, sodium bicarbonate, glucose plus insulin, and Kayexalate enema. More aggressive measures to reduce extremely high serum potassium may include dialysis or exchange transfusion.If drowning preceded the victim’s hypothermia, successful resuscitation will be rare. Because severe hypothermia is frequently preceded by other disorders (eg, drug overdose, alcohol use, or trauma), the clinician must look for and treat these underlying conditions while simultaneously treating the hypothermia. If the victim appears malnourished or has a history of chronic alcoholism, administer thiamine (100 mg IV) early during the rewarming procedures.Withholding and Cessation of Resuscitative EffortsIn the field, resuscitation may be withheld if the victim has obvious lethal injuries or if the body is frozen so completely that chest compression is impossible and the nose and mouth are blocked with ice.22APhysicians in the hospital should use their clinical judgment to decide when resuscitative efforts should cease in a hypothermic arrest victim. Complete rewarming is not indicated for all victims. Predictors of outcome may be unreliable in the face of injury or other complicating factors. A high (nonhemolyzed) serum potassium has been associated with a poor outcome, but these results will be unreliable in the presence of crushing injuries, hemolysis, or succinylcholine administration.5ACirculation. 2000;102(suppl I):I-229–I-252.Download figureDownload PowerPoint Figure 1. Figure. Hypothermia treatment algorithm.Download figureDownload PowerPoint Figure 2. Figure. Uniform reporting of submersion episodes. Table 1. Clinical Factors Associated With Submersion MortalityClassification GradeDefinitionMortality, %91Normal pulmonary auscultation, with coughing02Abnormal pulmonary auscultation, with rales in some fields0.63Pulmonary auscultation=acute pulmonary edema; no arterial hypotension5.24Acute pulmonary edema with arterial hypotension19.45Isolated respiratory arrest446Cardiopulmonary arrest93Download figureDownload PowerPoint Figure 3. Figure. Left lateral position for pregnant woman. Table 1A. Primary and Secondary ABCD Surveys: Modifications for Pregnant WomenACLS ApproachModifications to Standard BLS and ACLS GuidelinesPrimary ABCD SurveyAirway No modifications.BreathingNo modifications.CirculationChest compressions are ineffective when a woman in her last trimester lies on her back because the gravid uterus blocks the return of blood from the inferior vena cava.Start chest compressions after you place the woman on her left side with her back angled 30° to 45° from the floor.orStart chest compressions after you place a wedge under the woman’s right side (so that she lies on her left side).orHave 1 rescuer kneel next to the woman on her left side and gently pull the gravid uterus laterally to relieve pressure on the inferior vena cava.DefibrillationNo modifications. Defibrillatory shocks transfer no significant current to the fetus in utero.Secondary ABCD SurveyAirway No modifications to intubation techniques.BreathingNo modifications to secondary confirmation of successful intubation.A gravid uterus is known to push up the diaphragm and therefore decrease ventilatory volumes and make positive-pressure ventilation difficult.CirculationFollow standard ACLS recommendations for administration of all resuscitation medications.Differential Diagnosis and DecisionsDecide whether to perform emergency cesarean section (see Table 2). Table 2. The C-Section Decision: Factors to Consider in the Decision to Perform Emergency Cesarean Section During ArrestFactors to ConsiderCommentsArrest factors to consider Has >3 or 4 minutes passed since the onset of arrest? Has the mother responded to appropriate BLS and ACLS care? CPR performed at the proper angle? Proper placement of the endotracheal tube? IV medications?Arrest factors Almost no time passes before the clinican must decide whether to perform a C-section. The optimal chance for survival of mother and child depends on rapid delivery of the child. This decision must be made within 4 to 5 minutes of the maternal arrest. We purposely omit recommending a maximum time to allow before making the decision. Such a “standard” is of interest only to those involved in disputes over proper care during the arrest. There are many legitimate reasons for additional minutes of delay. Ensure that the mother has received superior resuscitative efforts. You cannot declare her “refractory” to CPR and ACLS unless all interventions have been implemented and implemented well.Mother-child factors Has the mother suffered an inevitably fatal injury? Is the only issue whether the child is old enough to have a good chance of meaningful survival? Is the fetus so small or young that survival is unlikely? Is the only issue whether the mother would benefit from C-section? Removing the fetus and placenta can be beneficial to the mother even when the fetus is too small to compress the inferior vena cava. Has too much time passed between the mother’s collapse and removal of the fetus? Is meaningful survival of either mother or infant highly unlikely or impossible?Mother-child factors Do not lose sight of the goal of this dramatic event: to yield a live, neurologically intact infant and mother. Carefully consider the future before pushing the margins of survivability. Even if the fetus’s chances of survival are extremely low, the mother may benefit from emergency C-section. Some obstetric experts argue for empirical postarrest C-section on any pregnant woman who has a cardiac arrest regardless of the cause.Setting and personnel Are appropriate supplies and equipment available? Is C-section within the rescuer’s “comfort zone” of skill? Are skilled pediatric support personnel available to care for the infant, especially if it is not at full term? Are obstetric personnel immediately available to support the mother after C-section? In both in-hospital and out-of-hospital settings, is there staff support and approval? In out-of-hospital settings, is bystander support available?Differential diagnosis Consider whether persistent arrest is due to an immediately reversible problem (eg, excess anesthesia, reaction to analgesia, or severe bronchospasm). If it is, do not perform C-section. Consider whether persistent arrest is due to a fatal, untreatable problem (eg, massive amniotic fluid embolism). If it is, quickly perform C-section to save the child, considering the viability of the child. References 1A Schneider SM. Hypothermia: from recognition to rewarming. Emerg Med Rep.1992; 13:1–20.Google Scholar2A Steinman AM. Cardiopulmonary resuscitation and hypothermia. Circulation. 1986;74(suppl IV):IV-29–IV-32.Google Scholar3A Holzer M, Behringer W, Schorkhuber W, Zeiner A, Sterz F, Laggner AN, Frass M, Siostrozonek P, Ratheiser K, Kaff A, Hypothermia for Cardiac Arrest (HACA) Study Group. Mild hypothermia and outcome after CPR. Acta Anaesthesiol Scand Suppl.1997; 111:55–58.MedlineGoogle Scholar4A Sterz F, Safar P, Tisherman S, Radovsky A, Kuboyama K, Oku K. Mild hypothermic cardiopulmonary resuscitation improves outcome after prolonged cardiac arrest in dogs [see comments]. Crit Care Med.1991; 19:379–389.CrossrefMedlineGoogle Scholar5A Larach MG. Accidental hypothermia [see comments]. Lancet.1995; 345:493–498.CrossrefMedlineGoogle Scholar6A Gilbert M, Busund R, Skagseth A, Nilsen PA, Solbo JP. Resuscitation from accidental hypothermia of 13.7 degrees C with circulatory arrest. Lancet.2000; 355:375–376. Letter.CrossrefMedlineGoogle Scholar7A Woodhouse P, Keatinge WR, Coleshaw SR. Factors associated with hypothermia in patients admitted to a group of inner city hospitals [see comments]. Lancet.1989; 2:1201–1205.MedlineGoogle Scholar8A Danzl DF, Pozos RS, Auerbach PS, Glazer S, Goetz W, Johnson E, Jui J, Lilja P, Marx JA, Miller J, et al. Multicenter hypothermia survey. Ann Emerg Med.1987; 16:1042–1055.CrossrefMedlineGoogle Scholar9A Gallaher MM, Fleming DW, Berger LR, Sewell CM. Pedestrian and hypothermia deaths among Native Americans in New Mexico: between bar and home [published erratum appears in JAMA.1992; 268:2378] [see comments]. JAMA. 1992;267:1345–1348.MedlineGoogle Scholar10A Weinberg AD, Hamlet MP, Paturas JL, White RD, McAninch GW. Cold Weather Emergencies: Principles of Patient Management. Branford, Conn: American Medical Publishing Co; 1990:10–30.Google Scholar11A Romet TT. Mechanism of afterdrop after cold water immersion. J Appl Physiol.1988; 65:1535–1538.CrossrefMedlineGoogle Scholar12A Reuler JB. Hypothermia: pathophysiology, clinical settings, and management. Ann Intern Med.1978; 89:519–527.CrossrefMedlineGoogle Scholar13A Southwick FS, Dalglish PH Jr. Recovery after prolonged asystolic cardiac arrest in profound hypothermia: a case report and literature review. JAMA.1980; 243:1250–1253.CrossrefMedlineGoogle Scholar14A Hall KN, Syverud SA. Closed thoracic cavity lavage in the treatment of severe hypothermia in human beings [see comments]. Ann Emerg Med.1990; 19:204–206.CrossrefMedlineGoogle Scholar15A Krismer AC, Lindner KH, Kornberger R, Wenzel V, Mueller G, Hund W, Oroszy S, Lurie KG, Mair P. Cardiopulmonary resuscitation during severe hypothermia in pigs: does epinephrine or vasopressin increase coronary perfusion pressure? Anesth Analg.2000; 90:69–73.CrossrefMedlineGoogle Scholar16A Reuler JB. Hypothermia: pathophysiology, clinical settings, and management. Ann Intern Med.1978; 89:519–527.CrossrefMedlineGoogle Scholar17A Zell SC, Kurtz KJ. Severe exposure hypothermia: a resuscitation protocol. Ann Emerg Med.1985; 14:339–345.CrossrefMedlineGoogle Scholar18A Althaus U, Aeberhard P, Schupbach P, Nachbur BH, Muhlemann W. Management of profound accidental hypothermia with cardiorespiratory arrest. Ann Surg.1982; 195:492–495.CrossrefMedlineGoogle Scholar19A Kristensen G, Drenck NE, Jordening H. Simple system for central rewarming of hypothermic patients. Lancet.1986; 2:1467–1468. Letter.Google Scholar20A Moss J. Accidental severe hypothermia. Surg Gynecol Obstet.1986; 162:501–513.MedlineGoogle Scholar21A Safar P. Cerebral resuscitation after cardiac arrest: research initiatives and future directions [published erratum appears in Ann Emerg Med.1993; 22:759] [see comments]. Ann Emerg Med. 1993;22:324–349.CrossrefMedlineGoogle Scholar22A Danzl DF, Pozos RS, Auerbach PS, Glazer S, Goetz W, Johnson E, Jui J, Lilja P, Marx JA, Miller J, et al. Multicenter hypothermia survey. Ann Emerg Med.1987; 16:1042–1055.CrossrefMedlineGoogle ScholarcirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & WilkinscirculationahaCirculationCirculationCirculation0009-73221524-4539Lippincott Williams & Wilkins220820002208200022082000220820002208200022082000Submersion or Near-DrowningSubmersion: OverviewThe most important and detrimental consequence of submersion without ventilation is hypoxia. The duration of hypoxia is the critical factor in determining the victim’s outcome. Therefore, oxygenation, ventilation, and perfusion should be restored as rapidly as possible. Immediate resuscitation at the scene is essential for survival and neurological recovery after submersion. This will require bystander provision of CPR plus immediate activation of the EMS system. Victims who have spontaneous circulation and breathing when they reach the hospital usually recover with good outcomes.Hypoxia can produce multisystem insult and complications, including hypoxic encephalopathy and acute respiratory distress syndrome (ARDS). These complications are relevant to the care of the victim after resuscitation and will not be addressed here.Victims of submersion may develop primary or secondary hypothermia. If the submersion occurs in icy water (<5°C [41°F]), hypothermia may develop rapidly and provide some protection against hypoxia. Such effects, however, have typically been reported only after submersion of small victims in icy water.1B Hypothermia may also develop as a secondary complication of the submersion and subsequent heat loss through evaporation during attempted resuscitation. In these victims the hypothermia is not protective (see Hypothermia earlier in this section).All victims of submersion who require resuscitation should be transported to the hospital for evaluation and monitoring. The hypoxic insult can produce an increase in pulmonary capillary permeability with resultant pulmonary edema.Definitions, Classifications, and Prognostic IndicatorsA number of terms are used to describe submersion. Clinicians and others who report about submersion often apply the misunderstood term drowning to victims who die within 24 hours of a submersion episode. They apply the term near-drowning to submersion victims who survive >24 hours after the episode if the victim also requires active intervention for one or more submersion complications. Complications can include pneumonia, ARDS, or neurological sequelae. Rescuers and emergency personnel find these definitions irrelevant, because the drowning versus near-drowning distinction often cannot be made for 24 hours.Pending the future recommendations of an ILCOR Task Force revising the Utstein Guidelines, the Guidelines 2000 Conference recommends these terms:Water rescue: a person who is alert but experiences some distress while swimming. The victim may receive some help from others and displays minimal, transient symptoms, such as coughing, that clear quickly. In general the person is left on shore and is not transported for further evaluation and care.Submersion: a person who experiences some swimming-related distress that is sufficient to require support in the field plus transportation to an emergency facility for further observation and treatment.Drowning: this is a “mortal” event; this refers to submersion events in which the victim is pronounced dead at the scene of the attempted resuscitation, in the Emergency Department (ED), or in the hospital. With drowning, the victim suffers cardiopulmonary arrest and cannot be resuscitated. Death can be pronounced at the scene, in the ED, or within 24 hours of the event. If death occurs after 24 hours, the term drowning is still used as in “drowning-related death.” Up until the time of drowning-related death, refer to the victim as a submersion victim.We recommend that the term near-drowning no longer be used.We recommend that clinicians, managers, and research teams stop the classification of submersion victims by submersion fluid (salt water versus fresh water). Although there are theoretical differences between the effects of salt-water and fresh-water submersion in the laboratory, these differences are not clinically significant. The single most important factor that determines outcome of submersion is the duration of the submersion and the duration and severity of the hypoxia.Although survival is uncommon in victims who have undergone prolonged submersion and require prolonged resuscitation,2B3B successful resuscitation with full neurological recovery has occasionally occurred in near-drowning victims with prolonged submersion in extremely cold water.4B5B6B Therefore, resuscitation should be initiated by rescuers at the scene unless there is obvious physical evidence of death, such as putrefaction, dependent lividity, or rigor mortis. The victim should be transported with continued CPR to an emergency facility. In many European countries a physician will be available on scene as part of the EMS team.Prognostic indicators after submersion in children and adolescents (up to 20 years of age) include 3 factors associated with 100% mortality in one study1B : Submersion duration >25 minutesResuscitation duration >25 minutesPulseless cardiac arrest on arrival in the EDAdditional factors associated with poor prognosis in the same study1B included Presence of VT/VF on initial ECG (93% mortality)Fixed pupils noted in the ED (89% mortality)Severe acidosis (89% mortality) in the EDRespiratory arrest (87% mortality) in the EDIn a more recent study of adults and children from the same investigators" @default.
• W4252054284 created "2022-05-12" @default.
• W4252054284 date "2000-08-22" @default.
• W4252054284 modified "2023-10-18" @default.
• W4252054284 title "Part 8: Advanced Challenges in Resuscitation" @default.
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• W4252054284 doi "https://doi.org/10.1161/circ.102.suppl_1.i-229" @default.
• W4252054284 hasPublicationYear "2000" @default.
• W4252054284 type Work @default.

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