Near drowning: radiological and clinical findings.

Near drowning: radiological and clinical findings. Poster No.: C-1566 Congress: ECR 2011 Type: Educational Exhibit Authors: R. Scandiffio, C. Giaconi, M. Barattini, P. Vagli, P. Bemi, A. 1 2 2 2 1 3 2 2 2 3 Mantarro, C. Bartolozzi ; pisa/it, Pisa/IT, Carrara (MS)/IT Keywords: Foreign bodies, CT, Conventional radiography, Thorax DOI: 10.1594/ecr2011/C-1566 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. www.myesr.org Page 1 of 20

Learning objectives To illustrate the radiological findings in near drowning. To evaluate complications and evolution. Images for this section: Fig. 1: Summersion in a 45 years old man. Chest X- ray obtained at the time of ammission reveals tiny alveolar opacities. Apices are spared. Heart diameter is preserved. Page 2 of 20

Fig. 2: Alveolar opacities (detail). Page 3 of 20

Background Drowning on page 5 is a suffocation by summersion [1], especially in water; it is an important cause of death and morbidity, especially in young age and is usual much higher in males than in females. In Italy, from 1969 to 1997 the mortality dropped from 1200 to 500 cases/year, and mortality rates decreased in all the age subgroups, but particularly in that of young people; this analysis indicates that some general factors have played an important role, like a better education and information, a greater surveillance by adults and a better organisation of summer resorts [2]. Near drowning is defined as survival, at last for 24 hours, after water inhalation; in Italy there are not statistical data about near drowning. Unconsciousness can be absent, and pulmonary involvement can be present also without cessation of breathing. There are some physiological considerations to do. Immersion in thermoneutral water hardly causes cardiorespiratory distress in a healthy person. Immersion in cold water causes reflexes called cold shock response, that includes peripheral vasoconstriction, 42-49% increase in heart rate and 59-100% increase in cardiac output, with a resulting increase in arterial and venous pressures. These responses increase cardiac workload and, coupled with catecolamine release, can lead to cardiac arrhytmias. In elderly people with cardiac and vascular disease, immersion in cold water can cause cardiovascular accident, than resulting in drowning. Hypothermia play an important role in successful outcome in near drowning, maybe related to brain protection from hypoxia; also diving response ( peripheral vasoconstriction, apnoea, bradycardia) is an important mechanism in oxygen saving. After submersion, conscious victim try to breath- hold until PaCO2 values are intolerable and respiratory muscle and cutaneous afferences force to take a breath (1). Three stages of near drowning are usually recognize. Stage 1. Inhalation of a small amount of water leads to laryngospasm, that is usually temporary and prevent further water aspiration. Sometimes, laryngospasm persists, negative pressure arises and can cause pulmonary lesions; this entity is called dry drowning. Stage 2. Patients present with laryngospasm and early water swallowing in the stomach. Stage 3. In 85-90% of victims, laryngospasm relaxes because of hypoxia and large amounts of water are inhalated. In 10-15% of patients, laryngospasm persists and they present dry drowning. Hypoxia is the first cause of damage in stage 2 and 3: lack of oxygen leads to cytokine release and permeability edema. Aspirated water damages endothelium and pneumocytes, and leads to surfactant production, causing DAD (diffuse alveolar damage). Aspiration of sand and debris can worsen the state. If situation persists, state can evolve into ARDS (adult respiratory distress syndrome) [3]. In these victims, near- drowning associated pneumonia would be expected; the case fatality rate associated with near-drowning-associated pneumonia is 60% (30 deaths in Page 4 of 20

50 cases); several factors associated with the pathophysiology of near-drowning likely determine the probability that pneumonia will develop. 10% of victims don't aspirate; it would be expected that a significant minority of these individuals would avoid aspiration and possibly be at lower risk for complicating pneumonia. Aspiration of gastric fluid is quite common in near- drowning patients, causing inflammatory damage in pulmonary parenchyma and contamination. The chemical composition of the water certainly affects the type of pathogenic organism involved in the pulmonary infection, but it is unknown if this factor affects the overall rate of infection [4]. We will describe 8 cases of near drowning evaluated in Pisa from July 2008 to September 2010. 2 cases are classified in stage 1, while 6 cases are in stage 2-3; we evaluate their evolution and complications (ARDS in 1 patient). Chest radiography and CT images are evaluated. Images for this section: Page 5 of 20

Fig. 1: Summersion in a 84 years old man: a case of drowning (man died few hours later). Chest- X ray obtained in 1 hour from summersion reveals multiple, confluent consolidations; opacities are fluffy and ill- defined. Peribronchial cuffing and cardiac enlargement are also visible. Likely pneumomediastinum is visible on the right. Fig. 2: Summersion in a 84 years old man: a case of drowning (man died few hours later). Chest X- ray obtained 3 hours later. Pattern is evolved. Page 6 of 20

Fig. 3: Summersion in a 84 years old man: a case of drowning (man died few hours later). Alveolar opacities (detail). Page 7 of 20

Imaging findings OR Procedure details Near- drowning is an emergency: an accurate, rapid assessment is fundamental, and chest X- ray is supportive in distinguish patients with or without evidence of aspiration and allows to evaluate therapy response and possible complications. CT on page 11 can be helpful in near- drowning associated to trauma, especially in suspicion of spinal chord injury, and in unexpected deterioration of victim condition. Stage 1 on page is characterized by perihilar alveolar consolidations on page, Kerley lines and peribronchial thickening; these findings are transient and usually disappear in 24-48 hours. Apices, bases and lateral lung fields tend to be spared. on page Radiological findings in stage 2 and 3 on page 8 are quite similar and aspecific; airspace consolidations can involve an entire lobe or present as small, ill- defined opacities. No changes in heart diameter are observed. Sand aspiration can lead to sand bronchogram, with radiodense material in tracheobronchial tree [7]. Resolution depends on alveolar and endothelium damage, but is usually slow and can be complicated by ARDS and superinfections [3, 5, 6]. ARDS and pneumonia present aspecific radiological findings in near- drowning; aerobic gram- negative bacteria are prevalent causes of pneumonia associated with neardrowning and usually manifest as lobar pneumonia. ARDS on page 13 is the most severe form of permeability edema associated with diffuse alveolar damage (DAD). Three stages are recognized in ARDS. Exudative stage is characterized by interstitial edema that rapidly evolves into alveolar consolidation in peripheral- cortical distribution with air bronchogram. ARDS tipically presents a gravitational gradient. In proliferative stage (stage 2), ground- glass areas appear, followed by fibrosis and subpleural and intrapulmonary cysts ( fibrotic stage). Images for this section: Page 8 of 20

Fig. 1: Summersion in a 82 years old man: near- drowning complicated with ARDS. Chest X- ray obtained at the time of ammission reveals tiny perihilar opacities. Page 9 of 20

Fig. 2: Summersion in a 82 years old man: near- drowning complicated with ARDS. CT obtained 7 hours later reveals bilateral airspace consolidation from apices to bases with anteroposterior gradient and air bronchogram. Ground - glass areas are also visible. Page 10 of 20

Fig. 3: Summersion in a 82 years old man: near- drowning complicated with ARDS. CT obtained 7 hours later reveals bilateral airspace consolidation from apices to bases with anteroposterior gradient and air bronchogram. Ground - glass areas are also visible. Fig. 4: Summersion in a 82 years old man: near- drowning complicated with ARDS. CT obtained 7 hours later reveals bilateral airspace consolidation from apices to bases with anteroposterior gradient and air bronchogram. Ground - glass areas are also visible. Page 11 of 20

Fig. 5: Summersion in a 82 years old man: near- drowning complicated with ARDS. CT obtained 7 hours later reveals bilateral airspace consolidation from apices to bases with anteroposterior gradient and air bronchogram. Ground - glass areas are also visible. Page 12 of 20

Fig. 6: Summersion in a 82 years old man: near- drowning complicated with ARDS. CT obtained 7 hours later reveals bilateral airspace consolidation from apices to bases with anteroposterior gradient and air bronchogram. Ground - glass areas are also visible. Page 13 of 20

Fig. 7: Summersion in a 82 years old man: near- drowning complicated with ARDS. CT obtained 7 hours later reveals bilateral airspace consolidation from apices to bases with anteroposterior gradient and air bronchogram. Ground - glass areas are also visible. Page 14 of 20

Fig. 8: Summersion in a 82 years old man: near- drowning complicated with ARDS. Chest radiograms obtained 3 and 9 days later (C- PAP therapy) reveal progressive resolution. Page 15 of 20

Fig. 9: Summersion in a 82 years old man: near- drowning complicated with ARDS. Chest radiograms obtained 3 and 9 days later (C- PAP therapy) reveal progressive resolution. Page 16 of 20

Conclusion Near- drowning diagnosis is based on anamnestic history, but chest X- ray gives information about pulmonary involvment and is an useful tool in monitoring therapy response. CT is supportive in trauma associated to near- drowning and in ARDS and pneumonia evaluation. Images for this section: Fig. 1: Summersion in a 32 years old freediving man. Chest X- Ray obtained at the time of ammission reveals few, ill- defined perihilar alveolar consolidation. Apices, bases and lateral lung fields tend to be spared. Page 17 of 20

Fig. 2: Summersion in a 32 years old freediving man. Chest X- ray obtained 5 days later reveals persistence of alveolar consolidations. Page 18 of 20

Fig. 3: Summersion in a 32 years old freediving man. Chest X- ray obtained 5 days later reveals persistence of alveolar consolidations. Page 19 of 20

Personal Information References 1] Immersion, near-drowning and drowning. Golden FS, Tipton MJ, Scott RC. Br J Anaesth. 1997 Aug;79(2):214-25. Review 2] [Accidents in recreational waters]. Giustini M, Ade P, Taggi F, Funari E. Ann Ist Super Sanita. 2003;39(1):69-76 3] Clinical and Radiologic Features of Pulmonary Edema; T. Gluecker et al., November 1999 RadioGraphics, 19, 1507-1531. 4] Pneumonia associated with near-drowning. Ender PT, Dolan MJ. Clin Infect Dis. 1997 Oct;25(4):896-907. Review. 5] Aspiration Diseases: Findings, Pitfalls, and Differential Diagnosis1; Tomás Franquet, MD, Ana Giménez, MD, Nuria Rosón, MD, Sofía Torrubia, MD, José M. Sabaté, MD and Carmen Pérez, MD; Radiographics. 2000;20:673-685. 6] MDCT Evaluation of Foreign Bodies and Liquid Aspiration Pneumonia in Adults; Miyoung Kim1, Ki Yeol Lee1, Kyung Won Lee2 and Kyongtae T. Bae3, AJR 2008; 190:907-915 7] Sand aspiration with near-drowning. Radiographic and bronchoscopic findings. Dunagan DP, Cox JE, Chang MC, Haponik EF. Am J Respir Crit Care Med. 1997 Jul;156(1):292-5. Review. Page 20 of 20