Steroids in the management of near-drowning
Date First Published:
March 1, 2000
Last Updated:
May 6, 2003
Report by:
Bernard A Foex, Specialist Registrar (Manchester STEM)
Search checked by:
Russell Boyd, Manchester STEM
Three-Part Question:
In a case of [near-drowning] does the [use of steroids] affect [outcome in terms of survival or pulmonary complications]?
Clinical Scenario:
A 15 year old boy was playing in the local canal. He jumped off a small bridge and got his foot caught in an old shopping trolley on the bottom. He was pulled out but he was unconscious and apnoeic. He was given BLS by the paramedics so that when he arrived in A&E he was conscious, tachypnoeic, and centrally cyanosed. He had rhonchi and coarse crepitations in both lung fields. You wonder whether he would benefit from intra-venous steroids.
Search Strategy:
Medline 1966 to 08/01 using the OVID interface.
Search Details:
(Exp drowning/ or exp near drowning/ or "drowning".mp) AND (exp steroids/ or "steroid".mp OR exp adrenal cortex hormones/ or "adrenal cortex hormones".mp OR exp adrenal cortex hormones/ or "corticosteroids".mp OR exp methylprednisolone/ or "methylprednisolone".mp OR exp hydrocortisone/ or "hydrocortisone".mp OR exp dexamethasone/ or "dexamethasone".mp OR exp prednisone/ or "prednisone".mp). LIMIT to human AND English language.
Outcome:
33 papers were identified by the search strategy. There were no prospective randomised placebo-controlled trials but there was one prospective study. 4 papers were retrospective analyses of case reports and included some data on the effects of steroids. Another retrospective analysis was found from the references. Of the remaining papers, nine were individual case reports or short series. All the others were irrelevant.
Relevant Paper(s):
| Study Title | Patient Group | Study type (level of evidence) | Outcomes | Key results | Study Weaknesses |
|---|---|---|---|---|---|
| Methylprednisolone therapy for pulmonary edema following near drowning. Sladen A, Zauder HL. 1971, USA | 10 fresh water near-drownings. | Prospective (?) No steroid versus methylprednisolone (5mg/kg/24 hr iv divided into 6 equal doses). | Survival | All steroid group survived, all others died. | Consecutive groups. Before and after study does not take account of potential change in other aspects of practice with time. Small numbers. |
| Drowning and near-drowning: A review of ten years' experience in a large Army Hospital. Martin CM, Barrett O Jr. 1971, USA | 64 cases near-drowning, 29 cases drowning. | Retrospective analysis. Unspecified steroid treatment. | Descriptive analysis | 9 cases received steroids - no benefit shown. | Retrospective. No standard treatment. Not a controlled trial. |
| Clinical course of 91 consecutive near-drowning victims. Modell JH, Graves SA, Ketover A. 1976, USA | 91 near-drownings (salt, fresh, brackish). (1-79 years). |
Retrospective analysis of charts. | Survival | 52 given steroids - 8 died. 38 no steroids - 2 died. | Retrospective. Different steroids, different doses. Not a controlled trial |
| A review of 98 cases of near-drowning at the Queen Elizabeth Hospital, Barbados. Corbin DO, Fraser HS. 1981, Barbados | 98 near-drownings. | Retrospective analysis of charts. | No outcome measure as all were survivors | 66 received unspecified steroids. | Retrospective. Not a controlled trial No deaths. Therefore a comparison of death rates impossible. |
| Prognosis and management of victims of near-drowning. Oakes DD, Sherck JP, Maloney JR, Charters AC 3rd. 1982, USA | 40 near-drownings. | Retrospective analysis of charts. | Survival | 30 dexamethasone ? number died | Retrospective. Not controlled trial. Variable doses, ? data. |
| Pulmonary oedema, pneumonia and mortality in submersion victims; a retrospective study in 125 patients. van Berkel M, Bierens JJ, Lie RL, et al. 1996, Netherlands | 125 submersion victims. | Retrospective analysis of charts. Prednisolone (10.6 mg/kg, then 2.5 mg/kg/day; 1.8d) | Pneumonia | Steroids: no effect on pneumonia. | Retrospective. Not controlled trial. No survival data. |
Author Commentary:
All the case reports suggested that steroids are of benefit in near-drowning.
The only prospective study included 10 patients. However, all seven of those given methylprednisolone (5mg/kg/24 hours i.v. divided into 6 equal doses) survived. All the other studies were retrospective analyses of case notes. None showed any benefit from steroids, but they did not provide enough data about the steroids used, the doses used, or specific outcomes to provide reliable evidence.
Case reports, which may be inherently biased, show some benefit, but there is no good evidence that the routine use of intra-venous steroids improves the outcome in cases of near-drowning. There may be a case for conducting a properly controlled trial to settle the issue.
The only prospective study included 10 patients. However, all seven of those given methylprednisolone (5mg/kg/24 hours i.v. divided into 6 equal doses) survived. All the other studies were retrospective analyses of case notes. None showed any benefit from steroids, but they did not provide enough data about the steroids used, the doses used, or specific outcomes to provide reliable evidence.
Case reports, which may be inherently biased, show some benefit, but there is no good evidence that the routine use of intra-venous steroids improves the outcome in cases of near-drowning. There may be a case for conducting a properly controlled trial to settle the issue.
Bottom Line:
There is very little evidence on the value of giving intra-venous steroids in cases of near-drowning.
References:
- Sladen A, Zauder HL.. Methylprednisolone therapy for pulmonary edema following near drowning.
- Martin CM, Barrett O Jr.. Drowning and near-drowning: A review of ten years' experience in a large Army Hospital.
- Modell JH, Graves SA, Ketover A.. Clinical course of 91 consecutive near-drowning victims.
- Corbin DO, Fraser HS.. A review of 98 cases of near-drowning at the Queen Elizabeth Hospital, Barbados.
- Oakes DD, Sherck JP, Maloney JR, Charters AC 3rd.. Prognosis and management of victims of near-drowning.
- van Berkel M, Bierens JJ, Lie RL, et al.. Pulmonary oedema, pneumonia and mortality in submersion victims; a retrospective study in 125 patients.