Background

Drowning and near-drowning are common causes of accidental death worldwide and remain leading causes of accidental death among young children in industrialised countries. Respiratory complications such as non-cardiogenic pulmonary oedema, acute respiratory distress syndrome (ARDS) and pneumonia are often seen.1 In order to diagnose these conditions chest x-ray (CXR) is recommended at baseline. However, as the CXR may underestimate the severity of lung injury further diagnostic tools are warranted.1 ,2

Lung ultrasound (LUS) can accurately diagnose, quantify and monitor non-cardiogenic pulmonary oedema, ARDS and pneumonia. Hence many investigators have found LUS to be superior to conventional chest x-ray in these settings.3,–,5 Thus, LUS may have a potential impact on the evaluation of drowning or near-drowning victims.

Case presentation

A 71-year-old man with atrial fibrillation, hypercholesterolaemia, arterial hypertension, ischaemic heart disease and type 2 diabetes mellitus was brought to hospital after accidental near-drowning in seawater. On arrival on scene of the accident, the emergency medical services recorded a transcutaneous oxygen saturation of 55%. Supplemental oxygen was administered, and the patient was evacuated to the level 1 trauma centre at this hospital.

Investigations

On admission, the patient was found alert and only mildly distressed. No signs or history of trauma was noticed. He was systematically evaluated with the ABCDE approach. (A) Upper airways were patent without support. (B) No cyanosis on high-concentration oxygen. Both sides of the chest were rising on inspiration, and bilateral crackles were present on lung auscultation. Transcutaneous oxygen saturation was 83% on 8 litres of oxygen/min, increasing to 93% on 15 litres of oxygen/min using a non-rebreathing system. Respiratory frequency was 22/min. (C) The skin was cold, but dry. Blood pressure was 134/68 mm Hg and pulse 82/min. No neck-vein distension was present and the trachea was in the mid-line. (D) Glasgow coma scale score was 15. Blood-glucose 8.3 mmol/litre. Spontaneous movement of all extremities was noticed. (E) Rectal temperature was 35.0°C.

With the patient in the supine position LUS was performed and multiple B-lines on the anterior and lateral surfaces of both lungs were found (figure 1). Lung sliding was present, and the pleural line was normal with no fragmentations. No pleural effusion or consolidations were seen. Focus assessed transthoracic echocardiography (FATE) showed no pericardial effusion and a normal global left ventricular function.

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Figure 1

(A) Chest x-ray taken 2 h after arrival at the hospital, showing bilateral infiltrates consistent with pulmonary oedema and a widened heart shadow. (B) Chest x-ray taken 3 days after arrival. The bilateral infiltrates have disappeared, the heart shadow is unaltered. (C) Lung ultrasound image from a patient with pulmonary oedema illustrating the same findings as were seen when lung ultrasound was performed on the near-drowning victim. The horizontal pleural line appears normal and multiple vertical B-lines are present. The multiple B-lines were present on the anterior and lateral surfaces of both lungs consistent with pulmonary oedema.

Arterial blood gas analysis on arrival: pH=7,34, pCO₂=5,42 kPa, pO₂=6,76 kPa, standard bicarbonate=21.2 mmol/l and lactate=3.8 mmol/l. Venous blood analyses were notable for leucocytosis. Electrolytes and tests for renal and liver function were normal. ECG showed atrial fibrillation with an average ventricular action of 75 beats/min, but no signs of acute myocardial infarction.

CXR taken 2 h after LUS showed bilateral infiltrates consistent with pulmonary oedema (figure 1).

Differential diagnosis

The findings on LUS and CXR were diagnostic of pulmonary oedema, with no signs of ARDS or pneumonia. A diagnosis of cardiogenic pulmonary oedema secondary to myocardial ischemia was not consistent with neither the clinical presentation and history, the ECG nor the FATE examination, leaving the final diagnosis of non-cardiogenic pulmonary oedema.

Treatment

The patient was closely monitored and treated with high-flow oxygen via a non-rebreathing mask.

Outcome and follow-up

On the third day, the patient was reaching his usual state of health, which in combination with a normalised CXR (figure 1) allowed discharge from the hospital.

Discussion

To our knowledge, this case report is the first to describe the use of LUS in the evaluation of a patient admitted to hospital after a near-drowning accident. Point-of-care LUS is already widely used in trauma, intensive care and emergency medicine, and it would be easy to apply the same principles in the evaluation of acute respiratory failure in a drowning or near-drowning victim.

In other types of pulmonary oedema LUS has been shown capable to monitor changes in the degree of interstitial oedema.3 Thus, theoretically repeated LUS examinations could also be used as an easy bedside tool to monitor the response of initiated treatment.

This case report emphasises the clinical value of LUS in the evaluation of a near-drowning victim. As the evidence in this field is sparse, further studies should be conducted in order to evaluate whether LUS can be legitimated as a diagnostic tool in the evaluation of drowning and near-drowning patients.