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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.
(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.

Search 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)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Sladen A and 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.
Martin CM and 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.
Modell JH et al, 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
Corbin DO and 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.
Oakes DD et al, 1982, USA	40 near-drownings.	Retrospective analysis of charts.	Survival	30 dexamethasone ? number died	Retrospective. Not controlled trial. Variable doses, ? data.
van Berkel M 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.

Comment(s)

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.

Clinical Bottom Line

There is very little evidence on the value of giving intra-venous steroids in cases of near-drowning.

References

1. Sladen A, Zauder HL. Methylprednisolone therapy for pulmonary edema following near drowning. JAMA 1971;215:1793-95.
2. Martin CM, Barrett O Jr. Drowning and near-drowning: A review of ten years' experience in a large Army Hospital. Milit Med 1971;136:439-43.
3. Modell JH, Graves SA, Ketover A. Clinical course of 91 consecutive near-drowning victims. Chest 1976;70:231-38.
4. Corbin DO, Fraser HS. A review of 98 cases of near-drowning at the Queen Elizabeth Hospital, Barbados. W I Med J 1981;30:22-29.
5. Oakes DD, Sherck JP, Maloney JR, Charters AC 3rd. Prognosis and management of victims of near-drowning. J Trauma 1982;22:544-49.
6. van Berkel M, Bierens JJ, Lie RL, et al. Pulmonary oedema, pneumonia and mortality in submersion victims; a retrospective study in 125 patients. Intensive Care Med 1996;22:101-7.