Near drowning: is emergency department cardiopulmonary resuscitation or intensive care unit cerebral resuscitation indicated?

Department of Pediatrics, Children's Hospital of Philadelphia, University of Pennsylvania School of Medicine 19104-4399.
Critical Care Medicine (Impact Factor: 6.12). 03/1993; 21(3):368-73. DOI: 10.1097/00003246-199303000-00013
Source: PubMed

ABSTRACT a) To report the neurologic outcome of a series of near-drowning victims treated with supportive management without aggressive cerebral resuscitation; and b) to identify patient characteristics that indicate prognosis and guide therapy at the scene, the Emergency Department, and in the intensive care unit (ICU).
Retrospective review of all near-drowning patients requiring admission to the ICU over a 6-yr period (1/1/82 to 12/31/88). Hospital records were examined for the circumstances of submersion and rescue, patient condition on arrival in the Emergency Department and ICU, treatments, hospital course, and ultimate outcome.
Emergency departments of the referring hospital and ICU of Children's Hospital.
Forty-four pediatric submersion victims were treated with therapy limited to the support of vital functions. Three patients who met cold-water drowning criteria were excluded from the analysis for predictors of neurologic outcome.
In our warm-water near-drowning patients, 56% survived neurologically intact, 32% survived in a persistent vegetative state, and the remaining 32% died. Unreactive pupils in the Emergency Department and a Glasgow Coma Score of < or = 5 on arrival to the ICU were the best independent predictors of poor neurologic outcome (odds ratio and 95% confidence intervals 374 [17 to 16,000] and 51 [5 to 2,200], respectively). However, no predictor was absolute and two nonhypothermic patients who arrived to the Emergency Department without vital signs, requiring cardiopulmonary resuscitation and cardiotonic medications, had full neurologic recovery.
Our results cast further doubt on the utility of aggressive forms of cerebral monitoring and resuscitation and emphasize the need for initial full resuscitation in the Emergency Department.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Therapeutic hypothermia in adult victims who suffer cardiac arrest following drowning has been applied in only a small number of cases. In the last 4 years, we have employed therapeutic hypothermia to decrease hypoxia-induced brain injury in these patients. The purpose of the present study was to report the results of the treatment of these patients. This study investigated the utilisation of therapeutic hypothermia on consecutive patients with cardiac arrest because of drowning between 2005 and 2008. The study was conducted retrospectively, collecting data by reviewing medical records. Hypothermia, with a target temperature of 32-34°C, was induced for 24 h. Neurological outcomes were classified using the cerebral performance categories (CPCs). The primary outcome was neurological function at discharge. Twenty patients were treated with therapeutic hypothermia. Four patients (20%) exhibited a favourable neurological outcome (CPC 1-2). Two patients (10%) remained in a vegetative state at discharge (CPC 4), and 14 patients (70%) died (CPC 5). The most common complications during therapeutic hypothermia were pancreatitis and rhabdomyolysis. A longer duration of advanced cardiac life support (P = 0.035), an absence of motor response to pain after 3 days (P = 0.003), an abnormal brain imaging (P = 0.005) and a lack of cortical response to somatosensory evoked potential (P = 0.008) were related to an unfavourable outcome (CPC 3-5). The present study did not demonstrate an advantage of therapeutic hypothermia in adult cardiac arrest after drowning compared with previous studies treated with conventional therapy. Further prospective studies are needed to evaluate the effects of therapeutic hypothermia.
    Acta Anaesthesiologica Scandinavica 10/2011; 56(1):116-23. · 2.36 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Drowning is a major source of mortality and morbidity in children worldwide. Neurocognitive outcome of children after drowning incidents cannot be accurately predicted in the early course of treatment. Therefore, aggressive out-of-hospital and in-hospital treatment is emphasized. There are "miracle" cases after long submersion times that have been reported in the medical literature, which mostly concern small children. However, many of the survivors will remain severely neurologically compromised after remarkably shorter submersion times and will consequently be a great burden to their family and society for the rest of their lives.The duration of submersion, the need of advanced life support at the site of the accident, the duration of cardiopulmonary resuscitation, whether spontaneous breathing and circulation are present on arrival at the emergency room are important factors related to survival with mild neurological deficits or intact function in drowned children. Data on long-term outcome are scarce. The used outcome measurement methods and the duration of follow-up have not been optimal in most of the existing studies. Proper neurological and neurophysiological examinations for drowned children are superior to outcome scales based chart reviews. There is evidence that gross neurological examination at the time of discharge from the hospital in young children does not reveal all the possible sequelae related to hypoxic brain injury and thus long-term follow-up of drowned resuscitated children is strongly recommended.
    Scandinavian Journal of Trauma Resuscitation and Emergency Medicine 08/2012; 20(1):55. · 1.68 Impact Factor
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: Drowning is a leading cause of accidental death. Survivors may sustain severe neurologic morbidity. There is negligible research specific to brain injury in drowning making current clinical management non-specific to this disorder. This review represents an evidence-based consensus effort to provide recommendations for management and investigation of the drowning victim. Epidemiology, brain-oriented prehospital and intensive care, therapeutic hypothermia, neuroimaging/monitoring, biomarkers, and neuroresuscitative pharmacology are addressed. When cardiac arrest is present, chest compressions with rescue breathing are recommended due to the asphyxial insult. In the comatose patient with restoration of spontaneous circulation, hypoxemia and hyperoxemia should be avoided, hyperthermia treated, and induced hypothermia (32-34 °C) considered. Arterial hypotension/hypertension should be recognized and treated. Prevent hypoglycemia and treat hyperglycemia. Treat clinical seizures and consider treating non-convulsive status epilepticus. Serial neurologic examinations should be provided. Brain imaging and serial biomarker measurement may aid prognostication. Continuous electroencephalography and N20 somatosensory evoked potential monitoring may be considered. Serial biomarker measurement (e.g., neuron specific enolase) may aid prognostication. There is insufficient evidence to recommend use of any specific brain-oriented neuroresuscitative pharmacologic therapy other than that required to restore and maintain normal physiology. Following initial stabilization, victims should be transferred to centers with expertise in age-specific post-resuscitation neurocritical care. Care should be documented, reviewed, and quality improvement assessment performed. Preclinical research should focus on models of asphyxial cardiac arrest. Clinical research should focus on improved cardiopulmonary resuscitation, re-oxygenation/reperfusion strategies, therapeutic hypothermia, neuroprotection, neurorehabilitation, and consideration of drowning in advances made in treatment of other central nervous system disorders.
    Neurocritical Care 09/2012; · 3.04 Impact Factor