Near-drowning in cold fresh water: current treatment regimen

Abstract

Near-drowning victims are admitted to tertiary care facilities within a few hours of submersion. Following initial improvements, many patients undergo progressive cerebral deterioration. A retrospective study (1970-1974) of 30 patients at The Hospital for Sick Children, Toronto, revealed a mortality of 3.3 per cent and permanent brain damage in 30 per cent. At the same time, excellent results were reported, using an aggressive treatment of closed-head injuries, following cold-water water drownings and in the use of profound hypothermia in cardiovascular surgery. In 1975 some specific therapeutic measures were instituted for near-drowning victims and have subsequently been revised and extended. The goal of treatment is to prevent a significant rise in intracranial pressure while maintaining optimal conditions for cerebral recovery. Therefore therapy is instituted immediately and continued as long as necessary. Treatment is often facilitated by the presence of immersion hypothermia. This regimen includes: (a) severe restriction of hydration; (b) controlled ventilation to obtain high oxygen blood levels and mild hypocarbia (PaCO 24 kPa [30 mm Hg]); (c) moderate hypothermia (30° C); (d) control of hyper-excitability by large doses of barbiturate and steriods and (e) control of hyper-rigidity by relaxants. Monitoring of all body systems is necessary and the continuous monitoring of intracranial pressure is mandatory. The results during evolution of treatment (1975-1977) in 26 cases showed 15.4 per cent mortality and brain damage in 7.7 per cent. In this limited series, with numerous variables, these results suggest that this therapeutic trial should be continued. In conclusion, statistical proof to justify these measures is not yet available clinically or experimentally. However, the magnitude of the problem, when associated with the minimal morbidity of treatment, justifies continuation of the program and possible extension to other types of brain injury. © 1978 Canadian Anesthesiologists.