Title: Drowning and Therapeutic Hypothermia: Dead Man Walking

Author(s): Angela Kavenaugh, D.O., Jamie Cohen, D.O., Jennifer Davis MD FAAP, Department of PICU

Affiliation(s): Chris Evert Children’s Hospital, Broward Health Medical Center

ABSTRACT BODY:

Background:

Drowning is the second leading cause of death in children and is associated with severe morbidity and mortality, most often due to hypoxic-ischemic encephalopathy. Those that survive are often left with debilitating neurological deficits. Therapeutic Hypothermia after resuscitation from ventricular fibrillation or pulseless ventricular tachycardia induced cardiac arrest is the standard of care in adults and has also been proven to have beneficial effects that persist into early childhood when utilized in neonatal birth asphyxia, but has yet to be accepted into practice for pediatrics.

Objective:

To present supportive evidence that Therapeutic Hypothermia improves mortality and morbidity specifically for pediatric post drowning patients.

Case Report:

A five year old male presented to the Emergency Department after pool submersion of unknown duration. He was found to have asphyxial cardiac arrest and received bystander CPR, which was continued by EMS for a total of 10 minutes, including 2 doses of epinephrine. CPR continued into the emergency department. Upon presentation to the ED, he was found to have fixed and dilated pupils, unresponsiveness, with a GCS of 3. Upon initial pulse check was found to have return of spontaneous circulation, with sinus tachycardia. His blood gas revealed 6.86/45/477/8/-25. He was intubated, given 2 normal saline boluses and 2 mEq/kg of Sodium Bicarbonate. The initial head CT was normal. He was then transported to the PICU, where he was sedated, paralayzed, and therapeutic hypothermia was induced. The hypothermia protocol consisted of the patient wrapped in a servo-controlled surface cooling system, continuous rectal temperature maintained between 32-34 °C, continuous EEG, and central arterial and venous monitoring. He was maintained for 48 hours of therapeutic hypothermia and paralysis was removed. Within 72 hours of the incident, he demonstrated purposeful movement and was extubated on day 10. Prolonging his extubation was fluid overload and aspiration pneumonia. Once extubated he continued to improve, and was downgraded to the pediatric inpatient floor. On day 17, the patient was discharged to inpatient rehabilitation. He was following 2-step commands, maintained normal PO intake, ambulated with mild deficits in functional ability.

Conclusion:

This case illustrates the potential for therapeutic hypothermia to decrease the neurologic sequelae due to drowning induced hypoxic-ischemic encephalopathy. Presentation to the emergency department in severe metabolic acidosis is associated with a poor outcome. Due to the severity of the patient’s initial presentation coupled with his favorable outcome, and the fact that this therapy is proven beneficial in other populations with similar mechanisms of neurological injury, therapeutic hypothermia should be studied more thoroughly in pediatric hypoxic ischemic encephalopathy.