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Near-Drowning in Cold Fresh Water: Current Treatment Regimen

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Near-Drowning in Cold Fresh Water: Current Treatment Regimen NEAR-DROWNING IN COLD FRESH WATER: CURRENT TREATMENT REGIMEN A.W. CONN, J.F. EDMONDS, AND G.A. BARKER DROWNING is defined as death by suffocation recovery, .7-t9 partly due to the "diving under water I and annually accounts for approx- reflex". Is,z~ This is a neurogenic reflex, inde- imately 1,300 deaths in Canada, 7,000 in U.S.A., 2 pendent of baro-receptors and chemo-receptors, and 140,000 around the world. 3 A newer term, which shunts blood away from non-essential or- "near-drowning", is defined as a submersion vic- gans to the heart and brain and is associated with tim who arrives at an emergency facility and sur- marked bradycardia. This reflex is triggered by vives for 24 hours. 4 This definition excludes submersion of the face with apnoea and is most those who "drowned", but ignores the degree active in young children, in cold water (<20 ~ C) of subsequent recovery. Contrary to some re- and is potentiated by fear. After rescue, it is usu- ports, 5"6 most papers 4.7,a-to and personal obser- ally impossible to verify the presence of this vation suggested that, using routine therapy, ini- reflex, as both severe hypoxia and hypothermia tial improvement was too often followed by pro- can cause bradycardia. Nevertheless, even if gressive cerebral deterioration. Routine therapy cardiac arrest occurs after a prolonged period of included oxygen and artificial ventilation as indi- bradycardia due to the driving reflex, the prog- cated, rapid restoration of body temperature, cir- nosis is much more favourable. culatory Support and maintenance of urine vol- Immersion in very cold water (5~ C) 22 has been ume. In 1975, a five-year ,'etrospective review of shown to produce an incredibly rapid fall in body 30 near-drowning victims at The Hospital for tempe,-ature, 23 which can be accelerated by vig- Sick Children, Toronto, revealed permanent orous swimming. In small children the rate of brain damage in 30 per cent t~ (Table I). At that temperature fall is maximal because of a rela- time, many reports ~2-ts had noted that if the tively larger surface a,'ea and lack of insulation. 9 drowning incident happened in very cold water, If subme,-ged, the swallowing of cold water in complete recovery could occur despite prolonged large quantities and the aspiration of ice water (15 submersion (up to 40 minutes), t6 This paper dis- per cent of cases exceed 22 ml/kg 24) are addi- cusses those factors which affect the ultimate fate tional reasons for rapid core cooling. In our series of near-drowning victims in cold fresh water and of 26 cases ( 1975-1977) admitted to The Hospital recommends rational therapeutic measures to for Sick Children after various intervals of treat- minimize permanent brain damage. ment, routine rectal temperatures ranged be- tween 29~ C and 39.5 ~ C but were below 35.5 ~ C in FACTORS AFFECTING SURVIVAL 46.1 per cent. In older children at approximately 35 ~ C alertness and at 33 ~ C consciousness are The survival and ,extent of recovery after a diminished, resulting in an early death fiom sub- submersion accident is determined by a number mersion and drowning* or a later death fi'om of factors. These include certain physiological progressive immersion hypothe,'mia, zs In either characteristics of the individual, the occurrence case the victim appears irretrievably dead and of immersion hypothermia, the submersion time, resuscitation may not be attempted, which is the initial resuscitation efforts and, later, the in- WRONG! The rapidly lethal effect of immersion tensive care management. hypothermia is partly counter-balanced by pro- It is generally accepted that, within narrow ducing simultaneously significant protection to margins, there is individual variation in tolerance the hypoxic brain. This is one of the few fringe to, and recovery from, severe hypoxia. Of greater benefits of the cold climate of central Canada. relevance is the age of the patient. The younger This protective effect is well documented in elec- the victim the greater the possibility for complete tive cardiovascular surgery :~176 where circula- tion can be discontinued for as long as 45 minutes A.W. Corm, M.D., F.R.C.P.(C), J.F. Edmonds, during profound hypothermia with complete re- M.B., F.R.C.P.(C), G.A. Barker, M.B., F.F.A.R.A.C.S., Intensive Care Unit, The Hospital for *This may be defined as submersion hypathermia Sick Children, Toronto and the Department of Anaes- where immersion hypothermia occurs with asphyxia of thesia, University of Toronto, Toronto. immediate onset. 259 Canad. Anaesth. Soc. J., vol. 25, no. 4. July 1978 260 CANADIAN ANAESTHETISTS' SOCIETY JOURNAL TABLE I RESULTS (ALL CASKS) Number Deaths CNS damage 1970-1974 30 1 (3.3~) 9 (30.07o) (routine) 1975-1976 li 0 2 08.17,) (Hyper R - 3 cases) 1977 15 4 (26.6~) 1 (6.6~)* (Hyper R - 7 cases) (Table 11) TOTALS (1970-1977) 56 5 (9~) 12 (21% *Admitted five days post-drowning. covery. Since drowning is not elective (!) cooling obtained by Dr. Mathew Spence of Auckland, lags behind hypoxic effects but has still proven to N.Z., in adults with severe head injuries, 3-~ using be protective j3-j6 and should be continued after hypothermia and hyperventilation, among other rescue. In warm-water drowning with cardiac ar- measures, for as long as two to three weeks. It rest, immediate induction of hypothermia has was considered that victims of near-drowning in been recommended 9'2''31's2 and may play a simi- cold fresh water might have less severe brain lar but less successful role. injury and that, using a similar approach, our The duration of submersion is very difficult to results might improve. The prime aim of therapy determine after the event, because of the emo- became "cerebral salvage". At intervals during tional excitement existing at the time. Estima- the next three years, all known measures for this tions in our 26 cases (1975-1977) showed <5 purpose were gradually introduced and took ab- minutes, 8 cases; 5-10 minutes, 7 cases; >10 solute priority over any other therapeutic consid- minutes, 6 cases; and unknown, 5 cases. It is erations. The twin goals of therapy became the generally accepted thal 4 to 5 minutes under preservation of any surviving cerebral cells water at normothermla represents a maximum which might be temporarily non-functioning, and time before irreversible neurological damage oc- the prevention of post-asphyxial brain swelling curs. This time-period needs re-examination in and subsequent rise in intracranial pressure. Fol- view of treatment outlined later. However, there lowing three years of trial and error, the following is little doubt that full recovery is unlikely after measures can be recommended as providing op- prolonged submersions (>30 minutes) even in timal management in near-drowning victims. very cold water'. The need for immediate resuscitation in all METHOD OF TREATMENT cases and regardless of circumstances cannot be over-emphasized. Mouth-to-mouth breathing Time is short, and closed chest massage should be instituted in The odds are great, the water, if possible, and maintained as long as The margins small, necessary or until cerebral death supercedes. The stakes infinite ... The heart of a normothermic child, if untreated, Winston Churchill can be restarted as long as 45 minutes after sub- (paraphrased) mersion, but survival with an intact brain is most "Their Finest Hour" unlikely. If the resuscitation time of a hypoxic normothermic heart exceeds 15 to 20 minutes, Following rescue, resuscitation, and stabiliza- chances of complete cerebral recovery also di- tion of the circulation, certain clinical features minish. Even a few minutes delay in commencing appear which may affect brain recovery. These treatment may be critical as far as recovery of the include evidence of hyperhydration and evidence brain is concerned. In the presence of severe of marked brain damage such as hyperventila- immersion or accidental hypot hermia, time limits tion, hyperpyrexia, hyper-excitability and hy- should be ignored until core temperature reaches per-rigidity. For discussion purposes and ease of 30 ~ C 33.J4 memory, the acronym H.Y.P.E.R. will be used, In 1975 a more aggressive approach was intro- duced in the intensive care management of near- Hyperhydration (H) drowning. This was based on )he good results During the drowning process, unknown quan- CONN, el C/].: NEAR-DROWNING 261 tities of fresh water may be both ingested and consumption, increased pulmonary shunting aspirated. After prolonged submersion, resusci- with hypoxaemia and hypocapnia. Blood oxygen tation requires large volumes of intravenous tensions on arrival in emergency departments fluids and sodium bicarbonate as well as other vary greatly, but in a high proportion of cases (77 volume expanders. Later, when the circulation per cent) ~~are Iow.t becomes stable, there is both a relative and abso- In all such cases, prophylactic nasotracheal lute overhydration in the presence of damaged intubation is done to prevent even minor airway capillaries. Fluid leaks into the tissues, particu- obstruction, which can be so disastrous to the larly into the lung and the brain. This state is post-hypoxic brain, lntubation permits I.P.P.V. analogous to that of the child after prolonged with P.E.E.P. and adequate suctioning to be per- cardiac by-pass surgery, who in the immediate formed. The presence of a small air leak around post-operative period has no clinical (except the tube prevents post-extubation complications. weight gain) or haemodynamic evidence (CVP, After global ischaemia, cerebral shunts or LA or CWP all normal) of excessive third space steals from stages of autoregulation cannot be fluid but who will later have a diuresis of several determined.
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