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

OBJECTIVES

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).

DESIGN

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.

SETTING

Emergency departments of the referring hospital and ICU of Children's Hospital.

PATIENTS

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.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

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.

CONCLUSIONS

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.