Summary
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.
Résumé
Les survivants de noyade sont hospitalisés dans des unités de soins tertiaires quelques heures après ľaccident. Après une amélioration initiale, beaucoup de ces patients manifestent une détérioration cérébrale progressive. Une analyse rétrospective portant sur trente patients hospitalisés à ľHôpital Sick Children de Toronto entre 1970 et 1974, a mis en évidence une mortalité de 3.3 pour cent et des dommages cérébraux permanents chez 30 pour cent des patients. Au cours de la même période, ľon rapportait ďexcellents résultats avec ľemploi ďune thérapie agressive dans les cas de traumatismes crâniens fermés, chez les survivants de noyade en eau froide et en chirurgie cardiovasculaire sous hypothermie profonde. En 1975, un protocole de traitement était établi pour les survivants de noyade, protocole qui a depuis été révisé et modifié au besoin.
Ľobjectif du traitement est de prévenir une augmentation de la pression intra-crânienne tout en maintenant des conditions optimales pour la récupération cérébrale. Ceci implique: (a) une hydratation réduite au minimum; (b) une ventilation contrôlée pour obtenir une PO 2élevée avec hypercapnée modérée (PaCO 24 kPa (30 mm Hg)); (c) une hypothermie modérée (30° C); (d) le contrôle de ľhyper-excitabilité cérébrale au moyen de doses élevées de barbituriques et de stéroïdes; (e) et enfin le contrôle des états ďhyperrigidité au moyen de curarisants. Une monitoring efficace de toutes les grandes fonctions, y compris le monitoring constant de la pression intracrânienne est essentiel.
Nous avons observé une incidence de 7.7 pour cent de dommages cérébraux permanents avec une mortalité à 15.4 pour cent chez 26 patients ainsi traités entre 1975 et 1977. Même si notre série est petite et présente de nombreuses variables, de tels résultats justifient, croyonsnous, la poursuite de ľévaluation de cette approache thérapeutique.
En conclusion, même si la preuve statistique de la validité clinique et expérimentale de ces mesures n’est pas encore disponible, le maintien ďun tel protocole et peut-être son application à ďautres cas de traumatismes cérébraux, nous semblent justifiés, surtout si ľon considère la gravité de la pathologie en cause et la morbidité minime liée au traitement lui-même.
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Conn, A.W., Edmonds, J.F. & Barker, G.A. Near-drowning in cold fresh water: current treatment regimen. Canad. Anaesth. Soc. J. 25, 259–265 (1978). https://doi.org/10.1007/BF03005645
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DOI: https://doi.org/10.1007/BF03005645