survival in adults after cardiac arrest due to drowning

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Page 1: Survival in adults after cardiac arrest due to drowning

Intensive Care Med (1990) 16:336-337 Intensive Care Medicine �9 Springer-Verlag 1990

Survival in adults after cardiac arrest due to drowning

N . D . E d w a r d s , A . C . T i m m i n s , B. R a n d a l l s , G . A . R . M o r g a n a n d A . D . S i m c o c k

Anaesthetic Department, Treliske Hospital, Truro, Cornwall, UK

Received: 28 June 1989; accepted: 5 February 1990

Abstract. S o m e r e m a r k a b l e cases o f fu l l n e u r o l o g i c a l r e c o v e r y a f t e r c a r d i a c a r r e s t f o l l o w i n g i m m e r s i o n in-

c i d e n t s h a v e b e e n i n t e r m i t t e n t l y r e p o r t e d in t h e j o u r n a l s ove r t h e years [1, 2, 3]. T h e s e h a v e l a r ge l y b e e n in c h i l d r e n o r t e e n a g e r s w h o h a v e f a l l en i n t o e x t r e m e l y c o l d water . W e r e p o r t h e r e t w o o l d e r a d u l t s w h o r e c o v e r e d c o m p l e t e - ly a f t e r a p e r i o d o f c a r d i a c a r r e s t i n c o l d water . C e r t a i n l y , d e a t h s h o u l d n o t b e p r o n o u n c e d in c o l d w a t e r d r o w n i n g , w i t h o u t a t h e r m o m e t e r r e a d i n g a n d E C G .

Key words: D r o w n i n g - C a r d i a c a r r e s t - R e s u s c i t a t i o n - N e u r o l o g i c a l o u t c o m e

Case 1

A 56-year-old man was found face down in harbour water (temperature 9.5 ~ 10 ~ after drinking several glasses of beer. The period of immer- sion is unknown, but 7 min after discovery, a helicopter diver found the victim to be apnoeic and pulseless with dilated pupils. He received ex- pired air ventilation and was then lifted into the helicopter. A diagnosis of cardiac arrest was made by the helicopter crew, trained in resuscita- tion. Cardiac massage was begun immediately and restored a weakly palpable pulse after 3 min. Cardiac massage ceased but mouth to mouth ventilation continued for a further 2 min until the patient started to make respiratory efforts. He was then given oxygen to breathe by face mask.

On arrival at hospital, 11 min after being taken from the sea, im- mediate assessment found him to be unconscious, making a poor respiratory effort, but with a palpable pulse. Endotracheal intubation was performed at once and frothy fluid and gastric contents were aspirated from the lungs. Positive pressure ventilation was commenced by an inflating bag with added oxygen, and he was transferred to the intensive care unit. Thirty minutes after rescue he was still hypothermic; core temperature 31.9 ~

Ventilation was continued with a fractional inspired oxygen (FiO2) of 0.6, plus 5 cm HzO of positive-end-expiratory pressure (PEEP). There was peripheral circulatory shutdown, an arterial blood pressure of 90 mmHg systolic, pulse rate 90/min and poor urine output.

Further initial treatment consisted of the rapid infusion of warmed polygeline (Haemaccel Hoechst, UK); intravenous Methylprednisolone 2g; and 10070 Mannitol 250 ml intravenously. A broad spectrum an- tibiotic regime was instituted after tracheal, blood and urine samples were taken for culture. Swan Ganz catheterisation after the infusion of 1500 ml of fluid showed unexpectedly high values of central venous pressure (CVP), 10mmHg; pulmonary capillary wedge pressure (PCWP), 22mmHg, and pulmonary artery pressure 36/26mmHg. Fluid therapy was restricted and these values returned to normal over the next hour. Rewarming over 6 h was by a warming blanket applied

next to the skin; warming the humidified inspired gases and warmed in- travenous fluids.

Progress was encouraging, satisfactory oxygenation was soon ob- tained with an FiO 2 of 0.4, the PaCO 2 was kept slightly reduced at 4.5 kPa. Ventilation was discontinued after 24 h as there were satisfacto- ry blood gases, little aspirate from the lungs and the patient was awake between sedation. Extubation quickly followed, and seven days after the incident he went home with no neurological abnormality.

Case 2

A 77-year-old female was found floating face down in an outdoor unheated fresh-water swimming pool. After removal from the water, a doctor diagnosed cardiac arrest, commenced basic resuscitation and a heart beat was restored after approximately 15 min. Methylprednisolone i g and Ampicillin 0.5 g were given intravenously and the unconscious patient transferred to hospital where she was intubated immediately on arrival and transferred to the ICU undergoing ventilation with 100070 oxygen. One litre of polygeline (Haemaccel, Hoechst, UK) was given in- travenously for hypotension and poor peripheral perfusion. A Swan Ganz catheter was passed at this point and showed a CVP of 11 mmHg and PCWP of 18 mmHg. Fluid replacement was therefore restricted and inotropic support commenced with dobutamine 10 gg/kg/min and dopamine 3 Ixg/kg/min. Both CVP and PCWP returned to normal over the next 2 h, and urine output improved. The temperature had been nor- mal throughout, and the ECG showed anterior ischaemia.

Initially large amounts of greyish coloured water had been removed from the lungs, and an FiO 2 of 0.65 with 5 - 7 cm H20 of PEEP re- quired to maintain a PaO 2 above 8 kPa. However, in the next 48 h, gas exchange improved, and the cardiovascular system stabilised. Inotropic support and then mechanical ventilation were gradually discontinued and she was extubated three days after admission. Raised cardiac en- zymes supported the view that she may have suffered an acute myocar- dial infarction. After several weeks she wrote to say she was enjoying a normal life.

Discussion

A l c o h o l is u n d o u b t e d l y a c o m m o n f a c t o r in m a n y i m - m e r s i o n i n c i d e n t s , a n d a n y m e d i c a l c o n d i t i o n w h i c h m a y i m p a i r c o n s c i o u s n e s s s u c h as m y o c a r d i a l i n f a r c t i o n , is g o i n g to i n c r e a s e t h e r i sk o f d r o w n i n g . T h e a c t u a l p e r i o d

o f i m m e r s i o n in t h e s e cases is n o t clear , b u t t h e d o c u m e n - t a t i o n o f t h e r e s c u e is ve ry precise . A n a p p r a i s a l o f t h e c l in ica l s t a t e o f t h e p a t i e n t was m a d e i m m e d i a t e l y a n d ex- p i r e d a i r r e s p i r a t i o n c o m m e n c e d . A d i a g n o s i s o f c a r d i a c a r r e s t was m a d e in b o t h p a t i e n t s o n a c l in i ca l b a s i s b y t r a i n e d p e r s o n n e l . T h e p e r i o d o f C P R was s h o r t (5 a n d

Page 2: Survival in adults after cardiac arrest due to drowning

N.D. Edwards et al.: Survival after cardiac arrest due to drowning

15 min) before heart beat and respiratory effort returned. This fits in with a favourable prognostic outcome as de- scribed by Pearn [4].

On arrival at hospital the drowned or near-drowned victim must be met by a resuscitation team, assessed, and if necessary intubated prior to transfer into the hospital. This is part of a well established practice and has formed part of a protocol which has previously been reported [5]. The victim is brought into hospital only after intubation and ventilation with 100% oxygen. A portable sucker is available to remove water from the lungs if ventilation is difficult due to water in the airway. The priorities on reaching an intensive care unit are to establish normal ox- ygenation and circulating blood volume as quickly as possible [61.

Both patients showed a typical ",hypovolaemic-like" picture; poor peripheral circulation, low blood pressure and poor urine output. Usually the CVP in such patients is low and responds to intravenous fluid therapy. In these two patients, however, the initial CVP was high. This may have been due to colloid infusion as the PCWP was also markedly elevated. It has been our concern that the func- tion of the left ventricle in particular may be affected by cold water immersion in adults, which has led us to pass pulmonary artery flotation catheters at an early stage of resuscitation. It may well be that after a colloid infusion sufficient to produce a normal PCWP, inotropic support is to be preferred to further fluid loading and this will form the basis of a further study by this unit.

Different fluid shifts in and out of the circulation have been shown in fresh compared with salt-water drowning in animals [7]. Unless large volumes of water are aspirated, this may not be detected clinically in humans, and temperature rather than the type of water can be critical. Cold water causes peripheral vasocon- striction but with an inadequate circulating blood volume. Aspiration of water into the lungs causes ventila- tion/perfusion mismatch leading to hypoxaemia.

Several more issues for debate are raised by these case reports. High dose corticosteroids were given, and their use has been questioned [8]. We have already reported on 82 patients who have inhaled water and were treated with Methylprednisolone 30 mg/kg intravenously soon after rescue. There were no problems with pulmonary infection and only one case of Respiratory Distress Syndrome [9]. However, the late or long-term use of steroids may only lead to an increased risk of infection and prospective studies are needed to finally resolve this issue. Likewise the use of antibiotics is open to question [10]. The male was found in harbour water with risks of pollution and had aspirated gastric contents. The latter is a very com- mon finding in drowned victims. Where drowning occurs in clean water, however, it would be reasonable to rely on regular cultures of tracheal aspirates. The priority re- mains cardio-respiratory stability with normal oxygen levels and moderate hypocarbia. If this is achieved, hypothermia will steadily correct itself. It is probably that too much emphasis has been placed on the treatment of hypothermia in the past [t 1].

The period of immersion and resuscitation compati- ble with full neurological recovery is at present unknown,

337

and there are several survivors after periods of resuscita- tion in excess of 2 h [10]. Consequently, resuscitation once commenced must not be abandoned until the core temperature has been raised to 32 ~ as it is only below 32 ~ that hypothermia affords substantial cerebral pro- tection through reduced oxygen consumption and metabolic rate [12]. In practice, this can be extremely dif- ficult to achieve if right heart bypass is not available [9]. However, we have now treated 20 cases of cardiac arrest from drowning, four have survived and only one is neuro- logically damaged. The essential factor in the survivors reported here is that they were resuscitated immediately after removal from the water by trained personnel, and resuscitation continued during transport to hospital. The prognosis in the near-drowned victim who has not suf- fered cardiac arrest is excellent, and we have lost only three such patients out of 148 treated [9]. T h e future therefore lies very much at the accident site and in relief of hypoxia as soon as the victim is removed from the water.

Conclusion

This short report shows that survival and full neurologi- cal recovery can occur following cardiac arrest caused by drowning in adults and the elderly. Recovery, however, in- volves relief of hypoxia and cardiovascular stability in the shortest possible time. This must be appreciated by rescuers; those involved in transport to hospital and hos- pital services concerned with the reception of such vic- tims.

References

1. Kvittingen TD, Nass A (1963) Recovery from drowning in fresh water. Br Med J 1:1315-1317

2. Theilade D (1977) The danger of fatal misjudgement in hypother- mia after immersion. Anaesthesia 32:889-892

3. Siebke H, Rod T, Brevik H, Lind B (1975) Survival after 40 minutes submersion without cerebral sequelae. Lancet h1275-1277

4. Pearn J (1985) Drowning. In: Dickerman, Lucey (eds) The critically ill child, diagnosis and management, 3rd edn. Saunders, Philadelphia, pp 128-156

5. Simcock AD (1979) Sequelae of near-drowning. Practitioner 222:527- 530

6. Simcock AD (1986) Treatment of near-drowning - a review of 130 cases. Anaesthesia 41:643-648

7. Swarm HG, Spafford NR (1951) Body salt and water changes dur- ing fresh and sea water drowning. Tex Rep Biol Med 9:356-382

8. Modell JH (1986) The treatment of near drowning. Crit Care Med 14:593-594

9. Simeock AD (1989) The resuscitation of immersion victims. Appl Cardiopulmonary Pathophysiol 2:293-298

10. Orlowski JP (1987) Drowning, near-drowning and ice-water sub- mersion. Pediatr Clin North Am 30:75-92

11. Golden F, Rivers J (1975) The immersion incident. Anaesthesia 30:364-373

12. Stern WE, Good RG (1960) Studies on the effect of hypothermia on CSF, oxygen tension and carotid blood flow. Surgery 48:13-30

Dr. A.D. Simcock Royal Cornwall Hospital Treliske Truro, Cornwall TRI 3LJ UK