Brain Resuscitation in the Drowning Victim

Abstract

. This manuscript is dedicated to the memory of Peter Safar, M.D. Peter Safar combined genius, incredible purpose, elegance, and humanism to move the collective fields of acute medicine to a new level. His work in resuscitation medicine, critical care, anesthesiology, emergency medicine, and disaster medicine saved countless lives. As a mentor he taught us a great deal. Peter left us with an important message-in both clinical care and research: namely, to always ask, "what is your intervention or research doing for the patient?" Whether physician or scientist, it is a critical message never to forget.Portions of this manuscript are being reproduced in the Handbook of Drowning. Bierens JJ (ed.). Springer, 2nd Edition. NIH Public Access AbstractDrowning is a leading cause of accidental death. Survivors may sustain severe neurologic morbidity. There is negligible research specific to brain injury in drowning making current clinical management non-specific to this disorder. This review represents an evidence-based consensus effort to provide recommendations for management and investigation of the drowning victim. Epidemiology, brain-oriented prehospital and intensive care, therapeutic hypothermia, neuroimaging/monitoring, biomarkers, and neuroresuscitative pharmacology are addressed. When cardiac arrest is present, chest compressions with rescue breathing are recommended due to the asphyxial insult. In the comatose patient with restoration of spontaneous circulation, hypoxemia and hyperoxemia should be avoided, hyperthermia treated, and induced hypothermia (32-34 °C) considered. Arterial hypotension/hypertension should be recognized and treated. Prevent hypoglycemia and treat hyperglycemia. Treat clinical seizures and consider treating nonconvulsive status epilepticus. Serial neurologic examinations should be provided. Brain imaging and serial biomarker measurement may aid prognostication. Continuous electroencephalography and N20 somatosensory evoked potential monitoring may be considered. Serial biomarker measurement (e.g., neuron specific enolase) may aid prognostication. There is insufficient evidence to recommend use of any specific brain-oriented neuroresuscitative pharmacologic therapy other than that required to restore and maintain normal physiology. Following initial stabilization, victims should be transferred to centers with expertise in age-specific postresuscitation neurocritical care. Care should be documented, reviewed, and quality improvement assessment performed. Preclinical research should focus on models of asphyxial cardiac arrest. Clinical research should focus on improved cardiopulmonary resuscitation, re-oxygenation/ reperfusion strategies, therapeutic hypothermia, neuroprotection, neurorehabilitation, and consideration of drowning in advances made in treatment of other central nervous system disorders.

Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning

“…Mild therapeutic hypothermia (TH) has been shown to decrease cerebral oxygen utilization and improve neurologically intact survival in patients with witnessed VF cardiac arrest. 77 Current American Heart Association/ International Liaison Committee on Resuscitation guidelines recommend that survivors of out-of hospital cardiac arrest with an initial rhythm of VF be cooled to 321C to 341C (901F to 931F) for 12 to 24 hours. 78 Many institutions have extrapolated these data to include non-VF causes of cardiac arrest.…”

Drowning

“…Within the hospital, little data define the role of intracranial pressure management or electrophysiologic monitoring, cerebral microdialysis, neurochemical markers, tissue oxygen management, pharmacologic intervention, glucose control, rewarming strategies (cold drowning), temperature management, or influence of respiratory care on brain outcome specific to drowning patients. 16 These all are factors for which anesthesiologists offer major expertise.…”