The management of neurologically intact survival in critical care drowning patients is a multifaceted approach that emphasizes early intervention, appropriate resuscitation techniques, and post-resuscitation care. The literature indicates several key strategies that can significantly improve outcomes for these patients.
The role of bystander intervention, particularly cardiopulmonary resuscitation (CPR), is critical in the immediate aftermath of drowning incidents. Studies have shown that bystander CPR is associated with improved neurologically favorable survival rates in drowning victims. For instance, Tobin et al. found that bystander CPR significantly enhances the likelihood of favorable neurological outcomes following cardiac arrest due to drowning (Tobin et al., 2017). Furthermore, the effectiveness of conventional CPR, which includes rescue breathing, has been highlighted as beneficial in cases of drowning, where asphyxia is a primary concern (Topjian et al., 2012). This is supported by findings from Kaneto, which suggest that bystander-performed rescue breathing can be particularly advantageous in drowning cases (Kaneto, 2024).
In addition to immediate CPR, the timing and quality of advanced life support interventions (early endotracheal intubation, early ventilation strategy implementation, early circulatory support, large bore IV access above the level of the diaphragm) are paramount. The use of therapeutic hypothermia has been shown to yield favorable neurological outcomes in pediatric near-drowning patients (Chen et al., 2016). This approach is particularly relevant in cases where prolonged resuscitation has occurred, as hypothermia can mitigate the effects of anoxic brain injury (Mohammad & Morrissey, 2021). Moreover, the implementation of extracorporeal membrane oxygenation (ECMO) has been associated with improved survival rates in drowning patients who experience cardiac or pulmonary failure (Cho et al., 2022). Studies indicate that patients who regain return of spontaneous circulation (ROSC) prior to ECMO initiation have significantly better outcomes (Cho et al., 2022).
The duration of submersion and the environmental conditions at the time of drowning also play critical roles in determining patient prognosis. For example, Kieboom et al. reported that neurologically intact survival rates in children varied widely based on the duration of cardiac arrest and the presence of hypothermia, with some cases achieving survival rates as high as 40% (Kieboom et al., 2015). This variability underscores the importance of rapid assessment and intervention tailored to the specific circumstances of the drowning incident.
Post-resuscitation care is equally important, as it involves monitoring and managing potential complications such as acute respiratory distress syndrome (ARDS) and multi-organ dysfunction (Mtaweh et al., 2015). The integration of neurorehabilitation strategies is essential for maximizing recovery and minimizing long-term neurological deficits. This includes physical therapy and other supportive measures aimed at restoring function and preventing complications such as spasticity (Raess et al., 2020).
In conclusion, the best treatment recommendations for neurologically intact survival in critical care drowning patients involve a combination of immediate bystander CPR, advanced life support interventions, therapeutic hypothermia and ECMO, and comprehensive post-resuscitation care. These strategies, when implemented effectively, can significantly enhance the chances of favorable neurological outcomes in drowning victims.
References:
- Chen, M., Chu, C., Cheng, C., Lin, J., Chen, J., & Chang, Y. (2016). Therapeutic hypothermia brings favorable neurologic outcomes in children with near drowning. Tzu Chi Medical Journal, 28(4), 180-182.
https://doi.org/10.1016/j.tcmj.2016.07.003
- Cho, S., Furukawa, T., & Ogawa, O. (2022). Drowning case complicated with a cardiopulmonary arrest and severe ards saved with a good neurological outcome by ecmo: a case report. Respirology Case Reports, 10(11).
https://doi.org/10.1002/rcr2.1053
- Kaneto, Y. (2024). Advantages of bystander-performed conventional cardiopulmonary resuscitation in out-of-hospital cardiac arrest presumably caused by drowning in japan: a propensity score-matching analysis using an extended nationwide database. BMJ Open, 14(5), e080579.
https://doi.org/10.1136/bmjopen-2023-080579
- Kieboom, J., Verkade, H., Burgerhof, J., Bierens, J., Rheenen, P., Kneyber, M., … & Albers, M. (2015). Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: dutch nationwide retrospective cohort study. BMJ, 350(feb10 1), h418-h418.
https://doi.org/10.1136/bmj.h418
- Mohammad, T. and Morrissey, S. (2021). Intact neurological recovery after seven days of glasgow coma score 3t following near-drowning and hypothermia in an adult. The American Surgeon, 89(4), 1232-1233.
https://doi.org/10.1177/0003134821989055
- Mtaweh, H., Kochanek, P., Carcillo, J., Bell, M., & Fink, E. (2015). Patterns of multiorgan dysfunction after pediatric drowning. Resuscitation, 90, 91-96.
https://doi.org/10.1016/j.resuscitation.2015.02.005
- Raess, L., Darms, A., & Meyer-Heim, A. (2020). Drowning in children: retrospective analysis of incident characteristics, predicting parameters, and long-term outcome. Children, 7(7), 70.
https://doi.org/10.3390/children7070070
- Tobin, J., Ramos, W., Pu, Y., Wernicki, P., Quan, L., & Rossano, J. (2017). Bystander cpr is associated with improved neurologically favourable survival in cardiac arrest following drowning. Resuscitation, 115, 39-43.
https://doi.org/10.1016/j.resuscitation.2017.04.004
- Topjian, A., Berg, R., Bierens, J., Branche, C., Clark, R., Friberg, H., … & Warner, D. (2012). Brain resuscitation in the drowning victim. Neurocritical Care, 17(3), 441-467.
https://doi.org/10.1007/s12028-012-9747-4