Controlled Hypothermia after cold water immersion – (more than) a therapeutic option?

Aims: Drowning is a leading cause of accidental death in children. Accidental hypothermia seems to reduce the secondary consequences of hypoxia and to improve neurological outcome.

Methods: Case report

Results: In a motoring accident, an 8-year-old boy was catapulted into a river as the occupant of a car. After 25 minutes the asystolic boy was rescued and resuscitation was started immediately, return of spontaneous circulation was achieved 60 minutes after placing the emergency call. Core body temperature was 26.7°C! In the ER pupils were fixed and dilated, pH 6.6, BE -23, lactate 149mg/dl. The cCT showed discrete signs of cerebral edema.

After rewarming to 33°C, controlled therapeutic hypothermia was continued for 36h by an external cooling system, followed by careful rewarming (0.05°C/h over 3 days). Initially, persistent singultus and intermittent ophisthotonic posturing were observed, cerebral Doppler studies showed negative early diastolic flows (ACM) and the EEG showed a fixed alpha rhythm. After 12h pupillary reflexes returned to normal, and Doppler flow profiles improved (cerebral edema I-II°). The cMRT showed isolated small areas of decreased diffusion as a consequence of microembolisms without additional signs of posthypoxic brain injury. Spontaneous movements and communication efforts developed over the following days, extubation on day 7 and transfer to a neurologic rehabilitation unit on day 13. 6 weeks after the incident, only pre-existing fine motor skills and attention deficits persisted.

Conclusion: Therapeutic hypothermia is an established procedure for neuroprotection after perinatal asphyxia and resuscitation in adulthood, although the protocols differ considerably. The significance of therapeutic hypothermia after resuscitation in children is currently explored.

More and more anecdotal reports describe an unexpectedly favourable neurological outcome in children treated with controlled hypothermia after cold water immersion. Therefore we suggest the development of a standardized therapeutic protocol.

near drowning - therapeutic hypothermia - neurological outcome