How is temperature in cold-water drowning patients managed?

Updated: Jun 19, 2019
  • Author: G Patricia Cantwell, MD, FCCM; Chief Editor: Joe Alcock, MD, MS  more...
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Answer

Optimal temperature management in drowning patients is a current topic of significant research and clinical interest. Hypothermic patients with core temperatures less than 86°F who have undergone sudden, rapid immersion in cold water may experience slowing of metabolism and preferential shunting of blood to the heart, brain, and lungs, which may exert a neuroprotective effect during submersion. This is not, however, the case with most immersion victims, who have become hypothermic gradually and are at risk for ventricular fibrillation and neurologic injury.

Many authors have postulated that a primitive mammalian diving reflex may be responsible for survival after extended immersion in cold water. The mechanism for this reflex has been postulated to be reflex inhibition of the respiratory center (apnea), bradycardia, and vasoconstriction of nonessential capillary beds triggered by the sensory stimulus of cold water touching the face.

These responses preserve the circulation to the heart and brain and conserve oxygen, thereby prolonging survival. The sudden temperature drop may depress cellular metabolism significantly, limiting the harmful effects of hypoxia and metabolic acidosis

Traditional studies suggested vigorous rewarming of hypothermic patients to normothermia. In order to rewarm, a number of modalities have been used. A nasogastric tube was placed to assist in rewarming efforts and a urinary catheter was passed to assess urine output.

Core rewarming with warmed oxygen, continuous bladder lavage with fluid at 40°C, and intravenous (IV) infusion of isotonic fluids at 40°C was initiated during resuscitation. Warm peritoneal lavage has been used for core rewarming in patients with severe hypothermia. A cascade unit on the ventilator has been used to warm inspired air.

Thoracotomy, with open heart massage and warm mediastinal lavage, was used in refractory situations. The hypothermic heart is typically unresponsive to pharmacotherapy and countershock. Extracorporeal blood rewarming has been used in patients with severe hypothermia who did not respond to lavage/thoracotomy or who were in arrest.

Central venous access was suggested to be utilized cautiously in hypothermic patients, in order to avoid stimulation of the hypothermic atrium with resultant dysrhythmias.


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