Pediatric Drowning: Stop Resuscitation After 30 Minutes

Troy Brown, RN

February 12, 2015

Resuscitation is likely to be futile for children who have cardiac arrest and hypothermia after drowning in seasons other than winter and who remain asystolic after 30 minutes of resuscitation, according to a retrospective cohort study.

"Our study shows that survival with good neurological outcome is unlikely" in such situations, write J. K. Kieboom, a pediatric intensivist from the Department of Paediatrics, Beatrix Children's Hospital, University Medical Centre Groningen, University of Groningen, the Netherlands. The authors present their findings in an article published online February 10 in BMJ.

Drowning is the main cause of death in children aged 2 to 5 years, accounting for approximately 3 deaths per 100,000 each year. Children who do not need resuscitation or who recover promptly usually experience good neurological outcomes. Current guidelines encourage resuscitation of at least 30 minutes in pediatric drowning victims with hypothermia. "The rationale is that hypothermia is a potentially reversible cause of cardiac arrest and that hypothermia could exert a protective effect on the brain by slowing its metabolism," the authors explain.

The researchers included 160 children aged up to 16 years who presented at emergency departments and/or were admitted to intensive care as a result of cardiac arrest and hypothermia after drowning from 1993 to 2012. The primary outcome measure was survival and neurologic outcome 1 year after the drowning episode. The researchers defined poor outcome as death or survival in a vegetative state or with profound neurological disability pediatric cerebral performance category (PCPC ≥4).

The investigators included asystolic children who drowned outside in unheated swimming pools and who had an initial core body temperature below 34°C. Outside drowning was an inclusion criteria, so the researchers could use season as a proxy for water temperature.

Resuscitation was performed for more than 30 minutes (median duration, 60 minutes) in 98 (61%) children. Of those, 87 (89%; 95% confidence interval [CI], 83% - 95%) children died and the remaining 11 (11%; 95% CI, 5% - 17%) all had a PCPC score of 4 or higher.

Among the 62 (39%) children who had resuscitation of 30 minutes or less, 17 (27%; 95% CI, 16% - 38%) lived with a PCPC score of 3 or lower after 1 year: 10 (6%) had a positive neurological outcome (score 1), five (3%) experienced mild neurological disability (score 2), and two (1%) had moderate neurological disability (score 3).

Only 44 of the original 160 were alive at 1 year "with any outcome," the authors write.

"Children with cardiac arrest with hypothermia after drowning have an extremely poor outcome if return of spontaneous circulation is not achieved within 30 minutes of advanced life support," the authors explain. "Good neurological outcome is more likely when return of spontaneous circulation occurs within 30 minutes, especially when the drowning occurs in winter. The findings of this cohort study question the therapeutic value of resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia."

"As outcomes from these hypoxic cardiac arrests are so poor, and most incidents occur well away from trained medical help, the most effective way to reduce mortality is through prevention programmes," write Ian Maconochie, PhD, from St Mary's Hospital, Imperial College National Health Service Healthcare Trust, London, United Kingdom, and Charles D. Deakin, MD, from the National Institute for Health Research Southampton Respiratory Biomedical Research Unit, Southampton University Hospital, Southampton, United Kingdom, in an accompanying editorial.

"Recent recommendations from [the World Health Organization] include teaching school aged children swimming and safe rescue skills, increasing public awareness, developing national safety water plans, and training bystanders in resuscitation."

The authors and editorialists have disclosed no relevant financial relationships.

BMJ. Published online February 10, 2015. Article full text, Editorial full text

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