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1326 PART 11: Special Problems in Critical Care

to temporarily decrease ICP is a comparably benign, but unproven
intervention. ICP monitoring has been advocated most strongly to guide KEY REFERENCES
therapy in the subset of patients with increased ICP and poor prognosis, • Butler T, Shin S, Collins J, Britt RC, et al. Cervical spinal cord
but experience with cerebral monitoring in these patients has been injury associated with near-drowning does not increase pneumo-
disappointing. 74 nia risk or mortality. Am Surg. 2011;77:426-429.
■ HYPOTHERMIA • Gempp E, Louge P, Henckes A, Demaistre S, Heno P, Blatteau JE.

Victims of drowning may develop primary or secondary hypothermia. If Reversible myocardial dysfunction and clinical outcome in
scuba divers with immersion pulmonary edema. Am J Cardiol.
the drowning episode occurs in cold water (5°C or 41°F), the rapid onset 2013;111(11):1655-1659.
of hypothermia may afford some protection from cerebral hypoxia. Such • Kanter AS, Stewart BF, Hampson NB. Myocardial infarction
effects are typically seen in children who survive submersion in ice-cold during scuba diving: a case report and review. Am Heart J.
water. Hypothermia may also develop as a complication of the submer- 1995;130:1292.
sion and subsequent resuscitation efforts in the field.
Patients with severe accidental hypothermia can survive after • Layon AJ, Modell JH. Drowning: update 2009. Anesthesiology.
either passive or active warming, and there is benefit from induced 2009;110:1390-1401.
hypothermia for comatose victims resuscitated from prehospital car- • Marini JJ, Culver BH. Systemic gas embolism complicating
diac arrests 42,75,76 but there are no compelling data to guide therapy in mechanical ventilation in the adult respiratory distress syndrome.
this subset of patients. A practical recommendation is to consider Ann Intern Med. 1989;110:699.
77
rewarming until a core temperature of 32°C to 34°C is achieved, • Pendergast DR, Lundgren CE. The underwater environment:
allowing body temperature to then settle out after a 24-hour period cardiopulmonary, thermal, and energetic demands. J Appl Physiol.
of intensive care, taking care to avoid shivering and hyperthermia 2009;106:276-283.
(>37°C). • Smith RM, Neuman TS. Elevation of serum creatine kinase in
■ PROGNOSIS divers with arterial gas embolization. N Engl J Med. 1994;330:19.

Overall, of patients who live to reach the hospital, about 80% of chil- • Soar J, Perkins GD, Abbas G, et al. European Resuscitation Council
dren and adults recover completely, 8% to 10% survive but with brain Guidelines for Resuscitation 2010 Section 8. Cardiac arrest in
damage, and 10% to 12% die. About 90% of category A and B and special circumstances: Electrolyte abnormalities, poisoning,
approximately 50% of category C patients make full recoveries, whereas drowning, accidental hypothermia, hyperthermia, asthma, ana-
10% to 23% of the later group survive but have permanent neurologic phylaxis, cardiac surgery, trauma, pregnancy, electrocution.
sequelae. 45,46,50,54 Thus, respiratory insufficiency in the absence of sepsis Resuscitation. 2010;81:1400-1433.
or infection is seldom the cause of death in these patients in hospitals • Tester DJ, Medeiros-Domingo A, Will ML, Ackerman MJ.
with modern intensive care capabilities. Unexplained drownings and the cardiac channelopathies: a molec-
Many parameters such as serum electrolytes, arterial blood-gas and ular autopsy series. Mayo Clin Proc. 2011;86:941-947.
pH values, electroencephalographic findings or clinical features (body • Vann RD, Butler FK, Mitchell SJ, Moon RE. Decompression
temperature, absence of pupillary response, cardiac arrest, duration of illness. Lancet. 2011;377:153-164.
submersion, and resuscitative efforts), and cross-brain oxygen content • Weaver LK. Hyperbaric oxygen in the critically ill. Crit Care Med.
differences have been examined as indicators of prognosis. None is suf-
74
ficiently discriminating to guide early therapy. Conversely, the presence 2011;39:1784-1791.
of cardiac arrest and absence of spontaneous respirations after resuscita-
tion are ominous signs associated with permanent neurologic impair-
ment or death. In a retrospective review of 44 children, all survivors REFERENCES
70
who regained good neurologic function, were awake with purposeful
motion 24 hours after the incident. 78 Complete references available online at www.mhprofessional.com/hall

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