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Canadian Journal of Anesthesia, Vol 27, 201-210, Copyright © 1980 by Canadian Anesthesiologists' Society

Cerebral Salvage in Near-Drowning following Neurological Classification by Triage

A. W. CONN 1, J. E. MONTES 1, G. A. BARKER 1, and J. F. EDMONDS 1

1 The Intensive Care Unit, Hospital For Sick Children, 555 University Avenue, Toronto, Canada M5G 1X8

This paper describes a simple neurological classification fornear-drowning victims into three main categories consisting of:

Category A (Awake)

Category B (Blunted Consciousness)

Category C (Comatose).

Category C is sub-classified into:

C.1 (Decorticate)

C.2(Decerebrate)

C.3 (Flaccid).

This triage classification is based on the level of consciousness at a post-rescue time interval of approximately one to two hours, and functions as a guide to therapeutic management. Cerebral salvage results using this classification and comparing routine and aggressive therapy are reported in a retrospective review of 96 patients seen at The Hospital for Sick Children, Toronto, during a 10-year period (1970-1979 inclusive). Aggressive therapy for neurological purposes included continuous dehydration, controlled hyperventilation, moderate hypothermia, barbiturate coma, and continuous muscular paralysis for four days.

All patients in categories A (51 cases) and B (6 cases) recovered completely using routine medical management.

In category C (39 comatose patients) there was an overall mortality of 33.3 per cent with a cerebral morbidity of 23.9 percent and normal recovery in 43.6 percent. When reviewing the results of treatment, two subcategories, (C.1 and C.2) were combined for comparative purposes. Results in 14 cases using routine therapy revealed a mortality of 21.4 percent, a morbidity of 42.8 per cent and an intact survival rate of 35.7 per cent. In comparison, 11 patients who received aggressive (H.Y.P.E.R.) therapy had no mortality, a morbidity of 9.0 per cent and a significant 90.9 per cent incidence of intact survival. In subcategory C.3 (14 patients) there were only four survivors, with one patient in each treatment group surviving intact (14.2 percent).

Intact cerebral survival is of paramount importance. Our findings justify immediate resuscitation in all near-drowning cases regardless of the patient's initial condition or possible prognosis. The use of an early neurological triage classification seems most appropriate to facilitate therapeutic management. Aggressive treatment (H.Y.P.E.R. therapy) in decorticate cases (subcategory C.1) and decerebrate cases (subcategory C.2) has led to a significant reduction in morbidity and mortality in near-drowned patients.






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Copyright © 1980 by the Canadian Anesthesiologists' Society.