Outcome after resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia: Dutch nationwide retrospective cohort study

Abstract

Objectives: To evaluate the outcome of drowned children with cardiac arrest and hypothermia, and to determine distinct criteria for termination of cardiopulmonary resuscitation in drowned children with hypothermia and absence of spontaneous circulation.

Design: Nationwide retrospective cohort study.

Setting: Emergency departments and paediatric intensive care units of the eight university medical centres in the Netherlands.

Participants: Children aged up to 16 with cardiac arrest and hypothermia after drowning, who presented at emergency departments and/or were admitted to intensive care.

Main outcome measure: Survival and neurological outcome one year after the drowning incident. Poor outcome was defined as death or survival in a vegetative state or with severe neurological disability (paediatric cerebral performance category (PCPC) ≥ 4).

Results: From 1993 to 2012, 160 children presented with cardiac arrest and hypothermia after drowning. In 98 (61%) of these children resuscitation was performed for more than 30 minutes (98/160, median duration 60 minutes), of whom 87 (89%) died (95% confidence interval 83% to 95%; 87/98). Eleven of the 98 children survived (11%, 5% to 17%), but all had a PCPC score ≥ 4. In the 62 (39%) children who did not require prolonged resuscitation, 17 (27%, 16% to 38%) survived with a PCPC score ≤ 3 after one year: 10 (6%) had a good neurological outcome (score 1), five (3%) had mild neurological disability (score 2), and two (1%) had moderate neurological disability (score 3). From the original 160 children, only 44 were alive at one year with any outcome.

Conclusions: Drowned children in whom return of spontaneous circulation is not achieved within 30 minutes of advanced life support have an extremely poor outcome. Good neurological outcome is more likely when spontaneous circulation returns within 30 minutes of advanced life support, especially when the drowning incident occurs in winter. These findings question the therapeutic value of resuscitation beyond 30 minutes in drowned children with cardiac arrest and hypothermia.

Fig 1 Patient flow and clinical outcome of children who drowned with cardiac arrest and hypothermia after presentation at emergency department. Final outcome was one year after drowning incident and categorised with paediatric cerebral performance categories (PCPC). Death, vegetative state, and severe disability were categorised as poor outcome. ROSC=return of spontaneous circulation, PICU=paediatric intensive care unit

Fig 2 Distribution of children who drowned with cardiac arrest and hypothermia by month and season

Fig 3 Outcome in drowned children with cardiac arrest and hypothermia according to duration of advanced life support

Fig 4  Proportion of children with good outcome of cardiac arrest and hypothermia after drowning according to season (as proxy for water temperature)

Fig 5  Estimated minimum and maximum durations of submersion and initial core body temperature in drowned children with cardiac arrest and hypothermia according to season (as proxy for water temperature)

Fig 6 Estimated maximum duration of submersion and outcome in drowned children with cardiac arrest and hypothermia

Fig 7 Proposed decision tree for continuation of resuscitation beyond 30 minutes in children with cardiac arrest and hypothermia (core body temperature <34°C) after drowning outside in temperate climate