Resuscitation for more than 30 minutes in young people after drowning is medically futile

In medical terms, resuscitation for more than 30 minutes in children after drowning s is futile if they have suffered cardiac arrest in combination with hypothermia. This is the conclusion of an in-depth study headed by paediatric intensivist Joke Kieboom from the University Medical Center Groningen. Although lengthy resuscitation did restore cardiac function, 90% of the children died, most of them within a few days. The remaining children survived in a vegetative state or suffered serious brain damage. Kieboom would like to see changes to the medical guidelines in this area. Her research is published in today’s edition of the British Medical Journal.

For her research, Kieboom studied all 736 cases of young people rescued from drowning and admitted to one of the 8 university medical centres in the Netherlands over the last 20 years. One hundred and sixty of these children had suffered cardiac arrest in combination with hypothermia (body temperature < 34 degrees Celsius) when resuscitation commenced. In 98 cases, the victims received cardiopulmonary resuscitation lasting longer than 30 minutes. Ninety percent of the children died and the remaining 10% were left with profound brain damage. According to Kieboom, the conclusions from the study are clear-cut, but unfortunately not positive: ‘It is indisputable that resuscitating these children for longer than 30 minutes does not produce a positive medical outcome. However difficult, we must be honest about this and accept the consequences.’

Kieboom wanted to learn more about the situations in which young children suffering oxygen deprivation and hypothermia could be successfully resuscitated. In medical terms, hypothermia is often a positive circumstance. It reduces the need for energy, and in cases with oxygen deprivation, hypothermia can actually help to protect the brain, as in the case of a person who gets lost in the snow and suffers cardiac arrest due to hypothermia. But these new results relating to children after drowning do not show a protective effect from hypothermia. This may be because oxygen deprivation is immediate, and hypothermia sets in later and more gradually. The children who drowned during the summer months and suffered cardiac arrest and hypothermia had most likely been under water for too long, and serious brain damage was inevitable.

Kieboom studied every case in the age group 0-16 years. More than 75% of the children were between 0-6 years old, as these children are able to walk but not swim.

The medical guidelines state that resuscitation after cardiac arrest should be stopped after 20 minutes, unless the victim is also suffering from hypothermia. There is no specific mention of how long people with hypothermia after drowning should be resuscitated. The decision is usually left to the doctor in charge. Kieboom would like to see the guidelines altered to advise a maximum of 30 minutes for resuscitating children who are suffering both cardiac arrest and hypothermia when the resuscitation attempt commences.

The results of this study do not provide information about specific, exceptional circumstances such as young people rescued from drowning after a car becomes immersed in water or from icy cold water. In these exceptional cases hypothermia may set in quickly, before the brain is deprived of oxygen. These specific exceptional situations are set out in a decision tree.

Kieboom also argues the case for more preventive measures; preventing drowning is the only way to reduce mortality. Kieboom: ‘Parents of young children, and in fact all adults, must be made fully aware of the dangers of open water to young children. Protective measures must be taken when building new housing estates close to water, to prevent children from falling in.’

Find the publication on: http://www.bmj.com/content/350/bmj.h418