Canadian Anaesthetists’ Society Journal

, Volume 27, Issue 3, pp 201–210 | Cite as

Cerebral salvage in near-drowning following neurological classification by triage

  • A. W. Conn
  • J. E. Montes
  • G. A. Barker
  • J. F. Edmonds


This paper describes a simple neurological classification for near-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 per cent and normal recovery in 43.6 per cent. When reviewing the results of treatment, two subcategories, (C.l and C.2) were combined for comparative purposes. Results in 14 cases using routine therapy revealed a mortality of 21.4 per cent, 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 per cent).

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.l) and decerebrate cases (subcategory C.2) has led to a significant reduction in morbidity and mortality in near-drowned patients.


Intracranial Pressure CANADIAN Anaesthetist Phenobarbitone Aggressive Therapy Triage Classification 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Ce travail décrit une classification neurologique simple pour les victimes de noyade. Trois catégories sont proposées: Catégorie A (conscience) Catégorie B (décébration) Catégorie C (coma). La catégorie C est subdivisée en trois classes: C1 (décortication) C2 (décébration) C3 (flaccidité).

Cette classification est basée sur le niveau de conscience évalué une à deux heures après le sauvetage et sert de guide pour la mise en marche du traitment. Les résultats de récupération cérébrale chez 96 patients du Hospital for Sick Children de Toronto obtenus ďaprès cette classification sont rapportés en retrospective pour la période de 10 années allant de 1970 à 1979 inclusivement. Une thérapeutique neurologique agressive signifiait ľhydratation continue, ľhyperventilation contrôlée, ľhypothermie, le coma barbiturique et une curarisation continue pendant quatre jours.

Tous les patients des classes A (51 cas) et B (6 cas) ont récupéré complètement avec le traitement médical usuel.

Dans la catégorie C (39 comateux), la mortalité totale a été de 33.3 pour cent avec une morbidité cérébrale de 23.9 pour cent et une récupération à la normalité de 43.6 pour cent. Lors de la révision du résultat thérapeutique, deux sous-catégories C1 et C2 ont été formées dans un but de comparaison. Chez 14 patients chez qui on avait employé le traitement usuel, on a trouvé une mortalité de 21.4 pour cent, une morbidité de 42.8 pour cent et une survie avec récupération totale de 35.7 pour cent. En comparaison, chez 11 patients traités de façon aggressive, il n’y a pas eu de mortalité, la morbidité a été de 9.0 pour cent et un taux significatif de 90.9 pour cent de survie sans séquelles a pu être constaté. Dans la sous-catégorie C3, (14 patients), il n’y a eu que quatre survivants dont un patient par groupe qui a récupéré complètement (14.2 pour cent).

Une survie avec une fonction cérébrale intacte est extrèmement importante. Nos données justifient une réanimation immédiate de toutes les victimes de noyade indépendemment de leur condition initiale ou du pronostic. Ľemploi ďune classification neurologique précoce semble appropriée à la mise en marche du traitement qui doit être aggressif en cas de décortication (sous-catégorie Cl) et de décérébration (sous-catégorie C2), dans le but de produire une réduction importante de la morbidité et de la mortalité chez les victimes de noyade.


  1. 1.
    Text: Dorland’s Medical Dictionary, 24th Edition, W. B. Saunders Company, Philadelphia (March 1967.Google Scholar
  2. 2.
    Schuman, S.H., Rowe, J.R., Glazier, al. “The Iceberg Phenomenon of Near-Drowning.” Soc. Crit. Care Med.,4: 127, 1976.CrossRefGoogle Scholar
  3. 3.
    Modell, J.H., Graves, S.A. &Kuck, E.J. “Near-Drowning: Correlation of Level of Consciousness and Survival.” Cdn. Anaes. Soc. J.27: 211–215, 1980.Google Scholar
  4. 4.
    Conn, A.W., Edmonds, J.F. &Barker, G.A. “Near-Drowning in Cold Fresh Water: Current Treatment Regimen.” Canadian Anaesth. Soc. J.,25: 259–265, 1978.CrossRefGoogle Scholar
  5. 5.
    Teasdale, Graham &Jennett, Bryan. “Assessment of Coma and Impaired Consciousness.” Lancet Vol.2: 81–83 (13 July) 1974.PubMedCrossRefGoogle Scholar
  6. 6.
    Lovejoy, F.H., Smith, A.L., Bresnaw, al. “Clinical Staging in Reye Syndrome.” Am. J. Dis. Child. Vol.128: 36–41, 1974.PubMedGoogle Scholar
  7. 7.
    Fandel, Ivar &Bancalari, Eduardo. “Near-Drowning in Children: Clinical Aspects.” Paediatrics58: 573–579, 1976.Google Scholar
  8. 8.
    Modell, J.H. “Drowning and Near-Drowning, Springfield, Illinois,” Charles C. Thomas, 1971, pp. 4, 5, 6.Google Scholar
  9. 9.
    Maclean, D. &Emslie-Smith, D. “Accidental Hypothermia.” Oxford, Blackwells Scientific Pubs., 1977, pp. 189, 383-384.Google Scholar
  10. 10.
    Fuller, R.N. “The Clinical Pathology of Human Near-Drowning.” Proc. Roy Soc. Med.,56: 35–38, 1963.Google Scholar
  11. 11.
    Barr, A.M. &Taylor, N.L. “A Case of Drowning.” Anaesthesia,31: 651–657, 1976.PubMedCrossRefGoogle Scholar
  12. 12.
    Conn, A.W., Edmonds, J.F. &Barker, G.A. “Cerebral Resuscitation in Near-Drowning.” Paediatric Clinics of North America26: 691–701, 1979.Google Scholar
  13. 13.
    Pearn, J., Nixon, J. &Wilkey, I. “Freshwater Drowning and Near-drowning Accidents Involving Children: A 5-Year Total Population Study.” Med. J. Austral.,2: 942–946, 1976.PubMedGoogle Scholar
  14. 14.
    Keatinge, W.R. “Survival in Cold Water.” Oxford, Blackwells Scientific Pubs., 1969, pp 5 and 42.Google Scholar
  15. 15.
    Modell, J.H., Moya, F., Williams, N.D. &Weibley, T.C. “Changes in Blood Gases and A-a DO2 During Near-Drowning.” Anaesthesiology29: 456–465, 1968.CrossRefGoogle Scholar
  16. 16.
    Petersen, B. “Morbidity of Childhood and Near-Drowning.” Paediatrics,59: 364–370, 1977.Google Scholar
  17. 17.
    Trubuhovich, R. “Water International Accidents.” N.Z.J. Sports Med. Supp #1: 48–54, May, 1976.Google Scholar
  18. 18.
    Conn, A.W. “The Role of Hypothermia in Near-Drowning, Proceedings of ‘Cold Water Symposium’.” Royal Life Saving Society of Canada, May 8, 1976, pp. 33–35.Google Scholar
  19. 19.
    Marsh, M.L., Marshall, L.F. &Shapiro, H.M. “Neurosurgical Intensive Care.” Anesthesiology,47: 149–163, 1977.PubMedCrossRefGoogle Scholar
  20. 20.
    Shapiro, H.M. “Anaesthesia, Intensive Care and the Neurosurgical Patient.” Am. Soc. Anaesth. Refresher Lecture Series, 1975.Google Scholar
  21. 21.
    Smith, A.L. “Barbiturate Protection in Cerebral Hypoxia.” Anaesthesiology,47: 285–293, 1977.CrossRefGoogle Scholar
  22. 22.
    Hagerdal, M., Welsh, F.A., Keykhah, al. “The Protective Effects of a Combination of Hypothermia and Barbiturates in Cerebral Hypoxia.” Crit. Care Med.,6: 110–111, 1978.CrossRefGoogle Scholar
  23. 23.
    Calderwood, H.W., Modell, J.H. &Ruiz, B.C. “The Ineffectiveness of Steroid Therapy for Treatment of Fresh-Water Near-Drowning.” Anaesthesiology,43: 642–650, 1975.CrossRefGoogle Scholar
  24. 24.
    Fishman, R.A. “Brain Oedema.” New Engl. J. Med.,293: 706–711, 1975.PubMedGoogle Scholar
  25. 25.
    Batzdorf, U. “The Management of Cerebral Oedema in Paediatric Practice.” Paediatrics,58: 78–87, 1976.Google Scholar
  26. 26.
    Black, P.R., Van Devawter, S. &Cohn, L.H. “Effects of Hypothermia on Systemic and Organic System Metabolism and Function.” J. Surg. Res.,20: 49–63, 1976.PubMedCrossRefGoogle Scholar
  27. 27.
    Modell, J.H. &Davis, J.H. “The Electrolyte Changes in Human Drowning Victims.” Anaesthesiology,30: 414–420, 1969.Google Scholar
  28. 28.
    Fisket al. “Influence of Duration of Circulatory Arrest at 20°C on Cerebral Changes.” Anaesth. Intens. Care,4: 126–134, 1976.Google Scholar
  29. 29.
    Virtue, R.W. “Hypothermic Anaesthesia.” Springfield, Illinois, Charles C. Thomas, 1955.Google Scholar
  30. 30.
    Conn, A.W. “Near-Drowning and Hypothermia” (editorial). Canadian Med. Assoc. J.,120: 397–400, 1979.Google Scholar
  31. 31.
    Dominguez de Villota, E., Barat, G., Peral, al. “Recovery from Profound Hypothermia with Cardiac Arrest after Immersion.” Brit. Med. J.,4: 394, 1973.PubMedCrossRefGoogle Scholar
  32. 32.
    Kvittingen, T.D. &Naess, A. “Recovery from Drowning in Fresh Water.” Brit. Med. J.,1: 1315–1317, 1963.PubMedGoogle Scholar
  33. 33.
    King, R.B. &Webster, I.W. “A Case of Recovery from Drowning and Prolonged Anoxia.” Med. J. Austral., June 13, 1964, pp 919–920.Google Scholar
  34. 34.
    Siebke, H., Rod, T., Breivik, al. “Survival after 40 minutes Submersion Without Cerebral Sequelae.” Lancet1: 1275–1277, 1975.PubMedCrossRefGoogle Scholar
  35. 35.
    Editorial: “Drowning and the Diving Reflex.” Canad. Med. Assoc. J.,108: 1209, 1973.Google Scholar
  36. 36.
    Hunt, P.K. “Effect and Treatment of Diving Reflex.” Canad. Med. Assoc. J.,111: 1330–1331, 1974.PubMedGoogle Scholar
  37. 37.
    Gooden, B.A. “Drowning and the Diving Reflex in Man.” Med. J. Austral.,2: 583–586, 1972.PubMedGoogle Scholar
  38. 38.
    Keatinge, W.R. “The Concept of Hypothermia, Proceedings of ‘Cold Water Symposium’.” Royal Life Saving Society of Canada, May 8, 1976.Google Scholar
  39. 39.
    Modell, J.H. “Drowning and Near-Drowning.” Springfield, Illinois, Charles C. Thomas, 1971, p. 70.Google Scholar
  40. 40.
    Gilston, Alan. “Cardiac Resuscitation Services: Principles and Practice.” (Editorial) Int. Care Med. Vol.5: 49–53, 1979.CrossRefGoogle Scholar
  41. 41.
    Harries, Mark G. “Survival After Cardiac Arrest.” International Med.1: 13–15, 1979.Google Scholar
  42. 42.
    Montes, J.E. &Conn, A.W. “Near Drowning: An Unusual Case.” Cdn. Anaes. Soc. Jour.27: 172–174, 1980.CrossRefGoogle Scholar
  43. 43.
    Greene, David G. “Drowning.” (Text) Handbook of Physiology Respiration II, Chapt.50: 1245–1312, 1965.Google Scholar
  44. 44.
    Giammona, S.T. “Drowning: Pathophysiology and Management.” Curr. Probl. Paediat.,1: 1–33, 1971.Google Scholar
  45. 45.
    Clarke, E.B. &Niggemann, E.H. “Near Drowning.” Heart and Lung,4: 946–955, 1975.PubMedGoogle Scholar
  46. 46.
    Modell, J.H., Graves, S.A. &Ketover, A. “Clinical Course of 91 Consecutive Near-Drowning Victims.” Chest Vol.70: 231–238 (#2 Aug.) 1976.PubMedCrossRefGoogle Scholar
  47. 47.
    Hasan, S., Avery, W.G., Fabian, C. &Sackner, M.A. “Near Drowning in Humans.” Chest59: 191–197, 1971.PubMedCrossRefGoogle Scholar
  48. 48.
    Orlowski, J.P. “Prognostic Factors in Drowning and the Post-submersion Syndrome.” Crit. Care Med.,6: 94, 1978.CrossRefGoogle Scholar
  49. 49.
    Kruuss, Bergstrom L. &Suutarinent Hyvonen, R. “The Prognosis of Near-Drowned Children.” ACTA Paediatr. Scand.68: 315–322, 1979.CrossRefGoogle Scholar
  50. 50.
    Cahill, J.M. “Drowning: The Problem of Nonfatal Submersion and the Unconscious Patient.” Surgical Clinics of North America98: 423–430, 1968.Google Scholar
  51. 51.
    Battaglia, J.D. &Lockhart, C.H. “Drowning and Near-Drowning.” Paediatric Annals98: 270–275 (April) 1977.Google Scholar
  52. 52.
    Hoff, B.H. “Multisystem Failure: A Review with Special Reference to Drowning.” Crit. Care Med.7: 310–320, 1979.PubMedGoogle Scholar
  53. 53.
    Plum, F. &Posner, J.B. “Diagnosis of Stupor and Coma.” (Text) F.A. Davis Co., Philadelphia, 1st Edition, 1966.Google Scholar
  54. 54.
    Shapiro, H.M. “Intracranial Hypertension.” Anaesthesiology,43: 445–471, 1975.CrossRefGoogle Scholar
  55. 55.
    Wood, M.M. (H.S.C.) Personal Communication.Google Scholar
  56. 56.
    Alexander, S.C. &Lassen, N.A. “Cerebral Circulatory Response to Acute Brain Disease.” Anaesthesiology,32: 60–68, 1970.CrossRefGoogle Scholar
  57. 57.
    Spence, M. Personal Communication.Google Scholar
  58. 58.
    Modell, J.H., Calderwood, H.W. &Ruiz, B.C. “Effects of Ventilatory Patterns on Arterial Oxygenation After Near-drowning in Sea Water.” Anaesthesiology,40: 376–384, 1974.CrossRefGoogle Scholar
  59. 59.
    Text: “Drowning” Special Report. The Practitioner, April/May, 1979 Chapter — Sequelae of Near-Drowning. Simcock, A.D.Google Scholar
  60. 60.
    Froese, A.B. &Bryan, A.C. Effects of anesthesia and paralysis on diaphragmatic mechanics in man. Anesthesiology41: 242–255 (1974).PubMedCrossRefGoogle Scholar

Copyright information

© Canadian Anesthesiologists 1980

Authors and Affiliations

  • A. W. Conn
    • 1
  • J. E. Montes
    • 1
  • G. A. Barker
    • 1
  • J. F. Edmonds
    • 1
  1. 1.The Intensive Care UnitHospital For Sick ChildrenTorontoCanada

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