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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
Article

Abstract

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.

Keywords

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.

Résumé

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.

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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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