Hypoxic-ischaemic brain injury: Case

This girl has a hypoxic-ischaemic brain injury after an out-of-hospital drowning arrest. The prolonged submersion and resuscitation time place her at high risk of a significant secondary injury. The primary injury is already fixed; the priority in intensive care is to protect the brain from the secondary cascade over the coming hours and days through targeted temperature management and the neurocritical care bundle. [1][7]

Clinical findings and assessment

The key findings are the coma after return of spontaneous circulation, the small and slowly reactive pupils, the borderline blood pressure, the mild hypothermia from immersion, and the normal glucose. The coma with intact but sluggish brainstem reflexes indicates a significant but not brainstem-destructive injury at this early stage, and the borderline blood pressure is an immediate concern because early postresuscitation hypotension is strongly associated with worse survival. The history of an unwitnessed or briefly delayed drowning with a long resuscitation time is the dominant predictor of severity. [6][7]

The working diagnosis is hypoxic-ischaemic brain injury from a drowning-related out-of-hospital arrest. The differential of ongoing coma includes the secondary injury itself, non-convulsive status epilepticus, a drug or sedative effect, and a primary intracranial cause such as a cervical spine injury from a dive. The bedside assessment confirms the airway is secure, the glucose is normal, and the child is ventilated, which allows the team to proceed to the neurocritical care plan. [7]

Immediate management and targeted temperature management

The immediate management is the neurocritical care bundle. I would ventilate to normoxia and normocapnia, titrating the inspired oxygen down to the lowest concentration that avoids hypoxia and targeting a normal carbon dioxide, because both hyperoxia and hypocapnia worsen the injured brain. I would defend the circulation to an age-appropriate mean arterial pressure from the first hour with fluids and inotropes, because the borderline blood pressure is the most urgent correctable threat. I would establish continuous EEG early to detect non-convulsive seizures. [6][7]

I would initiate hypothermic targeted temperature management at 32 to 34 degrees Celsius for 48 hours, because this is an out-of-hospital arrest and the THAPCA out-of-hospital trial supports hypothermia as a reasonable option. I would cool with a surface or intravascular device and a continuous core temperature, treat shivering with sedation and a neuromuscular blocker as needed, and rewarm at no more than 0.5 degrees Celsius per hour after the 48-hour period. I would maintain normothermia and treat fever for the remainder of the admission, because fever extends the ischaemic lesion. [1][7]

Drowning-specific considerations

In parallel I would address the three drowning-specific features. I would manage the lung injury from water aspiration, which may progress to acute respiratory distress syndrome and complicate oxygenation and ventilation, with lung-protective ventilation and careful fluid balance. I would incorporate the immersion hypothermia into the temperature plan, recognising that the mild hypothermia may have been protective during the arrest. I would exclude a cervical spine injury from a possible dive with imaging before removing the cervical collar, because an occult cervical injury in a drowned child is easily missed in a comatose patient. [4][5]

I would seek and treat other contributors, including electrolyte disturbance from immersion, aspiration pneumonitis, and the possibility of a coexisting ingestion or trauma. The child would be admitted to the paediatric intensive care unit, and the paediatric neurology, rehabilitation, and where relevant ear-nose-throat and surgical teams would be involved early. [4]

Neuroprognostication and family communication

I would not prognosticate before 72 hours and not before sedation had cleared. At 72 hours or beyond I would run a multimodal assessment combining the motor response, the brainstem reflexes, the continuous EEG background, the neuroimaging, and the biomarkers, with no single predictor sufficient. Topjian and colleagues showed that the early electroencephalographic background is among the strongest predictors of outcome, with a continuous reactive background reassuring and a suppressed or burst-suppressed background with electrographic seizures concerning. [8]

I would counsel the family honestly at every stage. In the early days I would explain that their daughter has had a cardiac arrest from drowning, that the brain has been injured, and that the team is cooling her and controlling her intensive care to protect the brain from further damage. I would state that the outlook will become clearer over the next days, that no single test defines the prognosis, and that I would hold a formal multidisciplinary prognostication meeting at 72 hours or beyond. The Slomine drowning analysis shows that drowning-related arrests can have comparable or even better neurobehavioural outcomes than other respiratory arrests when managed well, and I would hold that measured hope alongside the uncertainty. [5][7]

Before discharge, the family would be connected to a structured rehabilitation and neurodevelopmental follow-up programme, because a substantial minority of survivors are left with a cognitive, motor, or seizure disorder that declares itself over months, and early rehabilitation improves the long-term function. The family would also receive drowning-prevention counselling, including pool fencing, supervision, and cardiopulmonary resuscitation training, because the prevention of a second event is part of the care of the first. [4]