A Successful Outcome in a Case of Cardiac Arrest due to Drowning with Severe Acidosis.

Sir,

A 28-year-old woman who traveled to Izu Peninsula from Tokyo as a tourist drowned while undertaking diving training in the sea. The diving instructors noticed her accident and rescued her from the sea floor, at a water depth of 2 m. She was moved to the nearby shore, which she reached at 12:20, within a few minutes after the accident occurred. As she was in a state of deep coma with apnea, chest compression was performed. Automated external defibrillation was also performed, with the patient receiving one electric shock. When emergency medical technicians checked her at 12:34, she was in cardiac arrest. The initial rhythm was a pulseless electrical activity. She was transported to our emergency room by an ambulance; during transportation, she received chest compression, insertion of a supraglottic airway, and ventilation. She had no relevant past or family history. On arrival at 13:00, she remained in a state of cardiac arrest with dilated nonreactive pupils (both 8 mm). She underwent tracheal intubation, mechanical ventilation, securing of a venous route, and infusion of adrenaline (1 mg). At 13:07, a return of spontaneous circulation was achieved. On arrival, an arterial gas analysis, under 15 L/min of oxygen, revealed the following findings: pH, 6.52; PCO2, 97.3 mmHg; PO2, 89.4 mmHg, HCO3−, 7.6 mmol/l, lactate, 22 mmol/L, and base excess,−37.2 mmol/L. Portable chest roentgenography revealed bilateral decreased radiolucency of the lung fields. Electrocardiography showed sinus tachycardia without ST change. Her vital signs at 13:10 were as follows: blood pressure, 134/54 mmHg; heart rate, 92 beats/min; respiratory rate, 14 breaths/min, and core temperature, 33.3°C. At 13:13, she showed generalized convulsions. Thus, infusion of 10 mg of diazepam and 500 mg of levetiracetam and continuous infusion of midazolam were initiated. Whole-body computed tomography showed preservation of the cortical ribbon, an abnormal mixed density lesion at the left posterior temporal lobe of the brain, and diffuse decreased density of the bilateral lung fields [Figure 1], which were compatible with aspiration. The main results of a biochemical analysis of blood were as follows: white blood cell count, 13,500/μL; glucose, 359 mg/dL; sodium, 163 mEq/L; potassium, 4.6 mEq/L; chloride, 134 mEq/L; calcium, 12.5 mg/dL; and fibrin degradation products, 395.6 μg/mL. These laboratory results were compatible with drowning in seawater and severe hypoxic insult. She underwent induced hypothermic therapy for 24 h, with a target core temperature of 33°C. After finishing rewarming, she was able to obey orders. After observing improvement in her respiratory function with a PaO2/FiO2 ratio of >300, she was extubated on day 3. Head magnetic resonance imaging on the same day demonstrated cavernous hemangioma with hemorrhage and thin subdural hemorrhage. This cerebral insult was thought to have been responsible for her drowning incident. On the 11thday, she was transported to Tokyo without neurological deficit for further examination of the cerebral cavernous hemangioma.

Figure 1

Thoracic computed tomography on arrival. The computed tomography showing diffuse decreased density of the bilateral lung fields, which was compatible with aspiration

A chain of survival, including accidental hypothermia and extended induced hypothermic therapy, may contribute to the achievement of a favorable outcome, even if a patient shows convulsions and unfavorable biochemical–hematological data.[12345]

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