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Three Part Question

In [patients who have nearly drowned] does [Barbiturate-induced coma] [improve outcome]?

Clinical Scenario

A 34 year old man has been fishing on a Sunday afternoon at his local pond. He has lost his footing and fallen in. A passing dog walker has seen him struggle and managed to pull him out, unconscious. He is resuscitated at the scene. He is brought to the Emergency Department still coughing up brown water, but not obeying commands. One of your colleagues, nearing retirement age, suggests a barbiturate-induced coma.

Search Strategy

Medline 1946- November Week 3 2014 using Ovid interface

(Near Drowning/ or exp Drowning/ or drowning.mp) AND (barbiturate$.mp or exp Barbiturates/ or thiopentone.mp or exp Thiopental/ or phenobarbitone.mp or exp Phenobarbital/)

Search Outcome

43 citations only 3 of which were considered relevant to the three part question.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Nussbaum & Maggi 1988 USA	31 near-drowned children in a flaccid state of coma admitted between 1983 and 1986. All children were treated with hyperventilation, fluid restriction and diuresis. Group A (16 children) were treated with hypothermia and IV pentobarbital therapy achieving >25 micrograms/mL within 48 hours of admission. Group B received hypothermia therapy without IV pentobarbital. There were no significant differences in age, time of submersion, intracranial pressure and core temperature on admission between the groups.	Prospective single centre cohort study	Complete recovery	6 in each group (NS)	Small cohort with potential selection bias. Unreliable admission data (including submersion time).
			Brain damage	6 in each group (NS)
			Death	4 in Group A and 3 in Group B (NS)
Oakes et al. 1982 USA	40 patients aged between 6 months and 71 years. 33 of the patients were aged under 17 years and the 7 adult patients were under the influence of alcohol. Barbiturate coma was used in 19 patients, 17 of which were comatose. Pentobarbital was the most commonly used barbiturate.	Retrospective, non-controlled, non-randomised single centre study	Complete recovery	29% with barbiturates compared to 38% without (NS)	Non-controlled, non-randomised study with a very varied study group. Small cohort size. No standardised treatment between patients, including which barbiturate used.
			Neurological deficit	35% with barbiturates and 13% without (NS)
			Death	35% with barbiturates and 50% without (NS)
Bohn et al. 1986 Canada	40 near-drowned children treated between 1978 and 1982. Between 1978-1980 24 were treated with hypothermia, hyperventilation and high-dose phenobarbitone. The 16 treated between 1980-1982 received the same treatment without hypothermia.	Retrospective review	Recovery	11 in Group 1, 9 in Group 2 (NS)	Sequential cohorts. All patients received phenobarbitone. Even so the authors concluded that barbiturates did not improve outcome but did not compare patients treated with or without barbiturates.
			Brain damage	3 in Group 1, 4 in Group 2 (NS)
			Death	10 in Group 1, 3 in Group 2 (NS)

Comment(s)

The prospective study had limited admission data with a small cohort. The retrospective study of case notes has little statistical significance based on the variation in patient presentation, patient demographics and small cohort size. Neither study showed significant clinical benefit from the use of barbiturates while describing the potential risks associated with their use. In the 1986 study all patients received barbiturates, but the authors concluded that this did not influence outcome. Although barbiturates seemed to control ICP many of the non-survivors had severe cerebral hypoxia but did not have uncontrolled ICP. Two other series of nearly drowned children showed no obvious benefit from the use of barbiturates (Black et al. 1976, Nussbaum and Galant 1986). In the absence of any other evidence patients admitted to intensive care after near-drowning should be provided with the same supportive care as any other out-of-hospital cardiac arrest patient.

Editor Comment

BAF submitting

Clinical Bottom Line

There is no evidence in favor of barbiturates in the treatment of near-drowning. If the patient has suffered a cardiac arrest current guidelines should be followed.

References

1. Nussbaum E, Maggi JC. Pentobarbital therapy does not improve neurologic outcome in nearly drowned, flaccid-comatose children Pediatrics 1988; 81(5): 630-634.
2. Prognosis and management of victims of near-drowning. Oakes DD, Sherck JP, Maloney JR, Charters AC. J Trauma-Injury Inf Crit Care 1982; 22(7): 544-549.
3. Bohn DJ, Biggar WD, Smith CR et al. Influence of hypothermia, barbiturate therapy, and intracranial pressure monitoring on morbidity and mortality after near-drowning. Crit Care Med 1986; 14(6): 529-534.
4. Black PR, van Devanter S, Cohn LH. Effects of hypothermia on systemic and organ system metabolism and function. J Surg Res 1976; 20:49-63.
5. Nussbaum E, Galant SP. Intracranial pressure monitoring as a guide to prognosis in the nearly drowned severely comatose child. J Pediatr 1983; 102: 215-218.