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Three Part Question

In [patients who have nearly drowned] does [a CT scan of the head] provide [useful diagnostic or prognostic information]?

Clinical Scenario

A 10-year-old boy presents to A&E after falling into a river. He was rescued and resuscitated at the scene but now has a GCS of 7. There is no evidence of trauma. You wonder if a CT scan of his head will aid the management

Search Strategy

Medline 1946 to June week 2 2015 and Embase 1980 to 2015 week 25 using the OVID interface.
Medline: [exp Near Drowning/ OR exp Drowning/ OR drowning.mp. OR drown$.mp.] AND [ exp Diagnostic imaging/ OR exp Tomography, X-Ray Computed/ OR CT Head.mp.] LIMIT to human AND English Language.

Embase: [exp Near Drowning/ OR exp Drowning/ OR drowning.mp. OR drown$.mp.] AND [ exp Diagnostic imaging/ OR exp Tomography, X-Ray Computed/ OR CT Head.mp.] LIMIT to human AND English Language.

The Cochrane Library Issue 6 of 12 date of searching 03/07/2015 : MeSH descriptor: [Drowning] explode all trees

Search Outcome

Altogether 141 papers were identified by the Medline search strategy and 149 by the Embase strategy. Of these, 3were considered relevant to the 3-part question. No relevant reviews were found in the Cochrane library.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Romano C et al 1993 Canada	19 near-drowned children admitted to the childrens hospital of Western Ontario between 1983 and 1991.	Retrospective chart review	Abnormal cranial CT compared to clinical outcome	15 received cranial CT within 36 h. 12 (80%) had normal CT. The clinical outcome of these patients varied between full recovery, long term neurological deficit and death. Of the 3 patients with abnormal CT, all died.	Retrospective series, one centre, small number of patients. Therapy not controlled or recorded.
Taylor SB et al 1985 USA	17 Children admitted to either the University Hospital Miami or the Childrens Memorial Hospital Chicago for near drowning, who had cranial CT within 24h of immersion incident between 1978 and 1984.	Retrospective chart review	Abnormal cranial CT compared to clinical outcome	12 had normal CT scans , clinical outcome in these patients was variable. Of the 5 with abnormal CT scans, 4 died (80%).	Retrospective series , small number of patients. Therapy not controlled or recorded.
Karim TR et al 2008 USA	156 children admitted to Rady’s childrens hospital San Diego with a diagnosis of drowning between Jan 1986 and April 2006 with no evidence of trauma, who received cranial CT within 24 h.	Retrospective chart review	Abnormal Cranial CT Scan	104 (82%) had normal CT. 24 (15%) had abnormalities on later scans. No patient with a GCS>4 had an abnormal CT at any time. Presenting GCS was significantly lower in those presenting with abnormal vs normal head CT (p = 0.001). All 28 patients with initial abnormal CT died.	Retrospective series. One Centre. Therapy not controlled or recorded.

Comment(s)

All the reports agree that a normal cranial CT scan within 24h offers little prognostic value. However they also agree that an abnormal cranial CT within 24h indicates a poor prognosis, and suggest avoiding aggressive treatment in these patients. The large study by Karim T R et al found that no patient with a GCS>4 had an abnormal CT scan, suggesting little need for the investigation in these patients.

Editor Comment

BF

Clinical Bottom Line

Cranial CT should be reserved for patients with a GCS <4 in near drowning patients. An abnormal result indicates a very poor prognosis and may suggest avoidance of aggressive treatment.

References

1. Romano C, Brown T, Frewen TC. Assessment of pediatric near-drowning victims: is there a role for cranial CT? Pediatr Radiol 1993;23: 261-3.
2. Taylor SB, Quencer RM, Holzman BH et al. Central nervous system anoxic-ischemic insult in children due to near-drowning. Radiology 1985;156(3): 641-6
3. Karim TR, Spear RM, Kuelbs C et al Cranial computed tomographic findings in a large group of children with drowning: diagnostic, prognostic and forensic implications. Pediatr Crit Care Med 2008;9(6): 567-72.