Cerebral protection

Neurological complications of cerebral anoxia secondary to drowning can be devastating and costly. The extent of neurological injury is the single most important predictor of morbidity and mortality, and correlates closely with the duration of immersion, water temperature, and the efficacy of early resuscitative efforts. No therapeutic measure has been shown consistently to prevent or reverse the sequelae of cerebral ischemia. Furthermore, neurological outcome cannot be reliably predicted (OjakesetjaJ 1982). The mainstay of neurological protection in the face of global cerebral ischemia is the control of intracranial pressure, prevention and control of seizures, and the maintenance of cerebral perfusion pressure and cerebral blood flow. Monitoring the intracranial pressure is not generally regarded as useful. Declining neurological status, as quantified by the Glasgow Coma Scale or increasing papilledema, correlates well with increasing intracranial pressure. Increases in intracranial pressure probably reflect the degree of neurological injury, and control of intracranial pressure alone does not imply functional neurological recovery. Increased intracranial pressure is inversely related to prognosis for functonal recovery.

Moderate hyperventilation to a PaCO2 of 25 to 30 mmHg (3.3-4 kPa) results in cerebral vasoconstriction and can therapeutically decrease intracranial pressure for a period of 18 to 24 h. Osmotic diuresis with mannitol and forced diuresis with furosemide (frusemide) or torsemide can decrease cerebral edema. Increasing venous drainage will also help to decrease intracranial pressure. Coughing and straining, particularly on the endotracheal tube with suctioning, has been shown to result in prolonged elevations of intracranial pressure ('plateau waves') and should be minimized by sedation or neuromuscular blockade. Seizures markedly increase the cerebral metabolic rate and predispose to further intracellular acidosis and edema. Seizures may be latent and require a high index of suspicion and electroencephalographic diagnosis. Immediate pharmacological control of seizures is indicated. Cerebral perfusion pressure (CPP) is maximized by decreasing intracranial pressure (ICP), decreasing central venous pressure (CVP), and maximizing mean arterial pressure (MAP):

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