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]