Barbiturates in near-drowning

Date First Published:
November 27, 2014
Last Updated:
December 13, 2014
Report by:
Paul Galaway, Medical Student (University College, London, UK)
Search checked by:
Bernard A Foëx, University College, London, UK
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
Search Details:
(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/)
Outcome:
43 citations only 3 of which were considered relevant to the three part question.
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Pentobarbital therapy does not improve neurologic outcome in nearly drowned, flaccid-comatose children Nussbaum E, Maggi JC. 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 DD, Sherck JP, Maloney JR, Charters AC. Prognosis and management of victims of near-drowning. 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)
Influence of hypothermia, barbiturate therapy, and intracranial pressure monitoring on morbidity and mortality after near-drowning. Bohn DJ, Biggar WD, Smith CR 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)
Author Commentary:
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.

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
  2. Prognosis and management of victims of near-drowning.. Oakes DD, Sherck JP, Maloney JR, Charters AC.
  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.
  4. Black PR, van Devanter S, Cohn LH.. Effects of hypothermia on systemic and organ system metabolism and function.
  5. Nussbaum E, Galant SP.. Intracranial pressure monitoring as a guide to prognosis in the nearly drowned severely comatose child.