[Survival with no sequelae after near-drowning with very poor signs for prognosis including persistent bilateral non-reactive mydriasis].

Introduction: The outcome of cases of near-drowning and initially poor prognostic signs are usually discouraging because of the severity of the consequent encephalopathy in most survivors. However, good recovery has been described, in spite of bad prognostic factors initially. It is difficult to establish the predictors of poor outcome which would enable one to decide when to establish and maintain advanced cardio-pulmonary resuscitation measures (CPR), since each case of near-drowning is different.
Clinical Case: A four year old boy survived near-drowning in cold water without sequelas but with initial signs of very poor prognosis, including prolonged immersion time, coma, severe metabolic acidosis, hyperglycemia and persistent bilateral arreactive mydriasis.
Discussion: The beneficial effect of hypothermia is well known, and explains (at least partially) survival in cases of apparently irreversible near-drowning. Potential benefits are reduced metabolic demand which prevents the adverse effects of hypoxia and the 'diving reflex' which short-circuits the blood supply to vital organs such as the brain and heart. We consider that the persistently arreactive pupils were not due to hypoxia, but rather to bilateral uncal compression of the third cranial nerves due to cerebral edema secondary to initial hypoxia and water intoxication.
Conclusion: This observation is yet another argument for the establishment and maintenance of aggressive manoeuvers of CPR and treatment in all children who have nearly-drowned, independently of the apparent seriousness or irreversibility.