Clinical scenario

A 15 year old boy was playing in the local canal. He jumped off a small bridge and got his foot caught in an old shopping trolley on the bottom. He was pulled out but he was unconscious and apnoeic. He was given BLS by the paramedics so that when he arrived in accident and emergency he was conscious, tachypnoeic, and centrally cyanosed. He had rhonchi and coarse crepitations in both lung fields. You wonder whether he would benefit from intravenous corticosteroids.

Three part question

In a case of [near-drowning], does the [use of corticosteroids] affect [outcome in terms of survival or pulmonary complications]?

Search strategy

Medline 1966 to 08/01 using the OVID interface. (Exp drowning/ or exp near drowning/ or “drowning”.mp) AND (exp steroids/ or “steroid”.mp OR exp adrenal cortex hormones/ or “adrenal cortex hormones”.mp OR exp adrenal cortex hormones/ or “corticosteroids”.mp OR exp methylprednisolone/ or “methylprednisolone”.mp OR exp hydrocortisone/ or “hydrocortisone”.mp OR exp dexamethasone/ or “dexamethasone”.mp OR exp prednisone/ or “prednisone”.mp). LIMIT to human AND English language.

Search outcome

Altogether 33 papers were identified by the search strategy. There were no prospective randomised placebo controlled trials but there was one prospective study. Four papers were retrospective analyses of case reports and included some data on the effects of corticosteroids. Another retrospective analysis was found fromthe references. Of the remaining papers, nine were individual case reports or short series. All the others were irrelevant (table 5).

Comment(s)

All the case reports suggested that corticosteroids are of benefit in near-drowning.

The only prospective study included 10 patients. However, all seven of those given methylprednisolone (5mg/kg/24 hours IV divided into six equal doses) survived. All the other studies were retrospective analyses of case notes. None showed any benefit from corticosteroids, but they did not provide enough data about the corticosteroids used, the doses used, or specific outcomes to provide reliable evidence.

Case reports, which may be inherently biased, show some benefit, but there is no good evidence that the routine use of intravenous corticosteroids improves the outcome in cases of near-drowning. There may be a case for conducting a properly controlled trial to settle the issue.

Clinical bottom line

There is very little evidence on the value of giving intravenous corticosteroids in cases of near-drowning.