A case of a Man Performed Therapeutic Hypothermia to the Hypoxic Encephalopathy due to Hot Spring Drowning

Abstract

Case Report: The patient was a 70-year-old man with a chief complaint of impaired consciousness. He had visited a hot spring in Yamagata Prefecture. While he was bathing in a hot spring, he lost consciousness and nearly drowned. There was no eye witness. Other guests discovered him floating in the bathtub. He was not breathing and received chest compression by a guest. Subsequently, the patient resumed spontaneous respiration. When the emergency medical team arrived, and Japan Coma Scale (JCS) was 300 and Glasgow Coma Scale (GCS) was E1V1M1. The patient was transported to our hospital, and JCS was 200 at admission. Plain chest x-ray and CT imaging revealed infiltrative opacities in the bilateral lungs, suggesting pneumonia. Head CT imaging was unable to identify the underlying cause of loss of consciousness and showed no hypoxic changes. He continued to have impaired consciousness after arrival at the hospital, and it was determined that he had postresuscitation hypoxic encephalopathy. He was immediately treated with cerebral hypothermia. Midazolam was used for sedation, fentanyl for analgesia, and vecuronium for prevention of shivering. In the emergency room, the patient underwent gastric lavage with cold water and infusion of cold fluid. An Arctic Sun^® was placed on the patient after admission to the ICU. A target body temperature of 34°C was reached approximately 4 hours after arrival. His temperature was maintained at 34°C for 24 hours and warmed to 36°C in the next 48 hours. Lung disorder caused by aspiration of hot spring water was treated with antibiotics (tazobactam/piperacillin and azithromycin) and positive-pressure ventilation by a mechanical ventilator. This treatment prevented the lung disorder from increasing in severity. Sedation was discontinued after the body temperature was warmed. Subsequently, the patient’s state of consciousness was improved to the premorbid level, and he eventually was able to return to his normal life.
Discussion: When patients nearly drown in a hot spring, their body temperatures are often elevated because they have been in hot water for a long time. Their body temperatures must be lowered quickly to a target level using various cooling methods. Immunity is lowered in a hypothermic state, and pneumonia will inevitably develop due to aspiration of hot spring water. Thus, appropriate management is necessary, including the use of antibiotics.
Conclusion: Cerebral hypothermia was effective for postresuscitation hypoxic encephalopathy caused by near drowning in a hot spring.