Between April 1979 and September 1984, 66 children were admitted to the intensive care unit (ICU) at Childrens Hospital of Los Angeles after a severe near-drowning episode. Each patient required full cardiopulmonary resuscitation and had an initial Glasgow coma score (GCS) of 3 in a referring emergency room. Patients were reclassified according to results of a neurologic examination (GCS) on arrival in the ICU. The overall results showed 16 patients (24%) with apparently intact survival, 17 patients (26%) with vegetative survival, and 33 deaths (50%). No patient who arrived at the ICU with a GCS of 3 (flaccid) survived neurologically intact. Out of 37 such patients arriving in flaccid coma, 26 patients died and 11 patients suffered severe brain damage. The majority of patients with GCS of less than 6 underwent intracranial pressure (ICP) monitoring and aggressive therapy directed to control ICP. Despite adequate control of ICP and maintenance of cerebral perfusion pressure, 12 monitored patients survived in a vegetative neurologic state. The results justify aggressive emergency room resuscitation of severe pediatric near-drowning victims but suggest that cerebral resuscitative measures must be subjected to critical prospective evaluation.