Part 10.3: Drowning D wning is a leading preventable cause of unintentional been found to be clinically significant. The most important morbidity and mortality. Although this chapter focuses factors that determine outcome of drowning are the duration on treatment, prevention is possible, and pool fencing has and severity of the hypoxia. been shown to reduce drowning and submersion injury( Class Although survival is uncommon in victims who have undergone prolonged submersion and require prolonged re- The most important and detrimental consequence of sub- suscitation, 4, 5 successful resuscitation with full neurologic mersion is hypoxia. Therefore, oxygenation, ventilation, and recovery has occasionally occurred with prolonged submer- perfusion should be restored as rapidly as possible. This will sion in icy water 6-8 For this reason, scene resuscitation require immediate bystander CPR plus immediate activation should be initiated ed and the victim transported to an ED unless of the emergency medical services(EMS)system. Victims there is obvious physical evidence of death who have spontaneous circulation and breathing when they reach the hospital usually recover with a good outcome Modifications to Basic Life Support Victims of drowning may develop primary or secondary for drowning hypothermia. If the drowning occurs in icy (<5C [) No modification of standard BLS sequencing is necessary water, hypothermia may develop rapidly and provide some Some cautions are appropriate, however, when beginning protection against hypoxia. Such effects, however, have CpR for the drowning victim. victims in icy water(see Part 10.4: Hypothermia).2 Recovery From the Water All victims of drowning(see definitions below) who When attempting to rescue a drowning victim, the rescuer require any form of resuscitation(including rescue breathing should get to the victim as quickly as possible, preferably by alone)should be transported to the hospital for evaluation and onveyance(boat, raft, surfboard, or flotati monitoring even if they appear to be alert with effective The rescuer must always be aware of personal safety cardiorespiratory function at the scene. The hypoxic insult Recent evidence indicates that routine stabilization of the can produce an increase in pulmonary capillary permeability cervical spine is not necessary unless the circumstances leading with delayed onset of pulmonary complications. to the submersion episode indicate that trauma is likely(Class Ila). These circumstances include a history of diving, use of a Definitions. Classifications and water slide, signs of injury, or signs of alcohol intoxication. 9 In Prognostic Indicators the absence of such indicators, spinal injury is unlikely. Manual A number of terms are used to describe drowning. to aid cervical spine stabilization and spine immobilization equipment he use of consistent terminology and the uniform reporting may impede adequate opening of the airway, and they compli of data from drowning, the Utstein definition and style of data cate and may delay the delivery of rescue breaths reporting are recommended Drowning is a process resulting in Rescue breathing respiratory impairment from submersion/immersion in a liq- The first and most important treatment of the drowning uid medium. Implicit in this definition is that a liquid/ victim is the immediate provision of ventilation. Prompt interface is present at the entrance of the victim's airway, initiation of rescue breathing increases the victims chance of preventing the victim from breathing air. The victim may live survival. 10 Rescue breathing is usually performed when the or die after this process, but whatever the outcome, he or she unresponsive victim is in shallow water or out of the water.If has been involved in a drowning incident. it is difficult for the rescuer to pinch the victims nose, A victim may be rescued at any time during the drowning support the head, and open the airway in the water, mouth- process and may not require intervention or may receive to-nose ventilation may be used as an alternative to mouth- appropriate resuscitation measures. In either case the drown- to-mouth ventilation. Untrained rescuers should not try to ing process is interrupted. provide care while the victim is still in deep water. The Utstein statement recommends that the term near- Management of the drowning victim's airway and breath- drowning no longer be used. It also de-emphasizes classifi ing is similar to that recommended for any victim of cardio- cation based on type of submersion fluid(salt water versus pulmonary arrest. There is no need to clear the airway of aspirated water, because only a modest amount of water is ave been reported in laboratory conditions, these have not aspirated by the majority of drowning victims and it is rapidly absorbed into the central circulation so it does not act as an ( Circulation.2005;112:Iv-133-Iv-135.) obstruction in the trachea. 5. Some victims aspirate nothing o 2005 American Heart Association because they develop laryngospasm or breath-holding. 5. 12 This special supplement to Circulation is freely available at http://www.circulationaha.org Attempts to remove water from the breathing passages by any means other than suction (eg, abdominal thrusts or the DOI: 10.1161/CIRCULATIONAHA. 105.166565 illich maneuver) are unnecessary and potentially danger IV-133Part 10.3: Drowning Drowning is a leading preventable cause of unintentional morbidity and mortality. Although this chapter focuses on treatment, prevention is possible, and pool fencing has been shown to reduce drowning and submersion injury (Class I).1 The most important and detrimental consequence of sub￾mersion is hypoxia. Therefore, oxygenation, ventilation, and perfusion should be restored as rapidly as possible. This will require immediate bystander CPR plus immediate activation of the emergency medical services (EMS) system. Victims who have spontaneous circulation and breathing when they reach the hospital usually recover with a good outcome. Victims of drowning may develop primary or secondary hypothermia. If the drowning occurs in icy (
5°C [41°F]) water, hypothermia may develop rapidly and provide some protection against hypoxia. Such effects, however, have typically been reported only after submersion of young victims in icy water (see Part 10.4: “Hypothermia”).2 All victims of drowning (see definitions below) who require any form of resuscitation (including rescue breathing alone) should be transported to the hospital for evaluation and monitoring even if they appear to be alert with effective cardiorespiratory function at the scene. The hypoxic insult can produce an increase in pulmonary capillary permeability with delayed onset of pulmonary complications. Definitions, Classifications, and Prognostic Indicators A number of terms are used to describe drowning. To aid in the use of consistent terminology and the uniform reporting of data from drowning, the Utstein definition and style of data reporting are recommended3: Drowning. Drowning is a process resulting in primary respiratory impairment from submersion/immersion in a liq￾uid medium. Implicit in this definition is that a liquid/air interface is present at the entrance of the victim’s airway, preventing the victim from breathing air. The victim may live or die after this process, but whatever the outcome, he or she has been involved in a drowning incident. A victim may be rescued at any time during the drowning process and may not require intervention or may receive appropriate resuscitation measures. In either case the drown￾ing process is interrupted. The Utstein statement recommends that the term near￾drowning no longer be used. It also de-emphasizes classifi￾cation based on type of submersion fluid (salt water versus fresh water). Although there are theoretical differences that have been reported in laboratory conditions, these have not been found to be clinically significant. The most important factors that determine outcome of drowning are the duration and severity of the hypoxia. Although survival is uncommon in victims who have undergone prolonged submersion and require prolonged re￾suscitation,4,5 successful resuscitation with full neurologic recovery has occasionally occurred with prolonged submer￾sion in icy water.6–8 For this reason, scene resuscitation should be initiated and the victim transported to an ED unless there is obvious physical evidence of death. Modifications to Basic Life Support for Drowning No modification of standard BLS sequencing is necessary. Some cautions are appropriate, however, when beginning CPR for the drowning victim. Recovery From the Water When attempting to rescue a drowning victim, the rescuer should get to the victim as quickly as possible, preferably by some conveyance (boat, raft, surfboard, or flotation device). The rescuer must always be aware of personal safety. Recent evidence indicates that routine stabilization of the cervical spine is not necessary unless the circumstances leading to the submersion episode indicate that trauma is likely (Class IIa). These circumstances include a history of diving, use of a water slide, signs of injury, or signs of alcohol intoxication.9 In the absence of such indicators, spinal injury is unlikely. Manual cervical spine stabilization and spine immobilization equipment may impede adequate opening of the airway, and they compli￾cate and may delay the delivery of rescue breaths. Rescue Breathing The first and most important treatment of the drowning victim is the immediate provision of ventilation. Prompt initiation of rescue breathing increases the victim’s chance of survival.10 Rescue breathing is usually performed when the unresponsive victim is in shallow water or out of the water. If it is difficult for the rescuer to pinch the victim’s nose, support the head, and open the airway in the water, mouth￾to-nose ventilation may be used as an alternative to mouth￾to-mouth ventilation. Untrained rescuers should not try to provide care while the victim is still in deep water. Management of the drowning victim’s airway and breath￾ing is similar to that recommended for any victim of cardio￾pulmonary arrest. There is no need to clear the airway of aspirated water, because only a modest amount of water is aspirated by the majority of drowning victims and it is rapidly absorbed into the central circulation, so it does not act as an obstruction in the trachea.5,11 Some victims aspirate nothing because they develop laryngospasm or breath-holding.5,12 Attempts to remove water from the breathing passages by any means other than suction (eg, abdominal thrusts or the Heimlich maneuver) are unnecessary and potentially danger- (Circulation. 2005;112:IV-133-IV-135.) © 2005 American Heart Association. This special supplement to Circulation is freely available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.105.166565 IV-133