lV-134 Circulation December 13. 2005 ous. The routine use of abdominal thrusts or the Heimlich note that it may be effective for other causes of cardiac arrest maneuve or drowning victims is not recommended lowever, the effectiveness of induced hypothermia for drowning victims has not been established, and evaluation of Chest Compressions this approach is warranted. The 2002 World Congress on As soon as the unresponsive victim is removed from the Drowning recommended further studies to identify the best water, the rescuer should open the airway, check for breath- ing, and if there is no breathing, give 2 rescue breaths that treatments for drowning victims. make the chest rise (if this was not done in the water). After S umma ry delivery of 2 effective breaths, the lay rescuer should imme- Prevention measures can reduce the incidence of drowning ately begin chest compressions and provide cycles of and immediate, high-quality bystander CPR and early BLS compressions and ventilations. The healthcare provider care can improve survival. Rescue breathing should be should check for a central pulse. The pulse may be difficult to provided even before the victim is pulled from the water if appreciate in a drowning victim, particularly if the victim is possible. Routine stabilization of the cervical spine is not cold. If the healthcare provider does not definitely feel a pulse within 10 seconds, the healthcare provider should start cycles needed. Further studies are necessary to improve neurologic outcome for drowning victims. of compressions and ventilations. Only trained rescuers should try to provide chest compressions in the water References Once the victim is out of the water. if the victim is 1. Thompson DC. Rivara FP. Pool fencing for preventing drowning in unresponsive and not breathing(and the healthcare provider children. Cochrane Database Syst Rev. 2000: CDO01047 does not feel a pulse) after delivery of 2 rescue breaths. 2. Quan L, Kinder D. Pediatric submersions: prehospital predictors of rescuers should attach an AED and attempt defibrillation if a outcome. Pediatrics. 1992. 90: 909-913 3. Idris AH, Berg RA, Bierens J. Bossaert L, Branche CM, Gabrielli A, shockable rhythm is identified. If hypothermia is present, Part 10.4 Szpilman D. Wigginton JG. Modell JH. Recommended guidelines for niform reporting of data from drowning: the"Utstein style. Resusci- Vomiting by the victim During Resuscitation falton.2003:59:45-57 The victim may vomit when the rescuer performs chest 4. Quan L, Wentz KR, Gore E, Copass MK Outcome and predictors of ome in pediatric submersion victims receiving prehospital care in compressions or rescue breathing. In fact, in a 10-year study King County, Washington. Pediatrics. 1990: 86: 586-59 in Australia, two thirds of victims who received rescue 5. Modell JH, Davis JH EconO breathing and 86% of victims who required compressions and Anesthesiology. 1969: 30: 41 ventilations vomited. 13 If vomiting occurs. turn the victim's 6. Southwick FS, Dalglish PHJ. Recovery after prolonged asystolic cardiac ofound hypothermia: a case report and literature review. mouth to the side and remove the vomitus using your finger. JAMA.1980243:1250-1253 a cloth, or suction. If spinal cord injury is possible, logroll the 7. Siebke H. Rod T, Breivik H, Link B. Survival after 40 minutes: sub- victim so that the head. neck and torso are turned as a unit. mersion without cerebral sequelae. Lancet. 1975: 1: 1275-1277. 8. Bolte RG. Black PG. Bowers RS. Thorne JK. Corneli HM. The use of corporeal rewarming in a child submerged for 66 minutes. JAMA Modifications to ACLS for Drowning 1988:260:377-379 The drowning victim in cardiac arrest requires ACLS, includ- 9. Watson Rs, Cummings P, Quan L, Bratton S, Weiss NS. Cervical spine ing early intubation. Every drowning victim, even one who injuries among submersion victims. J Tranma. 2001: 51: 658-662 requires only minimal resuscitation before recovery, requires 10. Kyriacou DN, Arcinue EL, Peek C, Kraus JF. Effect of immediate resuscitation on children with submersion injury. Pediatrics. 1994: 9. monitored transport and evaluation at a medical facility Victims in cardiac arrest may present with asystole, pulse- Il. Rosen P, Stoto M, Harley J. The use of the Heimlich maneuver in less electrical activity, or pulseless ventricular car-drowning: Institute of Medicine report J Emerg Med. 1995 97-405 tachycardia/ventricular fibrillation (VF). Follow the guide- 12. Modell JH. Drowning. N Engl J Med. 1993: 328:253-256 lines for pediatric advanced life support and ACLS for 13. Manolios N, Mackie I. Drowning and near-drowning on Australian treatment of these rhythms. Case reports document the use of beaches patrolled by life-savers: a 10-year study, 1973-1983. Med J Aust surfactant for fresh water-induced respiratory distress, but 1988:148:165-167,170-171 further research is needed. 14-16 The use of extracorporeal 14. Onarheim H, Vik V. Porcine surfactant(Curosurf) for acute respiratory ailure after near-drowning in 12 year old. Acta Anaesthesiol Scand. membrane oxygenation in young children with severe hypo 2004:48:778-781 thermia after submersion is documented in case reports& 17 15. Staudinger T, Bankier A, Strohmaier w,Weiss K, Locker GI, Knapp S, There is insufficient evidence to support or refute the use of Roggla M, Laczika K, Frass M. Exogenous surfactant therapy in a patient barbiturates, steroids, 8 nitric oxide, 9 therapeutic hypother with adult respiratory distress syndrome after near drowning. Resusci- mia after ret f spontaneous circulation, 20 or 16. Suzuki H, Ohta T, Iwata K, Yamaguchi K, Sato T Surfactant therapy for 383-3ga y failure due to near-drowning. Eur J Pediatr. 1996: 155 Improving Neurologic Outcomes: 17. Thalmann M, Trampitsch E, Haberfeliner N, Eisendle E. KraschI R, Kobinia G Resuscitation in near drowning with extracorporeal membrane Therapeutic Hypothermia oxygenation. Ann Thorac Surg. 2001: 72: 607-608 Recent randomized controlled trials (LOE 1)22 and (LOE 2) 18.F gency medicine: best and subsequent consensus recommendations,25 support the BETs from the Manchester Royal Infirmary. Corticosteroids in the m use of therapeutic hypothermia in patients who remain in a 19. Takano Y. Hirosako s. Yamaguchi T, Saita N, Suga M, Kukita I coma after resuscitation from cardiac arrest caused by vF and Okamoto K, Ando M. [Nitric oxide inhalation as an effective therapy forous.11 The routine use of abdominal thrusts or the Heimlich maneuver for drowning victims is not recommended. Chest Compressions As soon as the unresponsive victim is removed from the water, the rescuer should open the airway, check for breath￾ing, and if there is no breathing, give 2 rescue breaths that make the chest rise (if this was not done in the water). After delivery of 2 effective breaths, the lay rescuer should imme￾diately begin chest compressions and provide cycles of compressions and ventilations. The healthcare provider should check for a central pulse. The pulse may be difficult to appreciate in a drowning victim, particularly if the victim is cold. If the healthcare provider does not definitely feel a pulse within 10 seconds, the healthcare provider should start cycles of compressions and ventilations. Only trained rescuers should try to provide chest compressions in the water. Once the victim is out of the water, if the victim is unresponsive and not breathing (and the healthcare provider does not feel a pulse) after delivery of 2 rescue breaths, rescuers should attach an AED and attempt defibrillation if a shockable rhythm is identified. If hypothermia is present, see Part 10.4. Vomiting by the Victim During Resuscitation The victim may vomit when the rescuer performs chest compressions or rescue breathing. In fact, in a 10-year study in Australia, two thirds of victims who received rescue breathing and 86% of victims who required compressions and ventilations vomited.13 If vomiting occurs, turn the victim’s mouth to the side and remove the vomitus using your finger, a cloth, or suction. If spinal cord injury is possible, logroll the victim so that the head, neck, and torso are turned as a unit. Modifications to ACLS for Drowning The drowning victim in cardiac arrest requires ACLS, includ￾ing early intubation. Every drowning victim, even one who requires only minimal resuscitation before recovery, requires monitored transport and evaluation at a medical facility. Victims in cardiac arrest may present with asystole, pulse￾less electrical activity, or pulseless ventricular tachycardia/ventricular fibrillation (VF). Follow the guide￾lines for pediatric advanced life support and ACLS for treatment of these rhythms. Case reports document the use of surfactant for fresh water–induced respiratory distress, but further research is needed.14 –16 The use of extracorporeal membrane oxygenation in young children with severe hypo￾thermia after submersion is documented in case reports.8,17 There is insufficient evidence to support or refute the use of barbiturates, steroids,18 nitric oxide,19 therapeutic hypother￾mia after return of spontaneous circulation,20 or vasopressin.21 Improving Neurologic Outcomes: Therapeutic Hypothermia Recent randomized controlled trials (LOE 1)22 and (LOE 2)23 and subsequent consensus recommendations24,25 support the use of therapeutic hypothermia in patients who remain in a coma after resuscitation from cardiac arrest caused by VF and note that it may be effective for other causes of cardiac arrest. However, the effectiveness of induced hypothermia for drowning victims has not been established, and evaluation of this approach is warranted. The 2002 World Congress on Drowning recommended further studies to identify the best treatments for drowning victims.3 Summary Prevention measures can reduce the incidence of drowning, and immediate, high-quality bystander CPR and early BLS care can improve survival. Rescue breathing should be provided even before the victim is pulled from the water if possible. Routine stabilization of the cervical spine is not needed. Further studies are necessary to improve neurologic outcome for drowning victims. References 1. Thompson DC, Rivara FP. Pool fencing for preventing drowning in children. Cochrane Database Syst Rev. 2000;CD001047. 2. Quan L, Kinder D. Pediatric submersions: prehospital predictors of outcome. Pediatrics. 1992;90:909 –913. 3. Idris AH, Berg RA, Bierens J, Bossaert L, Branche CM, Gabrielli A, Graves SA, Handley AJ, Hoelle R, Morley PT, Papa L, Pepe PE, Quan L, Szpilman D, Wigginton JG, Modell JH. Recommended guidelines for uniform reporting of data from drowning: the “Utstein style.” Resusci￾tation. 2003;59:45–57. 4. Quan L, Wentz KR, Gore EJ, Copass MK. Outcome and predictors of outcome in pediatric submersion victims receiving prehospital care in King County, Washington. Pediatrics. 1990;86:586 –593. 5. Modell JH, Davis JH. Electrolyte changes in human drowning victims. Anesthesiology. 1969;30:414 – 420. 6. Southwick FS, Dalglish PHJ. Recovery after prolonged asystolic cardiac arrest in profound hypothermia: a case report and literature review. JAMA. 1980;243:1250 –1253. 7. Siebke H, Rod T, Breivik H, Link B. Survival after 40 minutes: sub￾mersion without cerebral sequelae. Lancet. 1975;1:1275–1277. 8. Bolte RG, Black PG, Bowers RS, Thorne JK, Corneli HM. The use of extracorporeal rewarming in a child submerged for 66 minutes. JAMA. 1988;260:377–379. 9. Watson RS, Cummings P, Quan L, Bratton S, Weiss NS. Cervical spine injuries among submersion victims. J Trauma. 2001;51:658 – 662. 10. Kyriacou DN, Arcinue EL, Peek C, Kraus JF. Effect of immediate resuscitation on children with submersion injury. Pediatrics. 1994;94: 137–142. 11. Rosen P, Stoto M, Harley J. The use of the Heimlich maneuver in near-drowning: Institute of Medicine report. J Emerg Med. 1995;13: 397– 405. 12. Modell JH. Drowning. N Engl J Med. 1993;328:253–256. 13. Manolios N, Mackie I. Drowning and near-drowning on Australian beaches patrolled by life-savers: a 10-year study, 1973–1983. Med J Aust. 1988;148:165–167, 170 –171. 14. Onarheim H, Vik V. Porcine surfactant (Curosurf) for acute respiratory failure after near-drowning in 12 year old. Acta Anaesthesiol Scand. 2004;48:778 –781. 15. Staudinger T, Bankier A, Strohmaier W, Weiss K, Locker GJ, Knapp S, Roggla M, Laczika K, Frass M. Exogenous surfactant therapy in a patient with adult respiratory distress syndrome after near drowning. Resusci￾tation. 1997;35:179 –182. 16. Suzuki H, Ohta T, Iwata K, Yamaguchi K, Sato T. Surfactant therapy for respiratory failure due to near-drowning. Eur J Pediatr. 1996;155: 383–384. 17. Thalmann M, Trampitsch E, Haberfellner N, Eisendle E, Kraschl R, Kobinia G. Resuscitation in near drowning with extracorporeal membrane oxygenation. Ann Thorac Surg. 2001;72:607– 608. 18. Foex BA, Boyd R. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary. Corticosteroids in the man￾agement of near-drowning. Emerg Med J. 2001;18:465– 466. 19. Takano Y, Hirosako S, Yamaguchi T, Saita N, Suga M, Kukita I, Okamoto K, Ando M. [Nitric oxide inhalation as an effective therapy for IV-134 Circulation December 13, 2005