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Drowning

Drowning is responsible for 500,000 deaths each year around the world. 1-2 In the case of a drowning
victim who has no signs of irreversible death, cardiopulmonary resuscitation (CPR) is administered
with prompt transfer to the nearest emergency room. Data suggest that rescuing a cardiac arrest
victim from drowning in cold or warm water results in successful resuscitation with full neurologic
recovery after CPR. 3-6 After rescuing a drowning victim, they must be transported to hospital for
monitoring regardless of the patient’s condition (Class I).
Getting to the drowning victim as quickly as possible is essential, while keeping in mind the safety of
the rescuer in the surrounding environment. There is no need to stabilize the victim’s cervical spine
because drowning victims have only a 0.009% chance of having a concomitant cervical spine injury.78

The key to rescuing a drowning victim is to restore oxygenation, ventilation, and perfusion as soon
as possible to reverse the effects of hypoxia. In light of this, CPR is commenced immediately with
the Airway, Breathing, Circulation (A-B-C) sequence and prompt activation of the emergency
response system. The drowning victim suffering only respiratory arrest will usually recover after a
few rescue breaths. Therefore, providing a drowning victim with immediate rescue breaths is
necessary, rather than starting with chest compressions as if currently recommended. This should be
done in an area where the water is shallow or with the victim out of the water altogether. If the
rescuer has a hard time pinching the victim’s nose, supporting the victim’s head, and opening the
airway in the water to perform the correct mouth-to-mouth procedure, mouth-to-nose ventilation is
feasible. In the drowning victim, water is rarely aspirated due to laryngospasm and the patient’s
voluntary breath-holding instinct. 4,9 Therefore, the recommended management of airway and
breathing is similar to other cardiac arrest cases. Any attempt to clear the airways with other
methods (i.e. Heimlich maneuver) besides suction is hazardous to the patient and is not
recommended (Class III).
When the rescuer has transferred the victim to an area suitable for resuscitation, he/she should give
two rescue breaths that result in observable chest rise. The rescuer then checks for pulse. If the
pulse is absent, the adult chain of survival is initiated. The rescuer should begin cycles of chest
compressions and ventilation as prescribed by the Basic Life Support (BLS) guidelines. An automatic
defibrillator is attached to the patient after one cycle (2 minutes) of CPR, making sure that the
victim’s chest and the surrounding area where resuscitation is taking place is dry, or at least not
saturated. If a shockable rhythm is identified a shock should be delivered.
For pediatric victims who have drowned in fresh water, treatment with surfactant may improve
survivability.10-13 479-482 Extracorporeal membrane oxygen administration in patients with severe
hypothermia has been described in other studies.14-15
There are no modifications needed for drowning victims that come to the emergency department in
asystole, pulseless electrical activity (PEA), or pulseless ventricular tachycardia/ventricular
fibrillation. The appropriate advanced cardiac life support algorithm is pursued.

The victim’s respiratory system is very active.30:414–420. Quan L. pulmonary hypertension. . the victim is unable to breath. Wentz KR. 2004. Bierens JJ. Joost. The development of post-hypoxic encephalopathy. but because of the obstruction in the larynx there is no exchange of air.When giving CPR to drowning victims. If the victim is not ventilated soon enough. hypercarbia. Berlin: Springer. Gore EJ. vomiting is a common occurrence. 17 At this time. 4. neck and torso turned as a single unit to protect the cervical spine. and acidosis and restore normal organ function. Washington. Vomiting patients should be laid in a left lateral decubitus position and vomitus should be removed using the fingers or a cloth if available to protect the patient from aspirating the vomitus.18 The victim then takes in large amounts of water. It should be noted that the heart and brain are the organs at greatest risk for permanent damage from relatively brief periods of hypoxia. This is an involuntary action triggered by the presence of fluid in the oropharynx and larynx. Modell JH. primarily because of tissue hypoxia. The victim then holds his breath. 2009. Oxygen is depleted and carbon dioxide concentrations increase. Drowning: a cry for help. Katz LM. Davis JH. Anesthesiology.86:586 –593. The victim may revive from the initial resuscitation efforts. with or without cerebral edema. 3. and acidotic. Warner DS. A victim can be rescued at any time during the drowning process and may not require intervention. Laryngospasm ensues after breathholding. JLM Handbook on Drowning. Outcome and predictors of outcome in pediatric submersion victims receiving prehospital care in King County. or may require appropriate resuscitative measures. is the most common cause of death in hospitalized drowning victims. Anesthesiology. 1969. or does not start to breathe on his or her own. The development of hypoxemia is secondary to surfactant washout. A “log-roll” of the victim may be necessary if spinal injury is suspected. Drowning is a process wherein the victim’s airways are submerged below the surface of water or another liquid. Copass MK. in which case the drowning process is interrupted. hypoxemix. 2.110:1211–1213. causing the patient to be hypercarbic. and in the absence of effective resuscitative efforts multiple organ dysfunction and death will result.16-17 The Drowning Process. 1990. Pediatrics. and shunting. This involves rolling the patient to one side with the head. Beerman SB. 19-20 Reference 1. Electrolyte changes in human drowning victims. A further drop in arterial oxygenation will cause the laryngospasm to stop and the victim then breathes in the water or liquid. with or without subsequent therapy to treat hypoxia. circulatory arrest will ensue.

Onarheim H. Kobinia G. Frass M. Black PG. Near-drowning: epidemiology. 11. and isotonic saline. 1966.51:658–662. Thalmann M.7°C with circulatory arrest. Knapp S. Watson RS. 5th ed. Weinstein MD.80:1088 –1089. 8.63:25– 31. 2000: 1416–1417. Anesthesiology. Am J Dis Child. Quan L. Moya F.5. Nelson WB. 15. Anesthesia. et al. Can Anaesth Soc J. Pa: Churchill Livingstone. Modell JH. 2000. N Engl J Med.328:253–256. Franchi F. Yamaguchi K. 12. Eisendle E. Trampitsch E. 1986. 27: 33–41. 6. Barker GA. 2004. 2001. Gaub M. Surfactant therapy for acute respiratory failure after drowning: two children victim of cardiac arrest. Ann Thorac Surg. Coratti G. pathophysiology. Nilsen PÅ. Corneli HM. Medline . 1997. Thorne JK. Vik V. JAMA. 1980. J Trauma. 14. and initial treatment. 1996.355:375–376. 1988. Ohta T. 1993. Outcome following cardiopulmonary resuscitation in severe pediatric near-drowning. Exogenous surfactant therapy in a patient with adult respiratory distress syndrome after near drowning. Resuscitation. ed. Gilbert M.72:607– 608.48:778 –781. Cummings P. 2001. Conn AW. 13. 2009. McComb G. distilled water. 17. 16. Suzuki H. Porcine surfactant (Curosurf) for acute respiratory failure after neardrowning in 12 year old. Resuscitation in near drowning with extracorporeal membrane oxygenation.140:571–575. Staudinger T. 18. Bowers RS. Weiss NS. Locker GJ. Physiologic effects of near drowning with chlorinated fresh water. Iwata K. Acta Anaesthesiol Scand. Weiss K. Cubattoli L. 19. Szpilman D. 2004.35:179 –182. 10. Modell JH. Solbø JP. Soares M. Resuscitation. Drowning. Lancet. Kraschl R. 7. Cervical spine injuries among submersion victims. Krieger BP. Eur J Pediatr. Bankier A. 9. Busund R.14:461– 467. 27: 201–210. Allman FD. J Emerg Med. Montes JE. Haberfellner N. Roggla M. et al. In-water resuscitation: is it worthwhile? Resuscitation. Strohmaier W.155: 383–384. Cerebral salvage in near-drowning following neurological classification by triage. Miller RD. Pacentine GA. Philadelphia. The use of extracorporeal rewarming in a child submerged for 66 minutes. 1996. Surfactant therapy for respiratory failure due to near-drowning. Sato T. Bolte RG. Resuscitation from accidental hypothermia of 13.260:377–379. Bratton S. Skagseth A. Laczika K.

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