What prehospital care is indicated in drowning patients?

Updated: Jun 19, 2019
  • Author: G Patricia Cantwell, MD, FCCM; Chief Editor: Joe Alcock, MD, MS  more...
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Optimal prehospital care is a significant determinant of outcome in the management of immersion victims worldwide. [82, 83, 84] Bystanders should call 911 immediately where this service, or similar service, is available. In developing countries, children may be transported more frequently by family members, by taxi or private vehicle, and from a greater distance. [31]

An individual may be rescued at any time during the process of drowning. No intervention may be necessary, or rapid rescue and resuscitation may be warranted. No two cases are entirely alike. The type of water, water temperature, quantity of water aspirated, time in the water, and individual's underlying medical condition all play a role.

The victim should be removed from the water at the earliest opportunity. Rescue breathing should be performed while the individual is still in the water, but chest compressions are inadequate because of buoyancy issues. [85] Victims of drowning have most likely suffered asphyxial cardiac arrest; therefore, rescue breathing as well as chest compressions are indicated as opposed to compression-only resuscitation for cardiac arrest. [51]

The patient should be removed from the water with attention to cervical spine precautions. If possible, the individual should be lifted out in a prone position. Theoretically, hypotension may follow lifting the individual out in an upright manner because of the relative change in pressure surrounding the body from water to air.

Bystanders and rescue workers should never assume the individual is unsalvageable unless it is patently obvious that the individual has been dead for quite a while. If they suspect injury, they should move the individual the least amount possible and begin cardiopulmonary resuscitation (CPR).

As in any rescue initiative, initial treatment should be geared toward ensuring adequacy of the airway, breathing, and circulation (ABCs). Give attention to cervical spine stabilization if the patient has facial or head injury, is unable to give an adequate history, or may have been involved in a diving accident or motor vehicle accident.

In the patient with an altered mental status, the airway should be checked for foreign material and vomitus. Debris visible in the oropharynx should be removed with a finger-sweep maneuver. The abdominal thrust (Heimlich) maneuver has not been shown to be effective in removing aspirated water; in addition, it delays the start of resuscitation and risks causing the patient to vomit and aspirate. In any event, ventilation is achieved even if fluid is present in the lungs.

Supplemental oxygen, fraction of inspired oxygen (FiO2)100%, should be administered as soon as available. The degree of hypoxemia may be difficult to determine on clinical observation. If available, continuous noninvasive pulse oximetry is optimal. If the patient remains dyspneic on 100% oxygen or has a low oxygen saturation, use continuous positive airway pressure (CPAP) if available. If it is not available, consider early intubation, with appropriate use of positive end-expiratory pressure (PEEP).

Higher pressures may be required for ventilation because of the poor lung compliance resulting from pulmonary edema.

First responders, including emergency medical service (EMS) personnel and professional ocean lifeguards, should be well versed in providing the time-critical institution of advanced interventions, such as airway management. Refresher training in resuscitation is extremely important to strive for excellence in skill maintenance. [25, 86] With the current move toward compression-only CPR, further study needs to be performed in the specific hypoxic and potentially hypothermic milieu of drowning before this is routinely performed. [80, 87]

More traditional literature proposes that prehospital care providers should begin rewarming. Wet clothing ideally is removed before the victim is wrapped in warming blankets. More recent studies have shown that therapeutic cooling after out-of-hospital ventricular fibrillation cardiac arrest in adults may be beneficial to reduce ischemic brain injury and death. [88, 89, 90] This area needs additional vigorous clinical research to determine the most effective treatment strategy in drowning victims. [81, 91, 92]

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