9.16. DROWNING

Related titles

Non-fatal drowning, fatal drowning, immersion.

Purpose of assistance

1. Quick examination and treatment of emergency conditions.
2. Rescue from the water environment.
3. Hospitalization of all patients for examination.

Description of the patient

Inclusion criteria

Patients who have suffered from drowning or drowning-related events, depending on the presence/absence of symptoms.

Exclusion criteria

Patients who did not suffer from drowning.

Providing assistance to the patient

Status assessment

1. Act in accordance with the instruction “General rules of assistance”.
2. The medical history should include details of the events preceding the dive, details of the mechanism of injury, time spent underwater and water temperature (if known).
3. Primary examination should include active control of airway patency and restoration of adequate breathing and oxygenation – in contrast to the standard C-A-B algorithm for cardiac arrest, patients with cardiac arrest due to drowning need to use the A-BC algorithm with proper airway control and supportive ventilation.
4. Anamnesis, mechanism of injury and examination should include suspicion of cervical spine injury, if cervical spine injury is suspected, minimize movements of the cervical spine.
5. Assess for other associated injuries, such as TBI or diving emergencies.

Treatment and intervention

1. Provide security at the scene. Get the patient out of the water as quickly as possible:

a) use the safest water rescue technique under the circumstances;
b) evacuate to land or aboard water transport as soon as possible;
c) in case of delay perform basic life support on the water, which includes only ventilation.

2. Control the respiratory tract (see the instruction “Control of the respiratory tract”).

3. Act according to the instructions “Cardiac arrest” and apply the AV-C algorithm (airways, breathing, circulation) in case of circulatory arrest due to drowning:

a) take 5 resuscitation breaths for artificial lung ventilation and perform 30 chest compressions;
b) after the first 5 breaths, perform resuscitation according to the scheme of 2 exhalations to 30 compressions.

4. If the mechanism of the injury or the details of the event indicate a neck injury – immobilize the cervical spine according to the instruction “Help with a spine injury”).

5. Monitor vital signs, including saturation.

6. If saturation is below 92%, provide oxygen therapy to raise saturation to 94-98%. Provide positive pressure ventilation if there are symptoms of difficulty breathing.

7. Suspect the presence of hypothermia, provide assistance according to the guideline “Hypothermia/exposure to a cold environment”.

8. If the victim participated in deep-sea diving and there are doubts about the treatment tactics, you should invite for a consultation and discuss the need for hyperbaric therapy. Discuss the following:

a) time of diving;
b) highest depth reached during diving;
c) rate of ascent to the surface;
d) mixture of gases .

9. Provide I/O access.

10. Infusion therapy – bolus, if necessary.

11. Apply additional means of ensuring the patency of the respiratory tract, if necessary – apply ventilation with PPTD setting in patients with respiratory failure.

12. Conduct cardiac monitoring.

Patient safety

1. Avoid hyperoxygenation of the patient.
2. Remember the safety of the EMD team.

Useful information for training

Key points

1. WHO defines drowning as “a process of respiratory failure due to immersion in liquid”.

2. Drowning is further divided into the following categories:

a) non-fatal – the patient was saved;
b) fatal – the onset of death (in any form of acute or subacute) as a result of drowning.

3. Immersion refers to situations where the patient’s airways are under water. Exhumation is a situation where the patient’s body is under watersimultaneous finding of the respiratory tract above water.

4. Warnings for children:

a) drowning is a common cause of death among children;
b) risk factors for the possibility of drowning include male gender, age under 14 years, alcohol consumption, lack of supervision, dangerous behavior .

5. All emergency services involved must coordinate efforts to ensure rapid access to and rescue of the patient.

6. Carrying out life support on the water through resuscitative ventilation can increase the chances of survival – carrying out indirect cardiac massage on the water is useless.

7. The European Resuscitation Council recommends the initial administration of 5 resuscitation breaths to a drowning victim:

a) initial ventilation can be complicated by the presence of water in the airways, which prevents alveolar expansion;
b) after 5 initial breaths and 30 compressions, a 2-breath resuscitation strategy should be used up to 30 compressions.

8. Active attempts to remove water from the body (by squeezing the abdomen or other methods) should be avoided, as this delays the start of resuscitation and increases the risk of vomiting and aspiration.

9. There is a theory that rescuers should always suspect damage to the cervical spine in every drowning victim:

a) new provisions in protocols regarding special conditions of cardiac arrest (by AAS, 2010 edition) state that the use of any spinal control methods is not required if the mechanism or the injury, history, or physical examination will not lead to cervical spine injury;
b) the mechanism of injury that indicates a high likelihood of cervical spine injury includes diving, water skiing, surfing, or water accidents.

10. There is uncertainty about the possibility of survival after drowning in cold water, however, recent reviews of the literature indicate:

a) if the water temperature is below 6°C and the patient has cardiac arrest due to immersion:

• • • • survival is possible if the patient was submerged for no longer than 90 minutes, so resuscitation measures must be started;
      • survival is unlikely when underwater for longer than 90 minutes and rescuers may decide not to start resuscitation at the scene;

b) if the water temperature is above 6°C and the patient has cardiac arrest due to immersion:

• • • • survival is possible if the patient was submerged for no longer than 30 minutes, so it is necessary to start resuscitation measures;
      • survival is unlikely if underwater for longer than 30 minutes and rescuers may decide not to start or stop CPR at the scene.

11. The patient may develop acute respiratory complications due to drowning, accordingly, all patients should be hospitalized for further examination.

Key elements of documentation

1. Mechanism of injury or details of the event indicating cervical spine injury.
2. Dive time.
3. Water temperature.
4. Events preceding the drowning.
5. Use standardized data collection methods, such as the Utstein format.

Criteria for the effectiveness of aid provision

1. Recognition and proper treatment of breathing and respiratory system problems.
2. Control of the cervical spine if indicated.
3. Following the guideline “Cardiac arrest”.