The American Academy of Pediatrics (AAP) and the American Heart Association have released updated guidance on steps to take when resuscitating someone who has drowned. Among the updates, it recommends cardiopulmonary resuscitation (CPR) with rescue breaths and chest compressions to anyone in cardiac arrest following drowning after they're taken out of the water.
The updated recommendations, which apply to both untrained lay rescuers as well as professional rescuers, are published in the flagship, peer-reviewed journals of each organization, Pediatrics and Circulation.
Drowning is the third-leading cause of death from unintentional injury worldwide. In the United States, drowning is the
number one cause of death for children ages 1-4 years old.
Disparities in access to swim lessons and other preventive strategies have created inequities; among children ages 17 and younger, U.S. drowning rates are highest among Black and American Indian and Alaska Native individuals.
"The focused update on drowning contains the most up-to-date, evidence-based recommendations on how to resuscitate someone who has drowned. It offers practical guidance for health care professionals, trained rescuers, caregivers and families," said writing group Co-Chair
Tracy E. McCallin, M.D., FAAP, associate professor of pediatrics in the division of pediatric emergency medicine at Rainbow Babies and Children's Hospital in Cleveland.
"While we work on a daily basis to lower risks of drowning through education and community outreach on drowning prevention, we still need emergency preparedness training that can be used in tragic circumstances if a drowning occurs."
Detailed in the new guideline update:
Anyone removed from the water without showing signs of normal breathing or consciousness should be presumed to be in cardiac arrest.
Rescuers should immediately start CPR that includes rescue breathing in addition to chest compressions. Multiple large studies over time show more people with cardiac arrest from non-cardiac causes such as drowning survive when CPR includes rescue breaths compared to Hands-Only CPR (calling 911 and pushing hard and fast in the center of the chest).
Restoring breathing & circulation after drowning
Drowning generally progresses quickly from initial respiratory arrest (when a person is unable to breathe) to cardiac arrest, meaning that the heart stops beating. As a result, blood cannot circulate properly throughout the body, and it is starved of oxygen.
"CPR for cardiac arrest due to drowning must focus on restoring breathing as well as restoring blood circulation," said writing group Co-Chair
Cameron Dezfulian, M.D., FAHA, FAAP, senior faculty in pediatrics and critical care at Baylor College of Medicine in Houston.
"Cardiac arrest following drowning is most often due to severe hypoxia, or low blood oxygen levels," Dezfulian said. "This differs from sudden cardiac arrest from a cardiac cause where the individual generally collapses with fully oxygenated blood."
The updated guidance advises untrained rescuers and the public to:
Provide CPR with breaths and compressions to all people who have a cardiac arrest after drowning. If a person is untrained, unwilling, or unable to give breaths, they can provide chest compressions only until help arrives.
In-water rescue breathing should be given only by rescuers trained in this special skill if it doesn't risk their own safety. Trained rescuers should also provide supplemental oxygen if available.
The initiation of CPR should always be prioritized and begin as soon as possible; early bystander CPR has been shown to improve outcomes from drowning.
The guidance recommends that an
automated external defibrillator (AED) should be placed in public facilities with aquatic features such as swimming pools or beaches. They can be used once the person is removed from the water, if available, yet should not delay starting CPR. If available, the AED should be connected to the patient to assess for shockable rhythms once CPR is ongoing.
Most cases of cardiac arrest following drowning do not have shockable rhythms. However, if a primary cardiac event such as a heart attack occurs while in the water, the best outcomes are when defibrillation is done quickly. AED use is safe and feasible in aquatic environments.
Anyone who needs any level of resuscitation following drowning, including those who only need rescue breaths, should be transported to a hospital for evaluation, monitoring and treatment.
Downing chain of survival: 3 key steps
In addition to the recommendations on drowning resuscitation, the guideline update also highlights the Drowning Chain of Survival, which includes the steps needed to improve chances of survival: prevention, recognition and safe rescue.
Drowning prevention
It has been estimated that more than 90% of all drownings are preventable. Research has found most infants drown in bathtubs, and the majority of preschool-aged children drown in swimming pools.
The AAP and the American Heart Association recommend being water aware and practicing water safety. A full review of prevention is outside the scope of this guideline, however, the topic is addressed in the AAP 2021 technical report,
Prevention of Drowning, and in guidelines from the World Health Organization and the Wilderness Medical Society.
Recognizing when someone is drowning
Recognition of drowning may be challenging because someone who is drowning may not be able to verbalize distress or signal for help. Drowning happens quickly. People in distress will rapidly submerge, lose consciousness and may be hidden from anyone not actively seeking them.
Safe rescue
The guideline updates recommends that appropriately trained rescuers, such as lifeguards, swim instructors or first responders, should provide in-water rescue breathing to an unresponsive person who has drowned if it does not compromise their own safety. Previous studies have proven this leads to more favorable survival outcomes.
A drowning person who is unconscious and likely in cardiac arrest should be removed from the water in a near-horizontal position, with the head maintained above body level and airway open. If the drowning individual is conscious, a more vertical position may be preferable to reduce the risk of vomiting.
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