What is the management for a near-drowning patient with no prior resuscitation (cardiopulmonary resuscitation)?

From the Guidelines

Immediate initiation of rescue breathing by trained rescuers is crucial in the management of a near-drowning patient with no prior resuscitation, as it may prevent the progression to cardiac arrest following drowning. The management of such a patient should begin with immediate assessment and stabilization of airway, breathing, and circulation, as outlined in the 2024 American Heart Association and American Academy of Pediatrics focused update on special circumstances: resuscitation following drowning 1.

Key Steps in Management

• Remove the patient from water and position them horizontally
• Establish airway patency and begin high-flow oxygen therapy via non-rebreather mask at 15 L/min or initiate bag-valve-mask ventilation if the patient is not breathing adequately
• Perform endotracheal intubation if the patient has a decreased level of consciousness or cannot maintain adequate oxygenation
• Monitor oxygen saturation continuously and obtain arterial blood gases to assess oxygenation and acid-base status
• Establish IV access and administer warmed IV fluids if the patient is hypothermic, typically starting with normal saline at 20 ml/kg
• Core temperature should be monitored, with active rewarming for temperatures below 35°C

Additional Considerations

• Perform a thorough secondary assessment for associated injuries or medical conditions that may have contributed to the drowning
• Obtain chest X-ray to evaluate for aspiration pneumonia or pulmonary edema
• Bronchodilators such as albuterol 2.5-5 mg via nebulizer may be needed for bronchospasm
• Antibiotics are not routinely recommended unless there are signs of infection
• Even patients who appear well initially should be observed for at least 6-8 hours due to the risk of delayed pulmonary edema, hypoxemia, and respiratory failure, as supported by the American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care 1.

The importance of prompt initiation of rescue breathing is emphasized in the guidelines, highlighting its potential to improve patient outcomes by preventing the progression to cardiac arrest following drowning 1.

From the Research

Management of Near-Drowning Patients

The management of a near-drowning patient with no prior resuscitation (cardiopulmonary resuscitation) involves several key steps:

• Establishing adequate oxygenation and ventilation to address hypoxemia, which is the most serious pathophysiologic consequence of near-drowning 2
• Rewarming and fluid administration as part of the initial resuscitative efforts 2
• Considering the length of time the victim was submerged, as this is a key factor in survival and neurologic damage 3

Initial Resuscitation and Treatment

Initial resuscitation and treatment of near-drowning patients should focus on:

• Addressing hypoxia, which is the primary physiologic insult and the starting point for all morbidity and mortality 4
• Managing associated clinical concerns such as hypothermia, mechanical ventilation, and traumatic injuries 4
• Forming safe and reasonable disposition plans based on the patient's condition and response to treatment 4

Special Considerations

Special considerations in the management of near-drowning patients include:

• The potential need for the Heimlich maneuver if foreign matter is suspected to be obstructing the airway or if the victim fails to respond to mouth-to-mouth ventilation 5
• The importance of prompt and high-quality prehospital and hospital care in determining the prognosis of near-drowning patients 3