From the Guidelines
Emergency airway management for a drowning victim should prioritize immediate assessment and establishment of a patent airway, with a focus on providing supplemental oxygen and initiating bag-valve-mask ventilation with 100% oxygen if the victim is unconscious and not breathing adequately, as recommended by the 2024 American Heart Association and American Academy of Pediatrics guidelines 1. The first step in emergency airway management is to remove the victim from the water and position them supine on a firm surface. Clear the airway of any visible debris or vomitus, and begin with basic airway maneuvers including head tilt-chin lift or jaw thrust if cervical spine injury is suspected.
- Provide supplemental oxygen at the highest concentration available (100% if possible) via a non-rebreather mask.
- If the victim is unconscious and not breathing adequately, initiate bag-valve-mask ventilation with 100% oxygen.
- For victims who remain hypoxic despite these measures or who are unconscious with absent protective reflexes, endotracheal intubation should be performed promptly, using rapid sequence intubation with medications such as etomidate (0.3 mg/kg) or ketamine (1-2 mg/kg) for induction, and succinylcholine (1-1.5 mg/kg) or rocuronium (1 mg/kg) for paralysis, as supported by the 2024 American Heart Association and American Academy of Pediatrics guidelines 1. Key considerations in airway management include:
- Be prepared for difficult intubation due to potential laryngospasm, bronchospasm, or pulmonary edema.
- If intubation fails, consider supraglottic airway devices like laryngeal mask airways as a bridge.
- In cases where conventional methods fail, cricothyroidotomy may be necessary as a last resort. After securing the airway, provide positive pressure ventilation with positive end-expiratory pressure (PEEP) of 5-10 cmH2O to help recruit alveoli and improve oxygenation, as drowning victims often develop non-cardiogenic pulmonary edema from aspiration, as noted in the 2022 international consensus on cardiopulmonary resuscitation and emergency cardiovascular care science with treatment recommendations 1.
From the Research
Emergency Airway Management for Drowning Victims
The emergency airway management for a drowning victim is crucial for their survival and recovery. The following steps and considerations are essential:
- Recognition of the difficult airway and its management is vital in emergent situations, as discussed in 2.
- Drowning involves unique physiological principles and medical interventions, including the aspiration of water into the airways, which can lead to acute lung injury and noncardiogenic pulmonary edema, as explained in 3.
- The initial reflex response to water aspiration is coughing, followed by hypoxemia, loss of consciousness, and apnea, which can result in hypoxic cardiac arrest if not rescued promptly, as described in 3.
Airway Management Techniques
Various airway management techniques can be employed, including:
- Endotracheal intubation with or without preceding bag valve mask ventilation, which can be used to achieve definite airway control in most emergency situations, as discussed in 4.
- Alternative techniques, such as nonsurgical and surgical airway interventions, may be required in cases where endotracheal intubation is not possible, as mentioned in 2 and 4.
- Manual methods of opening the airway and establishing definitive control of the airway, as well as devices to maintain control and ensure adequate oxygenation and ventilation, are essential, as described in 5.
Initial Treatment and Resuscitative Efforts
Initial resuscitative efforts should focus on:
- Establishing adequate oxygenation and ventilation, as hypoxemia is a major consequence of near-drowning, as explained in 6.
- Rewarming and fluid administration, as part of the initial treatment, as discussed in 6.
- Observation for at least 4 to 6 hours for asymptomatic patients and at least 24 hours for those requiring closer monitoring, as recommended in 6.