From the Guidelines
Emergency department (ED) thoracotomy is generally not recommended for drowning patients, and the primary management should focus on standard resuscitation protocols including airway management, ventilation, and chest compressions. The most recent and highest quality study, 1, published in 2024, emphasizes the importance of rescue breathing in cardiac arrest following drowning, but does not support the use of ED thoracotomy in these cases.
Key Considerations
- The primary pathophysiology in drowning is hypoxic injury rather than a surgically correctable lesion, making ED thoracotomy less beneficial 1.
- The hypoxic damage affects multiple organ systems, particularly the brain and lungs, which cannot be addressed through thoracotomy.
- Resources are better directed toward aggressive respiratory support, temperature management, and addressing metabolic derangements.
- ED thoracotomy carries significant risks, including infection, bleeding, and injury to medical personnel, with minimal benefit in drowning cases.
Select Cases for ED Thoracotomy
- ED thoracotomy should only be considered in extremely select cases where the drowning victim has a witnessed cardiac arrest, received immediate high-quality CPR, has a short transport time to the ED (typically less than 15 minutes), and shows signs of life such as pupillary responses, spontaneous movement, or organized cardiac electrical activity.
- If cardiac arrest occurs in a drowning victim due to a concomitant traumatic injury such as a penetrating chest wound, different considerations may apply, but for primary drowning, ED thoracotomy has extremely poor outcomes and should not be routinely performed 1.
Evidence-Based Recommendation
- The 2024 American Heart Association and American Academy of Pediatrics focused update on special circumstances: resuscitation following drowning, recommends rescue breathing as soon as possible, but does not support the use of ED thoracotomy in drowning cases 1.
- The 2014 Annals of Emergency Medicine study on withholding or termination of resuscitation in pediatric out-of-hospital traumatic cardiopulmonary arrest, also does not support the use of ED thoracotomy in drowning cases, and emphasizes the importance of standard resuscitation protocols 1.
From the Research
Guidelines for Emergency Department Thoracotomy
- The guidelines for Emergency Department (ED) thoracotomy in patients with drowning-related injuries are not explicitly stated in the provided studies.
- However, the studies provide information on the use of ED thoracotomy in trauma patients and the outcomes of patients with drowning-related injuries.
Indications for ED Thoracotomy
- According to 2, ED thoracotomy is indicated for acute resuscitation of selected dying trauma patients, particularly those with penetrating trauma and witnessed cardiopulmonary arrest with the presence of vital signs at the trauma center.
- The study does not specifically address drowning-related injuries, but it provides general guidelines for ED thoracotomy in trauma patients.
Outcomes of Drowning-Related Injuries
- Studies 3, 4, and 5 report on the outcomes of patients with drowning-related injuries, including the use of extracorporeal membrane oxygenation (ECMO) and cardiopulmonary bypass (CPB) in these patients.
- The studies suggest that survival is possible in selected cases, particularly those with shorter submersion times and lower water temperatures.
- However, the studies do not provide specific guidelines for ED thoracotomy in patients with drowning-related injuries.
ED Thoracotomy in Blunt Trauma
- Study 6 reports on two cases of survival and full recovery after blunt cardiac rupture requiring ED thoracotomy.
- The study suggests that ED thoracotomy may be an important use in blunt trauma patients, particularly those with cardiac tamponade and hemorrhage.
- However, the study does not specifically address drowning-related injuries.