What is the initial management for a drowning patient?

Initial Management of Drowning Patients

The immediate provision of ventilation is the first and most critical treatment for drowning victims, as hypoxia is the primary cause of death and must be reversed as rapidly as possible. 1

Immediate Rescue and Safety Considerations

• Rescuer safety is paramount during any water rescue attempt 1
• Do NOT routinely immobilize the cervical spine unless there are specific circumstances suggesting spinal injury (diving, trauma, motor vehicle crash into water), as cervical spine injury occurs in only 0.009% of drowning cases and unnecessary immobilization delays critical airway management 1

Airway and Breathing: The Priority

For healthcare providers, use the A-B-C sequence (not C-A-B) for drowning victims because cardiac arrest from drowning is hypoxic in nature, not a primary cardiac event 1

Rescue Breathing Protocol

• Begin rescue breathing as soon as the victim is removed from the water (or in shallow water if safe) 1
• If trained and safe to do so, in-water rescue breathing may prevent progression to cardiac arrest and should be initiated before removing the victim from water 1
• Give 2 initial rescue breaths that make the chest rise before checking for pulse 1
• Mouth-to-nose ventilation is an acceptable alternative if mouth-to-mouth is difficult 1

Critical Airway Management Principles

• Do NOT attempt to clear water from the airway using abdominal thrusts or the Heimlich maneuver—this is unnecessary and potentially dangerous 1
• Most drowning victims aspirate only modest amounts of water, which is rapidly absorbed into the central circulation 1
• Suction is the only acceptable method for clearing the airway if needed 1

Chest Compressions and Full CPR

• After delivering 2 effective breaths, if no pulse is definitely felt within 10 seconds, immediately begin chest compressions 1
• Provide cycles of compressions and ventilations according to standard BLS guidelines 1
• Attach an AED and attempt defibrillation if a shockable rhythm is identified once the victim is out of the water 1

Oxygen Administration

• Administer high-concentration oxygen as soon as available, as cardiac arrest following drowning results from severe hypoxemia 1
• Patients with more severe symptoms may require positive airway pressure ventilation 2

Transport and Monitoring

ALL drowning victims who require ANY form of resuscitation (including rescue breathing alone) must be transported to the hospital for evaluation and monitoring, even if they appear alert with effective cardiorespiratory function at the scene 1

Rationale for Universal Transport

• Decompensation can occur in the first 4-6 hours after the drowning event 1
• Patients may develop acute respiratory distress syndrome (ARDS) with pulmonary edema, hypoxemia, and respiratory failure hours after the initial event 3, 2, 4
• Minimum observation period is 4-6 hours for all patients requiring any resuscitation 1

Common Pitfalls to Avoid

• Never delay ventilation to perform cervical spine immobilization in the absence of trauma indicators 1
• Never use abdominal thrusts or Heimlich maneuver as routine treatment 1
• Never assume a patient is stable for discharge without appropriate hospital observation, even if they appear well initially 1
• Do not underestimate the risk of secondary deterioration—the acute lung injury causes loss of surfactant, increased capillary-alveolar permeability, and noncardiogenic pulmonary edema that may worsen over hours 3

Expected Clinical Course

• Vomiting is common during resuscitation (occurs in two-thirds of victims receiving rescue breathing and 86% of those requiring compressions) 1
• The combined effects of aspirated fluid, surfactant loss, and increased capillary-alveolar permeability result in decreased lung compliance and right-to-left shunting 3
• Premature discontinuation of ventilatory support may cause return of pulmonary edema requiring re-intubation 3