What are the immediate management steps for a drowning patient?

Immediate Management of Drowning Patients

Begin rescue breathing immediately as soon as the victim is accessible—either in shallow water or upon removal from water—because hypoxia is the primary lethal mechanism in drowning, and prompt ventilation is the single most critical intervention that determines survival and neurological outcome. 1, 2

Rescuer Safety and Cervical Spine Considerations

• Prioritize rescuer safety above all else during any water rescue attempt. 1, 2
• Do NOT routinely immobilize the cervical spine unless there are specific circumstances suggesting spinal injury (such as diving into shallow water, water slide injury, or signs of trauma), as unnecessary immobilization delays airway opening and ventilation delivery. 1, 2 The incidence of cervical spine injury in drowning victims is extremely low (0.009%). 1

Airway and Breathing: The First Priority

Healthcare providers must use the A-B-C sequence (Airway-Breathing-Circulation) for drowning victims, NOT the standard C-A-B sequence used for witnessed cardiac arrest. 1, 2 This is because drowning causes hypoxic cardiac arrest, not a primary cardiac event, and victims with only respiratory arrest typically respond after a few rescue breaths. 1

Rescue Breathing Protocol

• Deliver 2 initial rescue breaths that visibly make the chest rise as soon as the victim is in shallow water or removed from the water. 1, 2
• For appropriately trained rescuers, in-water rescue breathing may be reasonable if it does not compromise rescuer safety, as this can prevent progression from respiratory arrest to cardiac arrest. 1, 2 One retrospective study found higher odds of return of spontaneous circulation and favorable neurological outcomes when in-water rescue breathing was provided. 1
• Use mouth-to-mouth or mouth-to-nose ventilation depending on what is feasible in the water environment. 1

Critical Airway Management Pitfalls to Avoid

• Never attempt to clear the airway of aspirated water using abdominal thrusts or the Heimlich maneuver. 1, 2, 3 Most drowning victims aspirate only a modest amount of water that is rapidly absorbed into the central circulation, and these maneuvers are unnecessary and potentially dangerous. 1
• Do NOT waste time trying to drain water from the lungs—proceed directly to rescue breathing. 1, 3
• Suction is acceptable if needed for vomitus or debris, but not for aspirated water. 1

Chest Compressions and Full CPR

• After delivering 2 effective rescue breaths, check for a pulse for no more than 10 seconds. 2
• If no pulse is definitely felt, immediately begin chest compressions and provide cycles of compressions and ventilations according to standard BLS guidelines. 1, 2
• Once out of the water, attach an AED and attempt defibrillation if a shockable rhythm is identified. 1, 2
• Expect vomiting during resuscitation—studies show two-thirds of victims receiving rescue breathing and 86% of those requiring full CPR will vomit. 1 If vomiting occurs, turn the victim to the side and clear the vomitus manually or with suction. 1

Oxygen Administration

• Administer high-concentration oxygen (100% via non-rebreather mask at 15 L/min) as soon as available, as cardiac arrest following drowning results from severe hypoxemia. 1, 2
• Oxygen supplementation should be provided only if it does not delay high-quality CPR. 1
• The combined effects of fluid in the lungs, loss of surfactant, and increased capillary-alveolar permeability result in decreased lung compliance and noncardiogenic pulmonary edema. 4

Mandatory Transport and Hospital Observation

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. 2, 5

• Minimum observation period is 4-6 hours for all patients requiring any resuscitation. 2, 5
• Patients with minimal or no symptoms require physical examination and observation prior to discharge. 5
• Patients with more severe symptoms (rales, foamy secretions, respiratory distress) should be managed with high-concentration oxygen and positive airway pressure. 5
• Premature discharge can result in delayed pulmonary edema and deterioration. 4

Prognostic Factors and Neurological Outcomes

• Submersion time and speed of CPR initiation are the primary determinants of neurological outcome. 3 Survival with good neurological outcome is 77-96% when CPR is initiated immediately after submersion for less than 10 minutes. 3
• For submersion times between 10-20 minutes, only 4-78% achieve good neurological outcomes, depending on water temperature and resuscitation speed. 3
• Unreactive pupils in the Emergency Department and Glasgow Coma Score ≤5 on ICU arrival are the strongest independent predictors of poor neurological outcome. 6 However, no predictor is absolute—even patients arriving without vital signs have achieved full neurological recovery. 6
• Cold water submersion cases warrant aggressive resuscitation regardless of initial presentation, as isolated cases of complete neurological recovery have been documented even after prolonged submersion in cold water. 3, 7

Algorithm Summary

1. Ensure rescuer safety 1, 2
2. Remove victim from water quickly (no cervical spine immobilization unless trauma suspected) 1, 2
3. Deliver 2 rescue breaths immediately (A-B-C sequence, not C-A-B) 1, 2
4. Check pulse for ≤10 seconds 2
5. If no pulse: begin chest compressions and attach AED when available 1, 2
6. Administer high-flow oxygen as soon as available 1, 2
7. Transport ALL victims requiring any resuscitation to hospital for minimum 4-6 hours observation 2, 5