What are the immediate treatment guidelines for a near drowning patient?

Immediate Treatment of Near Drowning Patients

For healthcare providers and trained rescuers, prioritize rescue breathing BEFORE chest compressions (A-B-C sequence) in drowning victims, reversing the standard C-A-B approach used for other cardiac arrests. 1, 2

Rescue and Initial Safety

• Remove the victim from water as rapidly and safely as possible while maintaining rescuer safety as the paramount concern 1, 2
• If trained and safe to do so, initiate rescue breathing while the victim is still in shallow water to prevent progression from respiratory to cardiac arrest 1, 2
• Do NOT routinely immobilize the cervical spine unless there are specific trauma indicators (diving injury, fall, watercraft collision), as this delays critical airway management 1, 2
• Extract the victim in a near-horizontal position with head elevated above body level when possible 1

Airway and Breathing: The Critical First Step

The hypoxic mechanism of drowning-related cardiac arrest makes ventilation the absolute priority, distinguishing this from standard adult BLS protocols. 1, 2

• Deliver 2 initial rescue breaths that visibly make the chest rise immediately upon removing the victim from water 2
• Do NOT waste time attempting to remove water from the airway with abdominal thrusts or Heimlich maneuvers—water does not act as an obstructive foreign body 2, 3
• Administer 100% high-flow oxygen via non-rebreather mask as soon as equipment is available 2

Circulation Assessment and Chest Compressions

• After delivering 2 effective breaths, check for a definite pulse for no more than 10 seconds 1, 2
• If no pulse is detected or pulse is less than 60/min with poor perfusion, immediately begin chest compressions 1, 2
• Use compression-to-ventilation ratios of 30:2 for single rescuer or 15:2 for two healthcare provider rescuers in pediatric victims 1
• Maintain compression rate of 100-120/min with depth of at least 2 inches (5 cm) in adults and children, 1.5 inches (4 cm) in infants 1

Lone Rescuer Algorithm

If you are alone, provide approximately 5 cycles (2 minutes) of CPR before leaving to activate emergency services and retrieve an AED. 1 This differs from standard adult cardiac arrest where activation occurs first, reflecting the critical importance of reversing hypoxia in drowning victims.

Defibrillation

• Dry the chest thoroughly before applying AED pads to ensure proper adhesion and shock delivery 1
• Attach AED and analyze rhythm as soon as available after removing victim from water 2
• Deliver shock if indicated for ventricular fibrillation or pulseless ventricular tachycardia 2

Special Considerations for Hypothermia

• Continue CPR for at least 30 minutes in hypothermic drowning victims, as neurologically intact survival has been documented after prolonged submersion in cold water 1, 4
• Hypothermia provides neuroprotection; do not terminate resuscitation prematurely in cold-water drowning 1

Critical Pitfall to Avoid

Never delay ventilation to perform cervical spine immobilization in the absence of clear trauma indicators. 2 A patent airway and adequate oxygenation take absolute precedence, as the hypoxic insult determines neurological outcome. If spinal injury is suspected, one rescuer can manually stabilize the cervical spine while another opens the airway with jaw thrust. 1

Transport and Observation Requirements

ALL drowning victims who require ANY form of resuscitation—even rescue breaths alone—must be transported to the emergency department for evaluation and monitoring, regardless of how well they appear at the scene. 1, 2

• Minimum observation period is 4-6 hours for asymptomatic patients with normal vital signs, oxygenation, and chest radiograph 2, 5
• Most victims require at least 24 hours of hospital observation due to risk of delayed pulmonary complications 5
• Aspiration-induced noncardiogenic pulmonary edema may develop or worsen after initial presentation 5

Prognostic Factors

• Submersion duration and speed of CPR initiation are the primary determinants of neurological outcome 3
• Submersion less than 10 minutes with immediate CPR: 77-96% survival with good neurological outcome 3
• Submersion 10-20 minutes: 4-78% favorable outcome depending on water temperature and resuscitation speed 3
• Submersion greater than 25 minutes: 0-18% favorable outcome, though rare complete recovery possible in cold water 3