Drowning

Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid. Drowning outcomes are classified as death, morbidity, and no morbidity – the latter two are now referred to as “non-fatal drownings”.

The most important consequence of drowning is interruption of the oxygen supply to the brain. Early rescue and resuscitation by trained first responders or first aiders at the scene offer the victim the best chance of survival.

Possible sequence of events

• Immersion of the face in water (or other liquid). Water entering the mouth is spat out, swallowed or aspirated.
• Breath-holding, usually lasting no more than a minute.
• Vigorous breathing efforts. These may continue, even after loss of consciousness. Some amount of water is aspirated into the airways causing coughing and sometimes laryngeal spasm, which temporarily prevents further water entering the lungs.
• Swallowing of air and water, often in large amounts. This usually causes vomiting or regurgitation of stomach contents, which may be aspirated into the lungs.
• Respiratory impairment causes brain hypoxia, leading to unconsciousness and cessation of breathing efforts.
• The heart rate initially increases with exercise and panic. With hypoxia, the heart rate and blood pressure begin to fall, progressing finally to a cardiac arrest, requiring CPR.

Management

• Remove the victim from the water as soon as possible but do not endanger your own safety. Throw a rope or something to provide buoyancy to the victim. Call for help; plan and effect a safe rescue.
• In minor incidents, removal from the water is often followed by coughing and spontaneous resumption of breathing.
• In more serious incidents, assess the victim. If unconscious or not breathing normally, commence resuscitation following DRSABCD).
• Assess the victim on the back with the head and the body at the same level, rather than in a head down position. This decreases the likelihood of regurgitation and vomiting and is associated with increased survival.
• The victim should not be routinely rolled onto the side to assess airway and breathing. Assessing the airway of the victim without turning onto the side (i.e., leaving the victim on the back or in the position in which they have been found).
• The exceptions to this would be where the airway is obstructed with fluid (water or blood) or particulate matter (sand, debris, vomit). In this instance the victim should be promptly rolled onto the side to clear the airway. The mouth should be opened and turned slightly downwards to allow any foreign material to drain using gravity.
• Vomiting and regurgitation often occur during the resuscitation of a drowned victim. If the victim has been rolled to the side to clear the airway, then reassess their condition. If breathing commences, the victim can be left on the side with appropriate head tilt. If not breathing normally, the victim should be promptly rolled onto the back and resuscitation.
• Avoid delays or interruptions to CPR. Do not empty a distended stomach by applying external pressure. Do not attempt to expel or drain clear water or frothy fluid that may re-accumulate in the upper airway during resuscitation.
• Victims who appear to have been successfully rescued and resuscitated require close monitoring to detect a relapse into cardiopulmonary arrest. This can occur in the minutes or hours following return of spontaneous circulation and breathing, due to persisting lung damage and hypoxic injury to the heart.
• Call an ambulance for all victims of an immersion event, even if seemingly minor or the victim appears recovered.

Use of the AED.

If available, the AED should be attached, and the prompts followed. Dry the victim’s chest before applying pads. Although the rhythm deterioration in drowning is usually to a non-shockable rhythm, the AED may be lifesaving in 6% of drowning victims who, on initial assessment, are found to have a shockable cardiac rhythm.

Compression-only CPR is not the recommended resuscitation method.

The primary cause of cardiac arrest in drowning is a lack of breathing. Compression-only CPR circulates oxygen-poor blood and fails to address the victim’s need for immediate ventilation. It is not the recommended resuscitation method in a victim of drowning and should only be used temporarily if the rescuer is unable or unwilling to perform rescue breathing before the arrival of a barrier device, face mask or bag-valve-mask device.

Oxygen

The administration of oxygen is beneficial in the resuscitation of drowned victims, but resuscitation efforts should not be delayed while waiting for oxygen equipment to become available.