Wednesday, June 1, 2016

A call for the proper action on drowning resuscitation

Below is a copy of our joint Letter to The Editor to Resuscitation Journal which was recently published:

We ask for your attention to the following review of pathophysiology-based recommendations for the initial resuscitation of cardiac arrest caused by drowning, which will improve outcomes.
While compression-only CPR (CCPR) for the treatment of out of hospital sudden cardiac arrest (SCA) has gained great momentum, it has come at the cost of a misunderstanding as to the proper treatment for cardiac arrest due primarily to a non-cardiac cause. With SCA of presumed cardiac origin, the majority of which is the result of coronary artery occlusion, current out of hospital guidelines recommend CCPR due to the possibility of increasing bystander compliance.1 In cardiac arrest caused by a drowning event the cause of arrest is usually systemic hypoxeamia. In these cases CPR requires both ventilations and chest compressions aiming to reverse hypoxemia and provide coronary and cerebral perfusion.2
Because ventilations can be difficult to perform, more detailed CPR instruction following the traditional Airway–Breathing–Circulation (ABC) approach is required. This is especially important for: parents with pools; lifeguards; water sport athletes; and emergency healthcare providers. In addition peri-arrest drowning patients often have foamy material or emesis in their airway, which could easily dissuade a provider from providing ventilations if the importance of reversing hypoxemia is not understood. This is not a new concept, it has been included in resuscitation guidelines for many years, cited below, but sometimes is overshadowed by the push for CCPR that is used for SCA of a primarily cardiac origin.
European Resuscitation Council Guidelines for Resuscitation 2015. Section 2 and 4.3, 4
“Most cardiac arrests of non-cardiac origin have respiratory causes, such as drowning (among them many children) and asphyxia. Rescue breaths as well as chest compressions are critical for successful resuscitation of these victims.”3
“Most drowning victims will have sustained cardiac arrest secondary to hypoxia. In these patients, compression-only CPR is likely to be ineffective and should be avoided.”4
American Heart Association (AHA) 20105
“CPR for drowning victims should use the traditional A-B-C approach in view of the hypoxic nature of the arrest”5
“The first and most important treatment of the drowning victim is the immediate provision of ventilation.”5
For the reasons above, we ask all providers to educate themselves on the most recent recommendations in the 2015 ERC and 2010 AHA Guidelines for drowning resuscitation and their conclusions. The initial resuscitation of cardiac arrest caused by drowning should follow the ABC sequence; commencing with 2–5 initial rescue breaths followed by 30 chest compressions, and continue with 2 rescue breaths to 30 compressions.
These recommendations were jointly produced and are supported by the following organizations:
  • -
    Surfing Medicine International (Netherlands).
  • -
    Sociedade Brasileira de Salvamento Aquatico-SOBRASA (Brazil).
  • -
    Lifeguards Without Borders (USA).
  • -
    Surf Lifesaving Great Britain (UK).

  • References

  1. Kleinman, M.E., Brennan, E.E., Goldberger, Z.D. et al. Part 5: adult basic life support and cardiopulmonary resuscitation quality: 2015 American Heart Association guidelines update for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2015; 132: S414–S435
  2. Szpilman, D., Bierens, J.J., Handley, A.J., and Orlowski, J.P. Drowning. N Engl J Med. 2012; 366: 2102–2110
  3. Perkins, G.D., Handley, A.J., Koster, R.W. et al. Adult basic life support and automated external defibrillation section Collaborators. European Resuscitation Council Guidelines for Resuscitation 2015: Section 2. Adult basic life support and automated external defibrillation. Resuscitation. 2015; 95: 81–99
  4. Truhlář, A., Deakin, C.D., Soar, J...., and Cardiac Arrest in Special Circumstances Section Collaborators. European Resuscitation Council Guidelines for Resuscitation 2015: Section 4. Cardiac arrest in special circumstances. Resuscitation. 2015; 95: 148–201
  5. Vanden Hoek, T.L., Morrison, L.J. et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2010; 122: S829–S861


  1. Hi Andrew:
    We totally agrre with your letter, plase take our sign with yours. and

  2. i was assigned to work on something similiar for a buy dissertation uk and i am so glad that i found your post with the research. i will be referencing the content because it is amazing

  3. Drowning is the "process of experiencing respiratory impairment from submersion/immersion in liquid." This definition resulted in only three legitimate drowning subsets: fatal drowning, non-fatal drowning with illness/injury, and non-fatal drowning without illness/injury.