Related Video: Spotting a Drowning Patient

Safety

Safety first is key in all resuscitation attempts and is especially true for drowning patients; responders should not increase the number of patients by doing something that puts their health or life at risk. 

Rescue

Rescue from water should be done quickly and is best if there is a method for transportation, such as a raft, boat, or floating device. Immobilizing the cervical spine is only needed if there is a concern for a spinal injury. Spinal precautions that are unjustified can decrease CPR efficacy.

Ventilation takes priority

As drowning causes hypoxia, oxygenation, ventilation, and reperfusion are mandatory to care. Bystander CPR is required immediately, followed by EMS activation. Unlike other causes of arrest, a witnessed drowning event should prompt immediate rescue breathing. Mouth to mouth breaths are preferred but are often difficult to initiate in the water due to the need to close the nose, provide head support while opening the airway. If the patient is in shallow water, mouth to nose breaths may be used as an alternative. Rescue breathing is not recommended in deep waters. The rescuer may use an assistant device such as floatation equipment to help support rescue breathing if feasible.

Airway and breathing are managed as with other emergency patients. Responders do not need to try to remove water from the lungs. While modest amounts of water may be aspirated, it is often absorbed by the vasculature and does not prevent rescue breaths. If the fluid is removed, it is often from the gastrointestinal system, not the lungs. The Heimlich maneuver should not be used unless there is a concern for a foreign body or the patient is choking.

Chest compressions

Once both patient and the rescuer are at a safe location, the rescuer should open the airway and evaluate for breathing. If none, provide two rescue breaths, looking for a rising chest. Next, begin chest compression. If you are alone and have no means for communication, you can provide five cycles of CPR before leaving the patient to activate the EMS. Chest compressions are difficult and often ineffective if done in water.

Additionally, the rescuer may put him or herself at risk. It may be made easier if there is a hard surface, such as a floating device or surfboard of if the patient is small and can be supported with the forearm. Only skilled responders should attempt this.

Rescuer Performing Chest Compressions

Emesis

Drowning patients may vomit while receiving rescue breaths or chest compressions. Vomiting threatens the airway and increases the risk of aspiration. Immediately turn the patient head to the side and remove vomitus with suction, or a finger. If there is a concern for spinal injury, use the log roll method.

Rescuer turns patient to the side while vomiting.

Defibrillation

Asystole is more common in drowning patients than shockable rhythms. However, patients who have a shockable rhythm should receive defibrillation. Defibrillation is only used once the patient has been removed from the water and following two rescue breaths. Never attempt defibrillation in water. However, the patient does not need to be completely dry. Instead, dry the chest before attaching the defibrillation pads and turning on the AED. Complete 5 CPR cycles the shock the patient if appropriate. Monitor for hypothermia as well and treat according to hypothermia guidelines. 

Drowning and Trauma

The patient may have associated trauma with drowning, especially if the drowning was associated with diving, high-speed boats, falls, surfing, parasailing/hang gliding, and water slides. This should also be a consideration if the patient is intoxicated. Cervical spine precautions should be adhered to if there is a suspicion for a spinal injury, even if this may make resuscitation more challenging. The rescuer should use the jaw thrust maneuver and not move the head to open the airway in these cases. Of course, if there is little cause for a spinal injury due to the mechanism of action or other factors, then do no use cervical spine precautions. (Class III; harmful, Evidence level B). Remember that cervical spine injury with drowning is very low at under 0.5%.

To care for a patient with a suspected spinal cord injury: 

• Keep the neck in neutral (no extension or flexion)
• Use the jaw thrust to open the airway. This is rather difficult in water. 
• Transfer the patient onto a firm support structure to before the removal from water 
• Logroll to turn the patient, supporting the entire spine in unison

Hypothermia

Careful assessment is needed in cases of associated hypothermia as the pulse and respirations may be difficult to identify. Responders should carefully evaluate for breathing and take ten seconds to evaluate for a pulse. 

If BLS appears ineffective, evaluate the temperature to assess for hypothermia. If core temperature is under 30 degrees C, then consider prolonged resuscitation attempts. With this temperature, the patient will need to be warmed: remove wet clothing, dry the body, and actively warm the patient. Further treatments include:

• Warm the patient by covering with a blanket or other cloth
• Obtain a core temperature and follow hypothermia guidelines
• Do not end resuscitation until the patient has been warmed as hypothermia can make CPR ineffective
• Patient with a temperature of 34 degrees C can be warmed passively
• Patients with a temperature between 30-34 degrees C should be externally warmed.

Drowning in cold waters is less likely to lead to protective hypothermia with metabolic slowing. This is because, in this case, hypoxia will occur following exhaustion, submersion, and the initial drowning process. The hypoxia will occur before the body reaching a low enough core temperature to be protective. On the other hand, icy water in which hypothermia occurs quickly and before hypoxia is more likely to be protective.