The use of the Heimlich maneuver in near drowning: Institute of Medicine report

Wilderness Medical Society Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2024 Update

The Wilderness Medical Society convened a panel to review available evidence supporting practices for acute management of drowning in out-of-hospital and emergency care settings. Literature about definitions and terminology, epidemiology, rescue, resuscitation, acute clinical management, disposition, and drowning prevention was reviewed. The panel graded available evidence supporting practices according to the American College of Chest Physicians criteria and then made recommendations based on that evidence. Recommendations were based on the panel's collective clinical experience and judgment when published evidence was lacking. This is the second update to the original practice guidelines published in 2016 and updated in 2019.

Fifteen-minute consultation: Drowning in children

Drowning is a significant cause of childhood morbidity and mortality globally. The underlying mechanisms vary with child development and most are modifiable to public health promotion strategies. This article serves to highlight some of the specific considerations for the clinical management of drowning in children, both prehospital and by the in-hospital paediatric resuscitation team. This includes changes to standard advanced paediatric life support in the presence of hypothermia.

Pediatric Drowning: A Standard Operating Procedure to Aid the Prehospital Management of Pediatric Cardiac Arrest Resulting From Submersion

OBJECTIVES

Drowning is one of the leading causes of death in children. Resuscitating a child following submersion is a high-pressure situation, and standard operating procedures can reduce error. Currently, the Resuscitation Council UK guidance does not include a standard operating procedure on pediatric drowning. The objective of this project was to design a standard operating procedure to improve outcomes of drowned children.

METHODS

A literature review on the management of pediatric drowning was conducted. Relevant publications were used to develop a standard operating procedure for management of pediatric drowning.

RESULTS

A concise standard operating procedure was developed for resuscitation following pediatric submersion. Specific recommendations include the following: the Heimlich maneuver should not be used in this context; however, prolonged resuscitation and therapeutic hypothermia are recommended.

CONCLUSIONS

This standard operating procedure is a potentially useful adjunct to the Resuscitation Council UK guidance and should be considered for incorporation into its next iteration.

Wilderness Medical Society Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2019 Update

The Wilderness Medical Society convened a panel to review available evidence supporting practices for acute management and treatment of drowning in out-of-hospital and emergency medical care settings. Literature about definitions and terminology, epidemiology, rescue, resuscitation, acute clinical management, disposition, and drowning prevention was reviewed. The panel graded available evidence supporting practices according to the American College of Chest Physicians criteria and then made recommendations based on that evidence. Recommendations were based on the panel's collective clinical experience and judgment when published evidence was lacking. This is the first update to the original practice guidelines published in 2016.

Aquatic Orthopaedic Injuries

Extremity injuries sustained in aquatic environments require unique considerations compared with injuries sustained on land. Knowledge of these considerations is becoming more important as aquatic recreational activities increase in popularity. Aquatic injuries may occur through mechanical contact with a variety of different objects or surfaces, such as a recreational device or watercraft part, or may occur through contact with marine animals. Marine animal injuries can be further categorized into bites, stings, or blunt contact, as well as venomous or nonvenomous, distinctions that should be used to guide clinical management. Numerous instances of retained foreign bodies after marine animal stings exist, which can result in infection and prolonged envenomization; thus, radiographic examination should be routinely performed in aquatic sting injuries to prevent these harmful sequelae. Any aquatic injury resulting in an open wound has an increased risk for infection, and prophylactic antibiotics must be given with consideration for the unique microbiologic flora of the aquatic environment.

Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning

The Wilderness Medical Society convened a panel to review available evidence supporting practices for the prevention and acute management of drowning in out-of-hospital and emergency medical care settings. Literature about definition and terminology, epidemiology, rescue, resuscitation, acute clinical management, disposition, and drowning prevention was reviewed. The panel graded evidence supporting practices according to the American College of Chest Physicians criteria, then made recommendations based on that evidence. Recommendations were based on the panel's collective clinical experience and judgment when published evidence was lacking.

[Unintentional drowning by immersion. Epidemiological profile of victims attended in 21 Spanish emergency departments]

OBJECTIVES

To determine the frequency of accidental drowning seen in paediatric emergency departments, to define the epidemiological profile of the victims, and to analyse the circumstances related to prognosis and survival.

PATIENTS AND METHODS

A multicentre, prospective and descriptive study was conducted on victims of accidental drowning seen in 21 paediatric emergency departments between June and September 2009 and 2010. We collected personal, environmental, safety, security data, as well as the need for cardiopulmonary resuscitation (CPR), hospitalisation rate, sequelae and mortality.

RESULTS

Out of 234,566 emergency department cases, 53 were due to accidental drowning (frequency: 2.2/10,000 consultations during the summer period, 64.2% males). The median age was 3.5 years (p25-75: 2.6-8.4), with 34 had less than 6 years. Thirty-two children were hospitalised. Most drowning occurred in the afternoon (40), in freshwater (49), in private pools (33) and unprotected (33). The victims, mostly healthy children (40), did not know how to swim (38) and were not wearing flotation systems (37/38). There was lack of supervision in 42 cases. Acidosis (20) and hypoxaemia (18) were the most frequent findings. Five children died, 4 were healthy, none knew how to swim or had a float device, and none were supervised. Thirty six children required CPR, mostly applied by family (15). In the children who died, CPR was started after 3 min. Two survivors had hemiparesis.

CONCLUSIONS

Accidental drowning was a rare cause of consultation in paediatric emergency departments. In children less than 6 years, who did not know how to swim, did not use flotation devices in unprotected private pools, and were not properly supervised, there is an increased of suffering from accidental drowning and its associated morbidity. An immersion time> 10 min, starting CPR > 3 min, acidosis, hyponatraemia, and hypothermia on arrival at the emergency department increases mortality. Training family members in cardiopulmonary resuscitation can be useful.

Subcapsular liver haematoma after cardiopulmonary resuscitation by untrained personnel

Although early cardiopulmonary resuscitation (CPR) is associated with increased survival of sudden cardiac arrest victims, it may also result in miscellaneous injuries. A 25-year-old inebriated man rescued from drowning in a swimming pool was apnoeic and pulseless after being pulled out of the water. Successful CPR was provided by untrained bystanders, including abdominal thrusts thought to remove water from the airways and chest compressions to provide haemodynamic support. As the patient progressively improved during his subsequent hospital stay, he complained of right upper abdominal and thoracic pain. A computed tomographic scan showed a 11 cm subcapsular haematoma contiguous to the right hepatic lobe. A favourable outcome was obtained after conservative, non-operative treatment. Subcapsular haematoma of the liver is a potentially life threatening complication that warrants consideration in survivors of cardiac arrest who have received closed chest compression and/or abdominal thrusts.

2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of pediatric and neonatal patients: pediatric basic life support

This publication presents the 2005 American Heart Association (AHA) guidelines for cardiopulmonary resuscitation (CPR) and emergency cardiovascular care (ECC) of the pediatric patient and the 2005 American Academy of Pediatrics/AHA guidelines for CPR and ECC of the neonate. The guidelines are based on the evidence evaluation from the 2005 International Consensus Conference on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations, hosted by the American Heart Association in Dallas, Texas, January 23-30, 2005. The "2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" contain recommendations designed to improve survival from sudden cardiac arrest and acute life-threatening cardiopulmonary problems. The evidence evaluation process that was the basis for these guidelines was accomplished in collaboration with the International Liaison Committee on Resuscitation (ILCOR). The ILCOR process is described in more detail in the "International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations." The recommendations in the "2005 AHA Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care" confirm the safety and effectiveness of many approaches, acknowledge that other approaches may not be optimal, and recommend new treatments that have undergone evidence evaluation. These new recommendations do not imply that care involving the use of earlier guidelines is unsafe. In addition, it is important to note that these guidelines will not apply to all rescuers and all victims in all situations. The leader of a resuscitation attempt may need to adapt application of the guidelines to unique circumstances. The following are the major pediatric advanced life support changes in the 2005 guidelines: There is further caution about the use of endotracheal tubes. Laryngeal mask airways are acceptable when used by experienced providers. Cuffed endotracheal tubes may be used in infants (except newborns) and children in in-hospital settings provided that cuff inflation pressure is kept <20 cm H2O. Confirmation of tube placement requires clinical assessment and assessment of exhaled carbon dioxide (CO2); esophageal detector devices may be considered for use in children weighing >20 kg who have a perfusing rhythm. Correct placement must be verified when the tube is inserted, during transport, and whenever the patient is moved. During CPR with an advanced airway in place, rescuers will no longer perform "cycles" of CPR. Instead, the rescuer performing chest compressions will perform them continuously at a rate of 100/minute without pauses for ventilation. The rescuer providing ventilation will deliver 8 to 10 breaths per minute (1 breath approximately every 6-8 seconds). Timing of 1 shock, CPR, and drug administration during pulseless arrest has changed and now is identical to that for advanced cardiac life support. Routine use of high-dose epinephrine is not recommended. Lidocaine is de-emphasized, but it can be used for treatment of ventricular fibrillation/pulseless ventricular tachycardia if amiodarone is not available. Induced hypothermia (32-34 degrees C for 12-24 hours) may be considered if the child remains comatose after resuscitation. Indications for the use of inodilators are mentioned in the postresuscitation section. Termination of resuscitative efforts is discussed. It is noted that intact survival has been reported following prolonged resuscitation and absence of spontaneous circulation despite 2 doses of epinephrine. The following are the major neonatal resuscitation changes in the 2005 guidelines: Supplementary oxygen is recommended whenever positive-pressure ventilation is indicated for resuscitation; free-flow oxygen should be administered to infants who are breathing but have central cyanosis. Although the standard approach to resuscitation is to use 100% oxygen, it is reasonable to begin resuscitation with an oxygen concentration of less than 100% or to start with no supplementary oxygen (ie, start with room air). If the clinician begins resuscitation with room air, it is recommended that supplementary oxygen be available to use if there is no appreciable improvement within 90 seconds after birth. In situations where supplementary oxygen is not readily available, positive-pressure ventilation should be administered with room air. Current recommendations no longer advise routine intrapartum oropharyngeal and nasopharyngeal suctioning for infants born to mothers with meconium staining of amniotic fluid. Endotracheal suctioning for infants who are not vigorous should be performed immediately after birth. A self-inflating bag, a flow-inflating bag, or a T-piece (a valved mechanical device designed to regulate pressure and limit flow) can be used to ventilate a newborn. An increase in heart rate is the primary sign of improved ventilation during resuscitation. Exhaled CO2 detection is the recommended primary technique to confirm correct endotracheal tube placement when a prompt increase in heart rate does not occur after intubation. The recommended intravenous (IV) epinephrine dose is 0.01 to 0.03 mg/kg per dose. Higher IV doses are not recommended, and IV administration is the preferred route. Although access is being obtained, administration of a higher dose (up to 0.1 mg/kg) through the endotracheal tube may be considered. It is possible to identify conditions associated with high mortality and poor outcome in which withholding resuscitative efforts may be considered reasonable, particularly when there has been the opportunity for parental agreement. The following guidelines must be interpreted according to current regional outcomes: When gestation, birth weight, or congenital anomalies are associated with almost certain early death and when unacceptably high morbidity is likely among the rare survivors, resuscitation is not indicated. Examples are provided in the guidelines. In conditions associated with a high rate of survival and acceptable morbidity, resuscitation is nearly always indicated. In conditions associated with uncertain prognosis in which survival is borderline, the morbidity rate is relatively high, and the anticipated burden to the child is high, parental desires concerning initiation of resuscitation should be supported. Infants without signs of life (no heartbeat and no respiratory effort) after 10 minutes of resuscitation show either a high mortality rate or severe neurodevelopmental disability. After 10 minutes of continuous and adequate resuscitative efforts, discontinuation of resuscitation may be justified if there are no signs of life.

Emergency physicians and the care of children

The care of children is an integral aspect of emergency medicine. This article reviews the many important contributions that emergency physicians have made in advancing the acute care of children.

Drowning: a review of epidemiology, pathophysiology, treatment and prevention

Although often preventable, drowning remains a leading cause of accidental death, especially in children. New definitions classify drowning as the process of experiencing respiratory impairment from submersion or immersion in a liquid. The key pathophysiological feature in drowning is hypoxia. Accurate neurological prognosis cannot be predicted from the initial clinical presentation, laboratory, radiological, or electrophysiological examinations. Prompt and aggressive resuscitation attempts are crucial for optimal survival. This article reviews the epidemiology, pathophysiology, treatment, and prevention of drowning.

Submersion

Many thousands of individuals are submersion victims each year in the United States. The majority of victims are young, previously healthy people. There have been no recent breakthroughs in medical technology or treatment modalities that have improved survival rates for submersion victims. The key to their successful outcome and return to productive, full lives is aggressive resuscitation by emergency physicians and prehospital care providers. Most submersion incidents should never take place. Emergency physicians can take the lead in public education and prevention.

Rupture of the lesser gastric curvature after a Heimlich maneuver

BACKGROUND

We present a case of lesser gastric curvature injury after a Heimlich maneuver due to obstruction of the breathing tract that was repaired by laparoscopic surgery.

METHODS

A patient with perforation of the lesser gastric curvature as a result of closed abdominal traumatism was operated on using the laparoscopic approach with the use of four trocars as work openings. With this technique, the diagnosis was confirmed, the injury repaired, and the abdominal cavity washed.

RESULTS

The postoperative period was favorable and the patient was released from the hospital on day 7 without any complications.

CONCLUSIONS

Laparoscopic surgery can be technically reproduced in the treatment of gastric injury as a result of closed abdominal traumatism.

Drowning and near-drowning

Water immersion is a frequent cause of accidental death and hospital admission. This article outlines the pathogenesis and principles of treatment. Drowning is defined as death by asphyxia due to submersion in a liquid medium. Near-drowning is defined as immediate survival after asphyxia due to submersion.

Update in pediatric resuscitation

This article updates research concerning the resuscitation of a pediatric patient. The topics discussed include the state of pediatric life support, the current guidelines, the management of those guidelines, and coping with death.

Part 9: pediatric basic life support. European Resuscitation Council

The epidemiology and outcome of pediatric cardiopulmonary arrest and the priorities, techniques, and sequence of pediatric resuscitation assessments and intervention differ from those of adults. Current guidelines have been updated after extensive multinational evidence-based review and discussion over several years. Areas of controversy in current guidelines and recommendations made by consensus are detailed. A large degree of uniformity exists in the current guidelines advocated by the AHA, Council on Latin American Resuscitation, Heart and Stroke Foundation of Canada, European Resuscitation Council, Australian Resuscitation Council, and Resuscitation Council of Southern Africa. Differences are currently based on local and regional preferences, training networks, and customs rather than scientific controversy. Unresolved issues with potential for future universal application are highlighted.

An interesting complication of the Heimlich manoeuvre

The removal of inhaled foreign bodies using the Heimlich manoeuvre is recommended as part of the immediate management of the choking child. We report on a case of witnessed laryngeal obstruction by a foreign body in which repeated Heimlich manoeuvres failed to expel the foreign body, but temporarily relieved the obstruction. The repeated Heimlich manoeuvres dislodged the foreign body into the trachea and may have contributed to the rapid development of extensive surgical emphysema, pneumomediastinum and pneumopericardium. The purpose of this report is to demonstrate that the Heimlich manoeuvre was effective in relieving the airway obstruction, but was associated with potentially severe complications.

Near-drowning: life-saving steps

Cervical-spine injury, trauma, and hypothermia should be considered in all sports-related near-drownings. The focus of resuscitation should be on prompt restoration of respiration, CPR, and advanced cardiac life support with cervical-spine precautions. A subset of near-drowning victims can be discharged after only 4 to 6 hours of observation. Although total drowning deaths have decreased 45% in the past 15 years, a greater emphasis on public education to prevent drowning remains in order.

Submersion injuries in children and adults

Drowning and near drowning remain a common cause of childhood death and disability. Toddlers aged one through four drown in private swimming pools. Submersions greater than 10 minutes and lack of CPR at the scene or the need for greater than 20 minutes of resuscitation portends a poor prognosis. Management of respiratory failure without neurologic impairment has the most successful outcome. Prevention of drowning morbidity is dependent on constant parental supervision, and immediate and expert CPR.

Environmental emergencies

This article reviews the pearls and pitfalls of high-altitude sickness, decompression sickness, and barotrauma; new findings relevant to the near-drowning patient; continued controversies on hyperbaric oxygen for carbon monoxide poisoning; pitfalls in hypothermia management; and updates on the management of venomous snakebites.

Near-drowning: epidemiology, pathophysiology, and initial treatment

Drowning is a major cause of accidental deaths, especially in children. The most serious pathophysiologic consequence of near-drowning is hypoxemia, which usually is due to aspiration-induced noncardiogenic edema. Therefore, initial resuscitative efforts need to be directed at establishing adequate oxygenation and ventilation, followed by rewarming and fluid administration. Although completely asymptomatic patients with normal vital signs, oxygenation and chest radiographs require only 4 to 6 hours of observation, many near-drowning victims will require at least 24 hours of observation. Despite these measures, approximately 25% of victims presenting to the Emergency Department will die and another 6% will develop neurological sequelae. Therefore, it is vital that better efforts be made by the community in promoting and instituting water safety programs.