Updated guidelines from the AAP and the American Heart Association (AHA) on resuscitation in children and adults following drowning recommend cardiopulmonary resuscitation (CPR) with rescue breaths for all victims who are in cardiac arrest after being pulled from the water.
The focused update also addresses the implementation of automated external defibrillators (AEDs) and public access defibrillation (PAD) programs; makes new recommendations on prehospital ventilation; and adjusts guidance on in-water rescue breathing.
The guidance titled 2024 American Heart Association and American Academy of Pediatrics Focused Update on Special Circumstances: Resuscitation Following Drowning is available at https://doi.org/10.1542/peds.2024-068444 and will be published in the December issue of Pediatrics.
“The focused update on drowning contains the most up-to-date, evidence-based recommendations on how to resuscitate someone who has drowned, offering practical guidance for health care professionals, trained rescuers, caregivers and families,” said co-author Tracy E. McCallin, M.D., FAAP, associate professor of pediatrics, Division of Pediatric Emergency Medicine at Rainbow Babies and Children’s Hospital in Cleveland.
The guidance updates AHA guidelines for CPR and emergency cardiovascular care.
Need for rescue breathing
Drowning is the leading cause of death in U.S. children ages 1-4 years and second-leading cause of death due to unintentional injury in those ages 5-14 years.
Drowning generally progresses from initial respiratory arrest due to submersion-related hypoxia to cardiac arrest. The guideline notes that distinguishing respiratory arrest from cardiac arrest can be challenging since pulses are difficult to palpate accurately within the recommended 10-second window.
Rescuers should assume that anyone removed from the water without signs of normal breathing or consciousness is in cardiac arrest, and CPR should be administered with rescue breathing and chest compressions.
“CPR for cardiac arrest due to drowning must focus on restoring breathing as well as restoring blood circulation,” said co-author Cameron Dezfulian, M.D., FAHA, FAAP, senior faculty in pediatrics and critical care at Baylor College of Medicine in Houston.
AED first vs. CPR first
Studies of adults and children show that shockable rhythms constitute only about 2%-12% of cardiac arrests following drowning.
“The low incidence of shockable rhythm supports the emphasis placed on high-quality CPR with rescue breaths elsewhere in this document,” the authors wrote.
However, an AED can save the life of someone whose drowning was caused by a cardiac event in the water.
The guideline recommends the following.
- In cardiac arrest following drowning, CPR with rescue breaths should be started before AED application.
- AED use is reasonable in cardiac arrest after drowning.
- The initiation of CPR should not be delayed to obtain or apply an AED in cardiac arrest following drowning.
The update also reinforces the importance of public access to defibrillators in public aquatic settings like beaches and pools. The authors said PAD programs have proven to be cost-effective, though data are lacking on their implementation in aquatic settings.
Five steps to survival
The guidance emphasizes the drowning chain of survival. The five-step approach calls for:
- preventing drowning,
- recognizing distress and asking someone to call for help,
- providing flotation to prevent submersion,
- removing the person from water if safe to do so, and
- providing care as needed by using basic life support and advanced life support.
“Multiple ‘layers of protection’ are necessary for drowning prevention, especially in children, because it is unlikely that any single strategy will prevent drowning deaths and injuries,” the authors wrote, pointing to the AAP policy statement Prevention of Drowning.
Additional recommendations
- Trained rescuers should provide supplemental oxygen if available to children with cardiac arrest after drowning.
- It may be reasonable for rescuers to provide in-water breathing to an unresponsive child who has drowned, if it does not compromise their own safety.
- If the rescuer is unwilling, untrained or unable to provide rescue breaths, it is reasonable to provide chest compressions only until help arrives.
- It is reasonable for trained rescuers to provide rescue breaths by the first means available (mouth-to-mouth, pocket mask or bag-mask ventilation) for children in cardiac arrest following drowning.
- Provision of rescue breathing using equipment (bag-mask or advanced airways) should be optimized by providing rescuers a competency-based training program.
