Drowning Process Resuscitation

Advanced Airway Management in Drowning Process Resuscitation

Last Full Review: ILCOR 2021

The drowning process results in asphyxia, hypoxemia and global ischemia, which if not reversed, will lead to cardiac arrest. Airway management and ventilatory and oxygenation support are key to successful resuscitation.

 

 

 

Evidence Summary

A 2020 scoping review (Wyckoff et al. 2021; Wyckoff et al. 2022, e645; Bierens et al. 2021a) by International Liaison Committee on Resuscitation (ILCOR) searched for studies of adults and children who were submerged in water who received advanced airway management compared with no advanced airway management. No studies were identified that evaluated a single airway management strategy compared with another airway management strategy or with no airway management strategy for submerged adults and children. Five observational studies were identified that indirectly evaluated airway management following the drowning process, including one in both adults and children (Hubert et al. 2016, 924) and four in children (Garner, Barker, and Weatherall 2015, 92; Joankecht et al. 2015, 123; Kieboom et al. 2015, h418; Salas et al. 2021, e192). These studies all described an association between severity of injury, including cardiac arrest, and intubation. Intubation was associated with worse outcomes in two studies, (Joankecht et al. 2015, 123; Kieboom et al. 2015, h418) which was felt by the review authors to be confounded by intubation being limited to more severe drowning (Bierens et al. 2021a). No recommendations were made by ILCOR from this scoping review. Past ILCOR recommendations for airway management during cardiac arrest apply to drowning victims, including the use of a supraglottic airway for adults with out-of-hospital cardiac arrest in settings with a low tracheal intubation success rate, and supraglottic airway or tracheal intubation for adults with out-of-hospital cardiac arrest in settings with a high tracheal intubation success rate (Soar et al. 2019, e826).

Insights and Implications

The unique pathophysiology of the drowning process and data from Cardiac Arrest Registry to Enhance Survival highlight the need for early ventilatory support in drowning victims in cardiac arrest. The ideal advanced airway management strategy following drowning remains a research and knowledge gap and may be influenced by the setting (in water, on a boat or on land) and the experience/skill of the healthcare professional.

Mechanical Ventilation in Drowning Process Resuscitation

Last Full Review: ILCOR 2021

Ventilation strategies for patients with lung injury following drowning can include noninvasive ventilation and invasive mechanical ventilation. Is there evidence to support the use of one strategy compared with the other?

 

 

 

Evidence Summary

A 2021 scoping review by International Liaison Committee on Resuscitation (ILCOR) searched for literature related to the use of mechanical ventilation in adults and children who have been submerged in water, compared with no mechanical ventilation (Wyckoff et al. 2021; Wyckoff et al. 2022, e645). The review included a retrospective observational study (Michelet et al. 2017, 295) and three case series or reports, all describing ventilation strategies following drowning in a total of 93 adults and children. The observational study (Michelet et al. 2017, 295) compared 48 adult intensive care unit (ICU) patients treated for moderate to severe lung injury with noninvasive ventilation (continuous positive airway pressure or bilevel positive airway pressure) with patients treated with mechanical ventilation. The noninvasive ventilation group had a better initial Glasgow Coma Scale (GCS) score and mean arterial pressure than the mechanical ventilation group. Both mechanical ventilation and noninvasive ventilation patients were reported to be associated with rapid (less than 6 hours) improvement of oxygenation and short ICU length of stay. The use of noninvasive ventilation was reported as successful in 92% of the patients with a 1.4-day average duration of ventilation (Wyckoff et al. 2021; Wyckoff et al. 2022, e645; Bierens et al. 2021d).

 

Insights and Implications

The evidence identified in this scoping review is extremely limited but suggests that noninvasive ventilation is a viable treatment option for moderate to severe lung injury following drowning events in hemodynamically stable patients with a higher GCS score. Further prospective randomized controlled trials are needed to assess clinical outcomes and strategies for transition to mechanical ventilation.

 

Extracorporeal Membrane Oxygenation in Drowning Process Resuscitation

Last Full Review: ILCOR 2021

The use of extracorporeal membrane oxygenation (ECMO) has been reported to treat drowning with refractory hypoxia and/or cardiac arrest. Is there evidence to support or guide the use of ECMO as part of the drowning process resuscitation?

 

 

Evidence Summary

A 2021 International Liaison Committee on Resuscitation (ILCOR) scoping review (Wyckoff et al. 2021; Wyckoff et al. 2022, e645; Bierens et al. 2021c) searched for literature related to the use of ECMO compared with no ECMO in adults and children following drowning. The review ultimately included two retrospective observational studies (Champigneulle et al. 2015, 126; Burke et al. 2016, 19) and multiple case series enrolling a total of 658 adults and children that evaluated the use of ECMO following drowning (Wyckoff et al. 2021; Wyckoff et al. 2022, e645; Bierens et al. 2021c). The use of venous-arterial ECMO was reported by most studies for patients in cardiac arrest, and venous-venous ECMO use was reported in several studies for respiratory failure, with a duration of treatment between 2 hours and 260 hours. Survival rates that were reported ranged from 10% to 100%, with the highest survival to discharge rate (71.4%) among patients without a cardiac arrest (Wyckoff et al. 2021; Wyckoff et al. 2022, e645; Bierens et al. 2021c).

Data from an international extracorporeal life support registry (Burke et al. 2016, 19) reported survival in 57.0% of patients requiring cardiopulmonary resuscitation (CPR) prior to ECMO. Multiple factors were reported as associated with worse outcomes, such as hyperkalemia, asystole as an initial rhythm, submersion duration greater than 10 minutes, and a low blood pH, while a core body temperature less than 26° C (78.8° F) and normal serum potassium were reported as associated with good outcomes (Wyckoff et al. 2021; Wyckoff et al. 2022, e645; Bierens et al. 2021c). The review concluded that the use of ECMO to treat cardiac arrest or severe respiratory failure caused by drowning is feasible. The evidence also supports existing ILCOR treatment recommendations (Bierens et al. 2021c).  for the use of extracorporeal CPR (ECPR) as a rescue therapy for select patients with cardiac arrest, as well as guidelines (Griffiths et al. 2019, e000420) suggesting the use of ECMO in select patients with severe acute respiratory distress syndrome.

 

Insights and Implications

While ECMO and ECPR appear to be of use in select drowning victims with cardiac arrest or severe respiratory failure, the indications and optimal timing for starting ECMO and ECPR remain a knowledge gap.

 

Criteria for Discharge in Patients Who Have Had a Drowning Event

Last Full Review: ILCOR 2021

The spectrum of signs and symptoms following a submersion event varies from asymptomatic to dyspnea, respiratory distress with hypoxemia, and respiratory or cardiac arrest. Not all drowning victims require hospitalization. Is there evidence to guide who can safely be discharged home from the emergency department?

 

 

 

Evidence Summary

A 2021 scoping review (Wyckoff et al. 2021; Wyckoff et al. 2022, e645; Bierens et al. 2021b) by International Liaison Committee on Resuscitation (ILCOR) searched for literature related to discharge criteria for adults and children following submersion (Bierens et al. 2021b). The review ultimately included five retrospective observational studies for data abstraction, including a total of 834 patients, all under the age of 18. Various objective clinical findings, such as lung examination, room air oxygen saturation, vital signs, mental status, dyspnea, and need for airway support, were evaluated in the studies to determine what factors might predict the safe early discharge of a patient. Other findings evaluated in some studies included chest radiography and arterial blood gas results. In summary, the included studies found that for drowning patients under 18 years of age and presenting to an emergency department with normal mentation, an observation period of at least 6 hours appears to be sufficient to allow for any clinical deterioration to be observed.

The included studies reported that patients who maintain normal mentation without the need for supplemental oxygen and with normal age-adjusted vital signs can be considered for discharge following an observation period of at least 6 hours (Wyckoff et al. 2021; Wyckoff et al. 2022, e645). A future systematic review will be required for any recommendations by ILCOR.

Insights and Implications

Limited studies identified by the scoping review report associations between various clinical findings and ancillary study results and the likelihood of hospital admission following drowning. Prospective studies are needed to confirm these associations and to develop and validate a clinical decision rule. None of the included studies evaluated discharge from the prehospital setting or scene of the submersion event.