Clinical paperA proposed decision-making guide for the search, rescue and resuscitation of submersion (head under) victims based on expert opinion☆
Introduction
In the UK and many other countries, immersion-related deaths remain one of the major causes of accidental death and the third most common cause of death in children. Amongst the more difficult decisions required of medics, paramedics and others involved in search and rescue is when to downgrade the search for a submerged individual from “rescue” to “body recovery”. This decision involves consideration of the chance of saving a life against the continued risk to those conducting the search; it is made more difficult by knowledge of what seem unbelievable cases of survival with full recovery after many minutes of submersion. For example, whilst the prognostic indicators of a poor outcome following submersion include a period underwater of longer than 5 min,1 the current record for submersion without sequelae is 66 min.2 It is not surprising that this variation engenders a degree of confusion, and consequent variation in policy, in those trying to address the question of how long should a search for a submerged individual continue before successful resuscitation becomes extremely unlikely.
In response to questions from different rescue services, we have endeavoured to propose a decision-making guide for the search, rescue and resuscitation of submerged (head under) victims. To do this we followed a route we have used successfully in the past of reviewing and analysing the relevant literature, meeting with relevant experts and search and rescue agencies and offering proposed guidance for peer review.
Section snippets
Methods
For the purposes of this project we defined submersion as “the complete immersion of an individual, including the airways” and “protracted period of submersion” as submersion for longer than 4 min. In order to formulate the guidance we reviewed current guidelines and practice, as well as the relevant literature, including case studies and media reports. We also held a meeting of relevant agencies and subject-area experts.
Review of current guidelines
We concluded that few formal guidelines exist in this area. From those that we contacted we learned that in the United States (C. Brewster, US Lifesaving Association), the standard practice for search and rescue of victims who have been submerged under water of a temperature “normally used for swimming”, is to continue an emergency search for 1 h. During this period if the victim is recovered, resuscitation procedures are normally attempted. After 1 h the emergency portion of the search is
Discussion
Numerous publications (e.g., Golden et al.5) have highlighted the importance of a young age, hypothermia and short submersion time on a positive prognostic outcome in drowning cases, for example:
Orlowski1: child (but older than 3 years), less than 5 min submersion;
Bierens et al.6: “young” age and less than 10 min of submersion;
Biggart and Bohn7: hypothermia (Tc < 33 °C) is one of two factors that determine outcome in near-drowning in children (the other is the presence of a heart beat).
On the basis
Conflict of interest statement
The authors have no conflicts of interest to declare.
Acknowledgements
Thanks to Paul Amos, Howard Ramm, Heather Lunt, Joanne Merritt, Gemma Milligan, Dr. John Stephenson, Dr. David Szpilman (Brazil), Dr. Chris Brewster (US), Mr. Norm Farmer (Aus) and Dr. Lumb for their help in producing this paper.
References (47)
- et al.
Near-drowning, and ice-water submersions
Pediatr Clin North Am
(1987) - et al.
Submersion in The Netherlands: prognostic indicators and results of resuscitation
Ann Emerg Med
(1990) - et al.
Effect of hypothermia and cardiac arrest on outcome of near-drowning accidents in children
J Pediatr
(1990) - et al.
Survival after prolonged survival in freshwater in Florida
Chest
(2004) - et al.
Outcome of 12 drowned children with attempted resuscitation on cardiopulmonary bypass: an analysis of variables based on the “Ustein Style for Drowning”
Resuscitation
(2007) - et al.
Recovery of a hypothermic drowned child after resuscitation with cardiopulmonary bypass followed by prolonged extracorporeal membrane oxygenation
Resuscitation
(2005) - et al.
Cold water submersion and cardiac arrest in treatment of severe hypothermia with cardiopulmonary bypass
Resuscitation
(2002) - et al.
Survival after 40 minutes submersion without cerebral sequelae
Lancet
(1975) - et al.
Prognostic markers in patients in accidental hypothermia and cardiovascular arrest
Resuscitation
(1994) - et al.
Resuscitation from accidental hypothermia of 13.7 degrees C with circulatory arrest
Lancet
(2000)
Portable cardiopulmonary bypass: resuscitation from prolonged ice-water submersion and asystole
Ann Thorac Surg
Recovery of a 62-year-old man from prolonged cold water submersion
Ann Emerg Med
Golden FStC. Basic life support on small boats at sea
Resuscitation
The use of extracorporeal rewarming in a child submerged for 66 minutes
JAMA
A care report of 22-minute submersion in warm water without sequelae
Immersion, near-drowning and drowning
Br J Anaesth (Review paper)
Full recovery after 45 min accidental submersion (letter)
Intensive Care Med
Effect and treatment of the “diving reflex”
Can Med J
Why some people do not drown. Hypothermia versus the diving response
Med J Aust
A canine study of cold water drowning in fresh versus salt water
Crit Care Med
Mechanisms of body cooling in submersed victims. Editorial
Resuscitation
Hypoxic hypotensive encephalopathy
Cited by (0)
- ☆
A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.02.021.