Elsevier

Resuscitation

Volume 82, Issue 7, July 2011, Pages 819-824
Resuscitation

Clinical paper
A proposed decision-making guide for the search, rescue and resuscitation of submersion (head under) victims based on expert opinion

https://doi.org/10.1016/j.resuscitation.2011.02.021Get rights and content

Abstract

There is some confusion, and consequent variation in policy, between the agencies responsible for the search, rescue and resuscitation of submersion victims regarding the likelihood of survival following a period of submersion. The aim of this work was to recommend a decision-making guide for such victims. This guidance was arrived at by a review of the relevant literature and specific case studies, and a “consensus” meeting on the topic. The factors found to be important for determining the possibility of prolonged survival underwater were: water temperature; salinity of water; duration of submersion; and age of the victim. Of these, only water temperature and duration are sufficiently clear to form the basis of guidance in this area. It is concluded that if water temperature is warmer than 6 °C, survival/resuscitation is extremely unlikely if submerged longer than 30 min. If water temperature is 6 °C or below, survival/resuscitation is extremely unlikely if submerged longer than 90 min.

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.

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    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.

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