AAP, AHA updates guidance for resuscitation following drowning | Image Credit: © Aleksandra Konoplya - © Aleksandra Konoplya - stock.adobe.com.

The American Academy of Pediatrics (AAP) and the American Heart Association (AHA) have collaborated to update Special Circumstances Guidelines on resuscitation after drowning. According to a press release from the AHA, the joint update reaffirms prior recommendations of for cardiopulmonary resuscitation (CPR), highlighting the importance of compressions with rescue breaths as a first step in responding to cardiac arrest after drowning.¹

The update, published in Pediatrics and Circulation, is based on 7 systematic reviews completed by the International Liaison Committee on Resuscitation task force, used to generate treatment recommendations and good practice statements.2 The reviews included the following drowning topics, according to the update published in Pediatrics¹:

• In-water resuscitation versus delayed resuscitation
• Oxygen administration following drowning
• Automated external defibrillator (AED) first versus CPR first in cardiac arrest after drowning
• Chest compressions, airway, breathing versus airway, breathing, chest compressions
• Implementation of PAD programs
• Ventilation with equipment versus without equipment before hospital arrival following drowning
• Compression only CPR

Drowning, the 3rd-leading cause of death from unintentional injury worldwide, is estimated to be the cause of approximately 236,000 deaths every year, per the World Health Organization. In the United States, drowning is the number one cause of death for children aged 1 to 4 years.¹

"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 writing group Co-Chair Tracy E. McCallin, M.D., FAAP, associate professor of pediatrics in the division of pediatric emergency medicine at Rainbow Babies and Children’s Hospital in Cleveland, in the press release.¹

"While we work on a daily basis to lower risks of drowning through education and community outreach on drowning prevention, we still need emergency preparedness training that can be used in tragic circumstances if a drowning occurs.”¹

Key updates

Each recommendation is assigned a Class of Recommendation (COR) based on the strength and consistency of the evidence and a Level of Evidence (LOE) based on quality, quantity, relevance, and consistency of available evidence. With each recommendation from the AAP and AHA is also the recommendation's respective COR and LOE, as stated by each entity.²

In-water resuscitation versus delayed resuscitation²

The AAP and AHA recommend that is could be reasonable for appropriately trained rescuers to provide in-water rescue breathing to an unresponsive child who has drowned, if it does not compromise their own safety. According to the updated guidance, most cases of respiratory arrest following drowning involve a prolonged in-water time before rescue breathing initiation. When arrest is corrected by rescue breathing that interrupts the drowning process, the death rate is lower (44%), compared to cases in which CPR is needed (93%).

COR: 2b

LOE: C-LD

Oxygen administration following drowning²

This recommendation is trained rescuers should provide supplemental oxygen if available to children with cardiac arrest following drowning. "Even with effective CPR, cardiac output, cerebral oxygenation, and blood flow range from 12% to 42% of prearrest values," stated the Pediatrics authors in the update. "Optimizing oxygenation may be beneficial because of decreased diffusion capacity of the lungs from aspiration. However, a full discussion on the pathophysiology of drowning is beyond the scope of this focused update."

COR: 1

LOE: C-EO

AED first versus CPR first in cardiac arrest following drowning²

Cardiac arrest after drowning is most commonly from a hypoxic drowning process, though it could be less commonly from a primary cardiac event. Of cardiac arrests following drowning, initial shockable rhythms constitute a minority (2%-12%), in relation to adult and pediatric subjects. With this, emphasis on high-quality CPR with rescue breaths is supported. The AAP and AHA recommend:

1. CPR with rescue breaths should be started before AED application in cardiac arrest following drowning. COR: 1. LOE B-NR.
2. AED use is reasonable in cardiac arrest after drowning. COR: 2a. LOE: B-NR.
3. CPR initiation should not be delayed to obtain or apply an AED in cardiac arrest following drowning. COR: 3-Harm. LOE: C-LD.

CPR in Cardiac Arrest Following Drowning²

Those who are removed from water without signs of normal breathing or consciousness are presumed to be in cardiac arrest, stated the guidance authors. BLS guidelines advise untrained lay rescuers to initiate chest compressions and rescue breathing without an initial pulse check. Health care professionals may check for a pulse for up to 10 seconds before initiating CPR.

Lay-rescuer CPR should be initiated immediately and without delay after initial assessment.

1. In cardiac arrest following drowning and after removal from the water, CPR with rescue breaths and chest compressions should be provided to children. COR: 1. LOE: B-NR

2. In cardiac arrest following drowning, if the rescuer is unwilling, untrained, or unable to provide rescue breaths, it is reasonable to provide chest compressions only, until help arrives. COR: 2a. LOE: B-NR.

3. In cardiac arrest following drowning, it may be reasonable for trained rescuers to initiate CPR with rescue breaths followed by chest compressions. COR: 2b. LOE: C-EO.

Implementation of public access defibrillation (PAD) programs for drowning²

The AAP and AHA recommend that the implementation of PAD programs is reasonable in areas where there is a high risk of cardiac arrest, including aquatic environments (eg areas with high population density, frequent utilization, other forms of exercise, long distances or response times to nearest AED).

COR: 2a

LOE: C-EO

Prehospital ventilation for the trained rescuer with versus without equipment following drowning²

The AAP and AHA recommend the following:

• 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 to avoid any delay in ventilation. COR: 2a. LOE: C-EO
• Provision of rescue breathing using equipment (bag-mask or advanced airways) should be optimized by providing rescuers a competency-based training program with regular retraining and maintenance of equipment. COR: 2a. LOE: C-EO

Prior coverage on drowning:

Practical reminders to prevent drowning among children

In a previous video interview with Contemporary Pediatrics, James Barry, MD, a pediatric emergency fellow in Rochester, New York, explained how drowning takes place and reminds providers of some common but practical safety tips to discuss with parents.³

Click play on the video above, or click here to view in a new window.³