Elsevier

Resuscitation

Volume 63, Issue 1, October 2004, Pages 25-31
Resuscitation

In-water resuscitation—is it worthwhile?

https://doi.org/10.1016/j.resuscitation.2004.03.017Get rights and content

Abstract

Objectives: At present, there is no reliable information indicating the best option of rescuing a non-breathing drowning victim in the water. Our objectives were to compare the outcomes of performing immediate in-water resuscitation (IWR) or delaying resuscitation until the victim is brought to shore. Material and methods: A retrospective data analysis was conducted of non-breathing drowning victims rescued by lifeguards in the coastal area of Rio de Janeiro, Brazil. Patients were coded as IWR and no-IWR (NIWR) cases based on the lifeguard’s decision whether to perform IWR. Death and development of severe neurological damage (SND) were considered poor outcome. Results: Forty-six patients were studied. Their median age was 17 (9–31) years. Nineteen (41.3%) patients received IWR and 27 (58.7%) did not. The mortality rate was lower for IWR cases (15.8% versus 85.2%, P<0.001). However, among surviving IWR cases, 6 (31.6%) developed SND. In multivariate analysis, higher age [odds ratio (OR)=1.12 (95% confidence interval (CI)=1.01–1.24), P=0.038] was associated with death, while IWR [OR=0.05 (95% CI=0.01–0.50), P=0.011] was protective. When death or the development of SND was set as the dependent variable, longer cardiopulmonary arrest (CPA) duration was the unique variable selected (OR=1.77 (95% CI=1.13–2.79), P=0.013]. Every patient with CPA duration higher than 14 min had a poor outcome. Conclusions: Delaying resuscitation efforts were associated with a worse outcome for non-breathing drowning victims. In the cases studied, IWR was associated with improvement of the likelihood of survival. An algorithm was developed for its indications and to avoid unnecessary risks to both victim and rescuer.

Sumàrio

Objectivos: Até agora não há evidência sólida que indique a melhor opção para resgatar uma vı́tima que não respira dentro de água. O nosso objectivo foi comparar a reanimação imediata na água (IWR) com a reanimação tardia quando a vı́tima chega a terra. Material e métodos: Foi feita uma análise retrospectiva dos dados referentes a vı́timas de afogamento que não respiravam e que foram reanimadas por nadadores salvadores na área costeira do Rio de Janeiro, Brasil. Os doentes foram escalonados em IWR e não IWR conforme a decisão dos nadadores salvadores. Foram considerados mau prognóstico as situações de morte e lesão neurológica grave (SND). Resultados: Estudaram-se 46 doentes. A idade media foi 17 (9–31) anos. Dezanove (41.3%) destes doentes receberam IWR e 27 (58.7%) não. A mortalidade foi mais baixa para o grupo IWR (15.8 versus 85.2%, P < 0.001). Dentro dos sobreviventes do grupo IWR 6 desenvolveram SND. Na análise multivariada, a idade esteve associada a maior mortalidade (OR = 1.12; intervalo de confiança a 95% = 1.01–1.24; P = 0.038) enquanto o IWR foi protector (OR = 0.05; intervalo de confiança a 95% = 0.01–0.5; P = 0.038). Quando as variáveis dependentes eram a morte ou a SND, a duração da paragem cardı́aca superior foi a única variável independente (OR = 1.77; intervalo de confiança a 95% = 1.13–2.79; P = 0.013). Todos os doentes com paragem superior a 14 minutos tiveram mau prognóstico. Conclusões: O atraso no inı́cio das manobras de reanimação esteve associado a pior prognóstico para as vı́timas de afogamento com paragem respiratória. Nos casos estudados a reanimação imediata dentro de água associou-se a um melhor prognóstico. Desenvolveu-se um algoritmo com as situações para que está indicada tornando mais segura a sua prática para nadadores salvadores e vı́timas.

Resumen

Objetivos: Hasta ahora, no hay información sólida que indique la mejor opción para rescatar del agua a una vı́ctima de ahogamiento que no respira. Nuestros objetivos fueron comparar el resultado de realizar reanimación inmediata en el interior del agua (IWR) o reanimación diferida hasta que la vı́ctima es traı́da a la orilla. Materiales y métodos: Se condujo un análisis retrospectivo de datos de vı́ctimas que no respiran, rescatadas por los salvavidas en el área costera de Rı́o de Janeiro. Los pacientes se codificaron como casos IWR y no-IWR (NIWR) basados en la decisión del salvavidas de realizar o no IWR. Se consideró resultado pobre la presencia de muerte o el desarrollo de daño neurológico grave (SND). Resultados: Se estudiaron 46 pacientes. La mediana de edad fue 17 (9–31) años. 19 pacientes (41%) recibieron IWR y 27 (58.7%) no lo hicieron. La tasa de mortalidad fue menor para los casos de IWR (15.8% versus 85.2%, P < 0.001). Sin embargo, entre los casos IWR sobrevivientes, 6 (31.6%) desarrollaron SND. En análisis multivariable, mayores edades [odds ratio (OR) = 1.12 (95% intervalo de confianza (CI) = 1.01–1.24), P = 0.038] se asociaron con muerte, mientras que IWR [OR = 0.05 (95% CI = 0.01–0.50), P = 0.011] fue protector. Cuando se estableció la muerte o el desarrollo de SND como variable dependiente, la mayor duración del paro cardı́aco (CPA) fue la única variable seleccionada [OR = 1.77 (95% CI = 1.13–2.79), P = 0.013]. Todo paciente con CPA cuya duración sea mayor de 14 minutos tuvo resultado pobre. Conclusiones: El diferir los esfuerzos de resucitación se asoció con peor resultado para las vı́ctimas de ahogamiento que no respiran. En los casos estudiados, IWR se asoció con mejorı́a en la probabilidad de sobrevida. Se desarrolló un algoritmo para sus indicaciones y para evitar riesgos innecesarios tanto para la vı́ctima como para el reanimador.

Introduction

Whenever an apparently non-breathing victim is found in the water, the rescuer is confronted with a difficult choice. Should the rescuer attempt resuscitation procedures in the water or first take the time to bring the victim to shore, and then attempt resuscitation? The hypoxia caused by water aspiration from immersion or submersion results in respiratory arrest [1], [2], [3], [4]. When respiratory arrest is not corrected, it is followed by cardiac arrest within a variable, but short interval, influenced by water temperature [1], [3], [4], [5], [6], [7], [8], victim’s physical condition [1], [3], [8], previous hypoxia [1], [3], [4], [7], [8], emotional state [3], [8], and associated diseases [1], [3], [4].

In drowning [9], hypoxic injury continues after the drowning event if the victim does not resume spontaneous breathing. Thus it follows that the sooner effective resuscitation is initiated, the less hypoxic injury will be incurred, resulting in improved outcome. Generally, resuscitation efforts have been shown to result in a lower death rate if respiratory arrest is corrected prior to the onset of cardiac arrest (0–44% versus 33–93%) [1], [3], [4]. In the water, cardiac compression is ineffective and pulse checks are unreliable [1], [2]. Attempt to ventilate a non-breathing drowning victim in deep water using a rescue board (a surfboard designed for water rescue) was first demonstrated in Australia, by Surf Life Saving New Zealand in 1975 [2]. This procedure was designated in-water resuscitation (IWR). In 1978, during a World Lifesaving-Medical Conference held in California, there was expert consensus that artificial ventilation with the aid of a flotation device should be employed whenever a delay in removing a non-breathing victim from the water could be anticipated [2]. No successful IWR had been reported until 1981 [2]. Although several lifesaving organizations worldwide have been teaching IWR, this recommendation has, so far, been supported by weak scientific evidence [1], [2].

It can be hypothesized that if a rescuer who recovers a non-breathing drowning victim offshore immediately initiates in-water resuscitation by providing ventilation, survivability and outcome for the victim would improve. The objective of the present study was to assess the value of attempting IWR versus delaying resuscitation maneuvers until the drowning victim is rescued to the shore or pool deck. With these data in perspective, we sought to identify variables associated with a poor outcome to refine the indications for performing IWR.

Section snippets

Setting

The coastal area of Rio de Janeiro is 90 km in length and falls under the authority of the Rio de Janeiro Rescue Service. Data collection was restricted to 55 km of coastline. In the studied area, beach attendance is sometimes estimated at 1.4 million persons during a single day. Seawater is warm throughout the year with an average temperature of 20 °C (68 °F) that encourages year-round beach use.

Lifeguard and medical assistance

Lifeguards are responsible for the initial evaluation and immediate resuscitation measures, including

Results

Out of 29,972 rescues made by lifeguards, 469 (1.6%) cases involved a drowning requiring medical assistance and referral to DRC. Of these cases, 86 were reported to be found unconscious and non-breathing in the water. Twenty-eight patients were excluded for missing essential data: estimated CPA time (n=14), outcome measures (n=9), and both (n=5). Twelve patients were excluded because the lifeguard(s) made no resuscitation attempt. Thirty-nine (97.5%) excluded patients died. There were no

Discussion

This study demonstrates, for the first time, that IWR may result in a significant outcome improvement for severe drowning victims. It further confirms that estimated CPA duration is a crucial factor to be taken into account when deciding to start any resuscitation efforts either in-water or not. Early intervention in the water can be expected to reduce death and SND rates by saving precious time during the rescue.

Patients receiving IWR had lower scene and in-hospital mortality rates than those

Conclusions

In retrospect, increasing attention must be given to the pre-hospital rescue of drowning victims because of the potential to save lives in this setting. IWR may be a promising intervention. Although IWR cases had a lower death rate and were more prone to have a favorable recovery, the possibility of resuscitating a person who subsequently develops persistent SND is worrisome. Higher CPA duration was independently associated with poor outcome; however further research is needed to guide the

Acknowledgements

We are indebted to Dr. Linda Quan, Dr. James Orlowsky and Chief B. Chris Brewster (ret.) for reviewing this manuscript critically. Dr. David Szpilman wishes to acknowledge the generous assistance of the staffs from the DRC-Fire Department of Rio de Janeiro, Hospital Municipal Miguel Couto, and Hospital Municipal Lourenço Jorge.

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