In-water resuscitation—is it worthwhile?☆
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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Presented at the World Congress on Drowning, Amsterdam, The Netherlands, in 2002.