Resuscitation After Drowning in Children: Updated Guidelines From the AHA and AAP

Drowning accounts for 1 in 14 deaths from unintentional injury worldwide. It is also the leading cause of death from unintentional injury in children younger than 5 years and the second leading cause in children 5 to 14 years of age. In one study of rescues by lifeguards, less than 1% of people rescued from drowning required resuscitation. The American Heart Association (AHA) and American Academy of Pediatrics (AAP) published updated guidelines for resuscitation after drowning.

The drowning chain of survival is a series of actions by trained and untrained rescuers that can reduce mortality from drowning.

One: Prevent Drowning

More than 90% of drownings are estimated to be preventable. Five interventions can prevent drowning in children:

• Four-sided isolation fencing around swimming pools
• Approved life jackets
• Swimming lessons, especially for children and nonswimmers
• Lifeguard supervision
• Close supervision of weak swimmers and nonswimmers in and near water

Two: Recognize Distress and Ensure Emergency Activation

Recognition of distress can be challenging if the drowning person cannot verbalize distress. Survival instincts prioritize breathing over signaling or calling for help. The initial response should include recognizing distress and calling emergency medical services.

Three: Provide Flotation

Lay rescuers should also remain out of the water and throw flotation devices. Approaching a drowning person in the water can create a second victim if the panicking person pushes the rescuer down.

Four: Remove From the Water When Safe

Removing a drowning person is essential, but it can be challenging. Unconscious patients should be removed in a near horizontal position with the head above the body level and airway open. Conscious patients should be removed in a more vertical position to facilitate spontaneous respirations and prevent vomiting.

Five: Provide Basic and Advanced Life Support

Although less than 1% of drowning cases involve cardiac arrest, early life support is critical. Any patient who requires rescue breathing should be transported to the emergency department.

In-water rescue breathing should be considered for nonbreathing unconscious patients when an appropriately trained rescuer is present and safe, appropriate equipment is available, and the distance to shore will cause a prolonged delay in starting shore resuscitation. In drowning cases that lead to respiratory arrest, prolonged time in the water without rescue breathing can lead to cardiac arrest. Mortality after respiratory arrest is less than one-half of that after cardiac arrest. Higher survival rates and favorable neurologic outcomes have been demonstrated with in-water rescue breathing.

Rescue breathing using the first means available—mouth-to-mouth or pocket mask—is recommended because ventilation is essential after drowning. A bag valve mask should be used when available to trained personnel.

Cardiopulmonary resuscitation (CPR) with rescue breathing is recommended for any unconscious nonbreathing child removed from the water because pulses are difficult to find after drowning. Compression-only CPR is not recommended.

Because cerebral oxygenation is limited in cardiac arrest even with effective CPR, supplemental oxygen is recommended whenever it is available.

In contrast to the treatment of general cardiac arrest, CPR appears to be more important than application of an automated external defibrillator (AED). Hypoxia is the immediate consequence of drowning; therefore, optimizing oxygenation (eg, rescue breathing, oxygen) is prioritized over using an AED. Only up to 1 in 8 cardiac arrests after drowning have initial shockable rhythms, so delaying CPR for AED use is more likely to be harmful than beneficial. Less favorable neurologic outcomes have been seen when AEDs were used. After starting CPR, use of an AED is reasonable. Public access defibrillators are generally available, including near aquatic facilities.