Effective initial resuscitative treatment of the drowning and near-drowning victim has an impact on the extent of functional recovery. Since the prediction of outcome is extremely difficult, maximal resuscitation efforts are indicated unless there is obvious physical evidence of death. The correction of hypoxemia and the restoration of adequate tissue perfusion are the first priorities of emergency management. Standard American Heart Association protocols (airway, breathing, circulation (ABC)) for basic life support (BLS) and advanced cardiac life support (ACLS) for the management of cardiopulmonary arrest, including adequate cardiopulmonary resuscitation, are key determinants of survival and neurological preservation. Profound bradycardia, hypotension, hypothermia, or vasoconstriction make determination of absence of pulse difficult and this should not delay cardiopulmonary resuscitation. Rescue breathing and external cardiac compressions should be started in the water if feasible; however, extraction should not be delayed. The intensity and level of care should escalate as facilities and personnel become available. In the presence of hypothermia and in children, conventional time limits to resuscitation are not applicable. The presence of associated injuries ( Table 1) should be considered.

Stabilization of the cervical spine is important, particularly in diving accidents, to minimize the potential for devastating iatrogenic injury. Foreign matter such as gastric contents or debris in the oropharynx should be removed using standard techniques for clearing obstructed airways. The Heimlich maneuver is used only if difficulty in ventilation is encountered, since it delays cardiopulmonary resuscitation and may promote regurgitation, and there are better ways to clear the airway in an unconscious victim. Freshwater is rapidly absorbed from the airways and does not directly interfere with ventilation; drainage of saltwater is debatable. In most situations, neither emergency cardiopulmonary bypass nor extracorporeal membrane oxygenation is possible or practical for the drowning victim, although they may facilitate warming while increasing oxygenation and perfusion.

Table 1 Injuries associated with drowning

Critical care of the near-drowning and drowning victim must address the following complications: acute lung injury, pulmonary edema, acute respiratory distress syndrome, shock (tissue perfusion deficit), hypothermia, cerebral hypoxic sequelae, infection, and associated injuries. Baseline physical and neurological examinations, electrocardiography, and laboratory and radiological studies as indicated will help guide resuscitation and intensive therapy.

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