Applied Evidence
Keeping older patients healthy and safe as they travel
For older patients, the trip of a lifetime can be fraught with health hazards. There’s much you can do to keep them harm free.
As of 2010, the AAP acknowledges that training may be beneficial for children in this age group, but cautions that not all children will be ready for swimming by this age.12 Infant water safety programs for children under the age of 1 are not recommended because evidence of benefit is lacking.12
Evidence is growing to support teaching basic water survival skills in low- to middle-income countries where water sources are abundant, particularly in Southeast Asia. Specifically, the SwimSafe survival swimming program has yielded impressive results in Bangladesh.15 This program targets children starting at age 5, and involves 20 lessons teaching basic water survival and rescue skills.
Results have shown a 93% reduction in drowning rates for children enrolled in the program, compared with those not enrolled.15 Subsequent analyses have proposed that swimming lessons for children in these parts of the world would be as cost effective as current attempts to prevent diarrheal and respiratory diseases in the same areas.16
Additional preventive measures that are effective in the United States include 4-sided pool fencing, use of personal flotation devices, and bystander cardiopulmonary
resuscitation (CPR).2,5,17
On-scene evaluation and treatment
Drowning victims can appear mottled and have minimal or no peripheral pulses despite a heartbeat. Rescuers may assume the victim is dead when, in fact, there is cardiac function. Because initial assessment in this situation is difficult, CPR should begin, if possible, the moment the victim is out of the water. Successful on-scene resuscitation is the surest predictor of survival.9,18 In fact, delay of CPR until the arrival of emergency personnel lessens the likelihood of survival.19
CPR applied to drowning. For cardiogenic cardiac arrest, chest compressions alone may be better than compressions with rescue breathing. For victims of drowning, though, coordinated compressions and rescue breathing are recommended.20 The
2010 revision of the American Heart Association Guidelines for CPR and Emergency Cardiovascular Care emphasize “compression first” for CPR in cases of cardiogenic cardiac arrest, but continue to support the traditional Airway-Breathing-Chest Compressions sequence for drowning victims in its Special Situations section.21
Ventricular fibrillation (VF) is rare after submersion injury. An external defibrillator should be used when available, but it is unlikely to play a significant role in initial resuscitation.9
Don’t attempt to remove water from the victim’s mouth before resuscitation. The volume of fluid in the oral cavity is usually insignificant, and trying to remove it by abdominal thrusts or Heimlich maneuver will delay CPR and may injure the patient.21
Cervical spine injury is uncommon in drowning episodes, making cervical spine immobilization unnecessary unless the mechanism of injury is known or if there are clinical signs suggesting such injury. Needless cervical spine immobilization can interfere with adequate ventilation.22,23 However, concern for head or cervical spine injury is warranted when recovering an unconscious victim from shallow water, where such injuries are more likely to result from falling or diving into the water.24
Administer oxygen supplementation when available to all spontaneously breathing individuals. Individuals who respond well to initial resuscitation and who don’t require intubation tend to have a very good prognosis overall.25
Total time of submersion and the temperature of the water have bearing on the likelihood of survival. Only in rare cases have victims survived submersion lasting longer than 30 minutes. Ten minutes generally is considered the “point of no return.”9,26 This is consistent with data suggesting 10 minutes of hypoxic insult causes irreversible neurologic damage, with each additional minute rapidly leading to coma.20 However, to complicate matters, unlike cardiac arrest victims, drowning victims can lose cerebral blood flow slowly after respiratory impairment, which makes duration of submersion a potentially unreliable predictor of neurologic outcome.20,26
Does hypothermia have a protective effect? Hypothermia can occur in water 85°F (30°C) or cooler.10 It has been hypothesized that resuscitation can be achieved after longer periods of submersion in cold water. However, the considerable debate on this topic has been based on little more than case reports.
For hypothermia to have a protective effect on neurologic function, cooling must take place rapidly and, ideally, before any hypoxic insult. The water would have to be exceptionally cold, likely less than 50°F (10°C).27 The greater surface-to-volume ratio in children enables more rapid cooling and quicker onset of hypothermia, which may explain why they seem to have better neurologic outcomes than adults after prolonged submersion.28