Episode 4 - Patch - Drowning

Episode Notes: Drowning

In this "Patch" episode, we tackle one of the most misunderstood areas of resuscitation: drowning. We’re moving away from the cardiac-centric "CAB" model and returning to the physiological roots of the drowning process. Using research from multiple sources we break down why your first 60 seconds on scene dictate the patient’s neurological outcome.

The Big Terminology Scrub

• Drowning is a Process, Not an Outcome: Stop using the term "near-drowning." A patient either drowned and survived (with or without morbidity) or they drowned and died.

• The Myth of "Dry/Secondary Drowning": There is no clinical evidence for "phantom water" causing death days later. If the patient is asymptomatic after the initial event, they are safe.

• The Dinner Table Rule: If a patient's coughing and sputtering lasts longer than what you’d expect from "water going down the wrong pipe" at dinner, they need an ER.

• The Spillman Metric: If a patient is alert and has clear lung sounds on auscultation, they have a near 100% survival rate. Any added rales or crackles require immediate transport.

Physiology Refresh

• Brain Problem, Lung Complication: Drowning is a hypoxic event. The heart stops because it ran out of oxygen, not because of a primary cardiac defect.

• Surfactant Washout: Aspiration causes pulmonary surfactant to foam like soap in a washing machine. This creates "stiff lungs" that are incredibly difficult to ventilate.

• The Stomach as a Cold Sink: 90% of victims swallow massive amounts of water. This distends the stomach, splints the diaphragm, and continues to cool the patient internally.

The Resuscitation Algorithm (ABC over CAB)

1. Horizontal Extrication: Keep the patient flat. Vertical extrication removes hydrostatic pressure and causes immediate cardiovascular collapse.

2. 5 Initial Rescue Breaths: Do not start with compressions. Deliver 5 breaths to overwhelm dead space and recruit collapsed alveoli.

3. Ignore the Foam: Do not waste time suctioning pulmonary edema foam. Use positive pressure (BVM) to push it back down.

4. Early Intubation: Supraglottic airways (iGels/Kings) often fail due to high inspiratory pressures. Secure the airway early with a cuffed ET tube.

5. Decompress: Use an NG/OG tube early to remove water from the stomach, improving ventilatory compliance and rewarming efficacy.

6. C-Spine: Statistically, <0.5% of drowning patients have spinal injuries. Do not let a collar delay the airway unless there is a clear traumatic mechanism.

Operational Timelines (Rescue vs. Recovery)

• The 25–30 Minute Rule: Submersion times over 30 minutes are almost universally fatal in temperate water.

• The 90-Minute Exception: Extended timelines are only considered for small/young patients in "icy" water (<6°C) due to the mammalian diving reflex and selective brain cooling.

• Start the Clock: For operational safety, the timer starts when the first rescuer arrives on scene, not at the estimated time of submersion.

References & Further Reading

• A proposed decision-making guide for the search, rescue and resuscitation of submersion (head under) victims based on expert opinion (LINK)

• Drowning resuscitation requires another state of mind (LINK)
• 2024 American Heart Association and American Academy of Pediatrics Focused Update on Special Circumstances: Resuscitation Following Drowning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care (LINK)

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