Recent discussions
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cindy valencia
bien -
ahmed abbas
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Chamila Jayasekera
With a confirmed cardiac arrest and airways possibly flooded, it may be prudent to give chest compressions first with the hope of circulating whatever the oxygen. With the manikin study showing minimal delay in giving breaths and considering the fact that consistency is maintained across BLS , it may be best to recommend CAB in drowning. -
Mike Janczyszyn
Thank you for this systematic review. I am new to providing public comments. It's nice to see that there is a recommendation for AEDs >1 years of age. In future reviews, I'd be very curious about Joules used to defibrillate; whether they used child modes or shocked with adult doses and whether there was any effect with CPC. I see that this is under your Research Priorities. Not having to purchase pediatric pads would add to the cost-effectiveness and ease of use. Although this would only relate to less than half the population from the studies; <8 y/o. I have some of the same concerns as Shinichiro where there are three articles published by the same people with some of the same timelines. Not sure if that was taken into account with reporting. Just a note, for the last line of knowledge gaps, is it supposed to say AED, or is it supposed to say performing CPR? -
Richard Field
I agree that initial ventilations are likely to be of importance in drowning where the cause is hypoxia and this should be taught to those with a duty to respond (lifeguards/healthcare professionals/rescue personnel). However the big question is how many people are willing to do mouth to mouth ventilations? The last 2 years has especially made people more cautious about risks to responders in resuscitation situations. I feel it likely that most would delay ventilations until a barrier device or facemask is available and therefore time should be spent doing chest compressions first whilst awaiting for equipment. However, in certain situations a rescuer may need to wait for help to get the casualty out of the water in which it would be ideal if they could commence ventilations in this period. Another question would be regardless of which order ABC vs. CAB should the first set of ventilations be more than 2 i.e. 5 or more? The idea being to maximise oxygen delivery during the subsequent cycle of chest compressions; this will depend on if supplemental oxygen is being used, the tidal volume being delivered, the patients FRC and clearance of expired gases amongst other factors. The most important point is whatever oxygen you have managed to get into the patient you need it to get from the alveoli to the organs which is only achieved by minimising no-flow time! My suggestion would be if ventilations can be performed immediately give the 5 with an ABC approach. However if there is a delay in obtaining equipment/unwillingness to start without adjuncts then adopt a CAB approach and stick to the standard compression:ventilation ratio to keep it simple. -
Wess Long
In drowning scenarios, a CAB approach is problematic for lifeguards rescuing an unresponsive swimmer who has not suffered any other sort of a medical event. Emphasis should be placed to provide respirations as early as possible, including in the water if possible. Time is critically important when treating hypoxia from drowning. By not emphasizing immediate & effective breaths, there can be a considerable time lapse from the swimmer's last breath through the time to recognition, rescue, extrication, dry land assessment, and then begin compressions. This time can be further lengthened if an AED is introduced early and begins assessment. Without immediate breaths, this delay only further lengthens the time that the individual is in hypoxia which then decreases their chance of survival. Conversely 5 in-water or immediate respirations out of the water can be provided quickly and effectively prior to further care without significant delay. I firmly believe early and effective respirations interrupt the drowning process and ultimately save lives. -
Tony Bennison
Agreed. It is flawed to expect anyone to differentiate the underlying cause of the arrest in this scenario - it could be cardiac in origin, even in a fit, young individual. -
Jacqueline Abela
When performing chest compresssions only and without airway maneuvers -
Tony Bennison
I am very pleased that this issue is now the subject of a review - long overdue, in my opinion, and I believe the debate should be widened beyond the standard 'drowning = respiratory' model.. For a start, it is flawed to assume that the apnoeic patient pulled from water has 'drowned'.. The underlying cause could very well be cardiac in origin - even in an apparently healthy, young individual. The UK charity Cardiac Risk in the Young advise that the incidence of cardiac pathology is probably under-reported at post-mortem due to assumptions made that drowning is the primary cause, when there could have in fact been an underlying arrhythmia. Especially difficult to detect post-mortem if this was an electrical/metabolic disorder such as Brugadas, as opposed to a structural disorder such as HCM. This was graphically shown in the episode of 'Bondi Rescue' of the young Japanese student dragged from the sea in arrest. He was treated by the lifeguards in accordance with drowning protocols. On admittance to hospital it became apparent he had an underlying dysrhythmia. Second flawed assumption is that blowing expired air (or even via BVM) into the patients mouth results in improved oxygen saturations. This is too simplistic a justification for this approach, on which the science and evidence is - at best - inconclusive. Finally, the debate needs to get away from the respiratory vs cardiac argument and stop extrapolating what we assume from hospital or lab based studies. None of these include the mental and physical stress of extricating this patient in the first place, the practical challenge of trying to quickly and accurately identify normal vs agonal efforts and a pulse, all in difficult circumstances and usually a public place. Opening and maintaining a patent airway in these patients is sometimes impossible, as is trying to deliver effective ventilation without causing reflux.. Chest compressions are simple and straightforward in this situation - airway and breathing are often not - particularly for the non-health care professional. And above all we have to keep in mind that if we want to make these guidelines accessible to everyone, so that any bystander is willing to step forward, they have to be simple and reassuring - complexity is the enemy here and it is ridiculous to expect anyone to differentiate cardiac vs respiratory in this highly stressful, often panicky environment - the rescuer here will mostly be lay people who train infrequently and rarely experience the reality of pre hospital arrest - they need clear, unambiguous instructions. I believe the approach should be good quality chest compressions first and foremost, reassuring the rescuer that if the patient is in cardiac arrest, the compressions will help promote a perfusion pressure until the defib arrives, but if the patient has 'drowned' and is in respiratory arrest with an output, the compressions by themselves will often stimulate the patient to cough, gag, vomit/reflux - actions which in themselves may well restore normal breathing.. Yes of course - the longer the problem continues - oxygen will become more imperative - but it is only EMS with an airway adjunct/BVM/high flow 100% who can influence this - if the patient doesnt survive this event - whether cardiac or respiratory in origin, it could never be shown to be because a bystander had failed to do the 'Kiss of Life'.. Thank you for allowing me to comment and apologies for my long response, done on my phone! Best wishes to all. -
Leonardo Manino
I believe that ABC traditional (more than 50 years ) it's the best approach for drowning all ages patients/casualties . Whit the ABC sequence could reverse a pulmonary arrest with the first ventilations or prevents a Cardiopulmonary arrest depending on the stage the first responder / rescuer start the resuscitation . On the other hand the oxygen (supplementary or expired air ) will be necessary in that cases when the organs are deprived of oxygen due to the etiology of the cardiopulmonary arrest. In fact for all ages my opinion is that the ABC sequence its the best choice. in drowning patients .