DROWNING - Medicine for Mountaineering and Other Wilderness Activities - page 434

Traumatic injuries, particularly head and neck injuries, should be sought. The head
should be immobilized. Conditions or circumstances consistent with child abuse, seizures,
or a cardiac disorder should be ascertained.
MANAGEMENT OF SURVIVORS
At the Scene
Pressure from the water produces a 32 to 66 percent increase in cardiac output in an
individual immersed in it, particularly if the person is in an upright position. Individuals
removed from the water suddenly lose this pressure, and pooling of blood in the lower ex-
tremities combined with this loss of pressure can result in circulatory collapse. Keeping
individuals horizontal as they are lifted from the water helps prevent this hypotensive phe-
nomenon.
Initial management should focus on assessment of the pulmonary, cardiovascular, and
central nervous systems. Ifthe individual is not breathing spontaneously and does not have
apulse,theairwayshouldbeclearedandCPRbegunimmediately.Anydelayincreasesthe
riskofneurologic damage anddeath. AlthoughCPRprovidedbynonprofessional bystand-
ers yields inconsistent results, early CPR is still recommended.
In studies of hospitalized individuals who have drowned, no emergency room or hos-
pital treatment has been found to be nearly as effective as competent CPR administered at
the scene of the accident. By the time the person has reached a medical facility, the die has
been cast.
Cervical spine injury may be a precipitating factor in drowning, particularly when in-
dividuals dive into the water. Attention to head and neck trauma with appropriate immob-
ilization is essential. Additional fractures or internal injuries can be sought after CPR is
underway.
RecentstudieshavefoundthatchestcompressionsaloneprovidebetterresultsthanCPR
that includes mouth-to-mouth ventilation for individuals who have suffered heart attacks.
However,individualswhohavehadacardiacarrestduetoasphyxia,whichincludespeople
who have drowned, do require ventilation as well as chest compressions.
Mouth-to-mouth ventilation should be performed with the head in a neutral position
(jaw thrust). If airway obstruction by a foreign body is suspected, the Heimlich maneuver
should be implemented. No evidence supports performing the Heimlich maneuver to re-
move water from the airways.
Mouth-to-mouthventilationcanbeattemptedwhilethedrownedindividualisstillinthe
water, but buoyancy problems usually prevent effective chest compressions.
Many people who have drowned are hypothermic as the result of immersion in cold
water. Although hypothermia helps protect the brain from anoxia association with the as-
phyxia of drowning, heat loss should be minimized as soon as effective CPR is underway.
Heat loss through evaporation and convection should be limited by sheltering individuals