European Resuscitation Council Guidelines for Resuscitation ... - CPR

18 de 0ctubre de 2010 www.elsuapdetodos.comJ. Soar et al. / Resuscitation 81 (2010) 1400–1433 1407when reporting outcomes from drowning incidents to improveconsistency in information between studies. 195Pathophysiologywater-slide use, signs of trauma or signs of alcohol intoxication. Ifthe victim is pulseless and apnoeic remove them from the water asquickly as possible (even if a back support device is not available),while attempting to limit neck flexion and extension.The pathophysiology of drowning has been described indetail. 195,196 In brief, after submersion, the victim initially breathholds before developing laryngospasm. During this time the victimfrequently swallows large quantities of water. As breath holding/laryngospasmcontinues, hypoxia and hypercapnia develops.Eventually these reflexes abate and the victim aspirates waterinto their lungs leading to worsening hypoxaemia. Without rescueand restoration of ventilation the victim will become bradycardicbefore sustaining a cardiac arrest. The key feature to note in thepathophysiology of drowning is that cardiac arrest occurs as a consequenceof hypoxia and correction of hypoxaemia is critical toobtaining a return of spontaneous circulation.TreatmentTreatment of a drowning victim involves four distinct but interrelatedphases. These comprise (i) aquatic rescue, (ii) basic lifesupport, (iii) advanced life support, and (iv) post-resuscitation care.Rescue and resuscitation of the drowning victim almost alwaysinvolves a multi-professional team approach. The initial rescuefrom the water is usually undertaken either by bystanders or thosewith a duty to respond such as trained lifeguards or lifeboat operators.Basic life support is often provided by the initial respondersbefore arrival of the emergency medical services. Resuscitationfrequently continues into hospital where, if return of spontaneouscirculation is achieved, transfer to critical care often follows.Drowning incidents vary in their complexity from an incidentinvolving a single victim to one that involves several or multiplevictims. The emergency response will vary according to the numberof victims involved and available resources. If the number ofvictims outweighs the available resources then a system of triageto determine who to prioritise for treatment is likely to be necessary.The remainder of this section will focus on the management ofthe individual drowning victim where there are sufficient resourcesavailable.Basic life supportAquatic rescue and recovery from the water. Always be aware ofpersonal safety and minimize the danger to yourself and the victimat all times. Whenever possible, attempt to save the drowningvictim without entry into the water. Talking to the victim, reachingwith a rescue aid (e.g., stick or clothing), or throwing a ropeor buoyant rescue aid may be effective if the victim is close to dryland. Alternatively, use a boat or other water vehicle to assist withthe rescue. Avoid entry into the water whenever possible. If entryinto the water is essential, take a buoyant rescue aid or flotationdevice. 197 It is safer to enter the water with two rescuers than alone.Never dive head first in the water when attempting a rescue. Youmay lose visual contact with the victim and run the risk of a spinalinjury.Remove all drowning victims from the water by the fastest andsafest means available and resuscitate as quickly as possible. Theincidence of cervical spine injury in drowning victims is very low(approximately 0.5%). 198 Spinal immobilisation can be difficult toperform in the water and can delay removal from the water andadequate resuscitation of the victim. Poorly applied cervical collarscan also cause airway obstruction in unconscious patients. 199 Cervicalspine immobilisation is not indicated unless signs of severeinjury are apparent or the history is consistent with the possibilityof severe injury. 200 These circumstances include a history of diving,Rescue breathing. The first and most important treatment forthe drowning victim is alleviation of hypoxaemia. Prompt initiationof rescue breathing or positive pressure ventilation increasessurvival. 201–204 If possible supplement rescue breaths/ventilationswith oxygen. 205 Give five initial ventilations/rescue breaths as soonas possible.Rescue breathing can be initiated whilst the victim is still in shallowwater provided the safety of the rescuer is not compromised.It is likely to be difficult to pinch the victim’s nose, so mouth-tonoseventilation may be used as an alternative to mouth-to-mouthventilation.If the victim is in deep water, open their airway and if there isno spontaneous breathing start in-water rescue breathing if trainedto do so. In-water resuscitation is possible, 206 but should ideally beperformed with the support of a buoyant rescue aid. 207 Give 10–15rescue breaths over approximately 1 min. 207 If normal breathingdoes not start spontaneously, and the victim is