The Australian and New Zealand Committee on Resuscitation (ANZCOR) makes the following recommendations in summary for managing those who are drowning:
1. If the person is not out of the water, only attempt a rescue them if it is safe to do so; rescue from land using lifebuoys or rope when in confined bodies of water, or from a watercraft in large bodies of water is the safest method.
2. All unresponsive drowning persons out of the water should be assessed on their back. Start cardiopulmonary resuscitation (CPR). Start cardiopulmonary resuscitation (CPR). Start cardiopulmonary resuscitation (CPR) if the person is not breathing normally, start cardiopulmonary resuscitation (CPR).
Resuscitation should not be delayed while waiting for oxygen equipment or an automatic external defibrillator (AED) to arrive.
3. If the airway is obviously obstructed, promptly roll the person onto their side to allow any foreign material to drain using gravity. Do this with a minimal interruption to CPR.
4. Do not clear the upper airway of froth that may re-accumulate during resuscitation.
5. Rescue breaths or ventilation via bagging should be administered as part of CPR.
6. All persons involved in a drowning incident require medical assessment even if seemingly minor or they appear to have recovered.
7. Defibrillation on a wet surface, for example, poolside, is not dangerous.
The WHO definition of drowning is: “Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid; outcomes are classified as death, morbidity and no morbidity”.
In layman’s terms, drowning is the process of being unable to breathe oxygen due to liquid entering the lungs. The outcome of drowning is classified as either fatal or nonfatal drowning. Other terms such as near-drowning, delayed, wet, dry, salt/fresh water, active, passive/silent, and secondary drowning have previously been used to describe incidents. These terms are inaccurate and should not be used. They either describe medical conditions that do not exist or, more importantly, do not alter the initial management of drowning by rescuers.
Early rescue and resuscitation by trained first responders offer the person the best chance of survival. As some drowning persons may still be in the water, additional safety measures are required to avoid rescuers getting into difficulty while attempting the rescue. The most important consequence of drowning is interrupting the brain’s oxygen supply. For this reason, prompt initiation of CPR, including rescue breathing, is important if the person is unresponsive and not breathing normally.
The management of drowning is summarised in the Drowning Chain of Survival. Laurie Lawrence is the loudest advocate for preventing drowning deaths in Australia. His water safety campaign aimed directly at young children learning to swim is called Stay alive- DO THE FIVE!
With drowning an ever-present risk at beaches, rivers, lakes, pools, bathtubs and even buckets for infants, first aiders, first responders, and health professionals play a critical role in drowning prevention. The World Health Organization has identified ten evidence-based interventions and strategies that set out the measures that need to be employed to address the drowning problem at the community, regional, state, or national level. Pool fencing has been shown to significantly reduce the risk of drowning in children. The International Task Force on Open Water Drowning Prevention has produced a series of messages to keep yourself and others safe in, on, or around water.
Keep Yourself Safe Keep Others Safe
- Learn swimming and water safety survival skills
- Help and encourage others, especially children, to learn swimming and water safety survival skills
- Always swim with others where possible, and if solo, swim in areas with lifeguards on patrol
- Obey all safety signs and warning flags
- Never go in the water after drinking alcohol
- Always provide close and constant attention to children you are supervising in or near water
- Know-how and when to use lifejackets, especially with children and weak swimmers
- Swim in areas with lifeguards or appoint a pool guardian in backyard pools
- Learn first aid and CPR
- Know the water and weather conditions before getting in the water
- Learn safe ways of rescuing others without putting yourself in danger
- Always enter shallow and unknown water feet first
- Obey all safety signs and warning flags. They were installed for a reason.
Removal From The Water
Remove the person from the water as soon as possible but do not endanger your safety. Throw a rope or something that floats; a life-ring, lifejacket, buoyant cool box lid, bodyboard, pool noodle, or inflated ball to provide buoyancy to the person and interrupt the drowning process. Call for help; plan and effect a safe rescue. Rescue from land or craft is the safest option; only enter the water with some form of flotation. If it is not safe to enter the water, wait for rescue services to arrive.
Assessment Of The Responsive Person
In minor incidents, removal from the water is often followed by coughing and the return of normal breathing. Although the incidence of post-drowning complications resulting in death is rare, these people still require health professional assessment, discharge advice, and in some cases, observation before they can be released. If the person has required treatment, even if they appear fully recovered, send for an ambulance.
Assessment Of The Unresponsive Person
In more serious incidents, assess the person on the back with their head and the body at the same level, rather than in a head-down position. This decreases the likelihood of regurgitation and vomiting and increases survival. The person should not be routinely rolled onto the side to assess airway and breathing.
Rescue Breaths
ANCOR recommends rescuers perform CPR with rescue breaths for those who are unresponsive and not breathing normally defer to DRSABCD protocols. This should continue until ambulance or rescue personnel take over.
Positioning Of Drowned Person For Assessment
Assessing the person’s airway without turning onto the side; leaving the person on their back or in the position in which they have been found has the advantage of taking less time to perform CPR. The exception would be when the airway is obviously obstructed by fluid or particulate matter (sand, debris, vomit). The person should be promptly rolled onto the side to clear the airway in this instance. The mouth should be opened and turned slightly downwards to allow any foreign material to drain using gravity.
Vomiting And Regurgitation
Vomiting and regurgitation often occur during the resuscitation of a drowned person. If the person has been rolled to the side to clear the airway, then reassess their condition. If breathing commences, the person can be left on the side with an appropriate head-tilt. If not breathing normally, the person should be promptly rolled onto their back and resuscitation recommenced as appropriate. Avoid delays or interruptions to CPR. Do not empty a distended (swollen) stomach by applying external pressure. During resuscitation, do not attempt to expel or drain frothy fluid that may re-accumulate in the upper airway.
Post-Resuscitation Care
People who have been rescued and resuscitated require close monitoring in case they deteriorate. This can occur in the minutes or hours following recovery due to persisting lung damage and injury to the heart from low oxygen levels. Send for an ambulance for anyone involved in a drowning incident, even if they seem okay or have recovered.
Other Considerations In Drowning
- Chest compression-only CPR
The primary cause of cardiac arrest in drowning is a lack of oxygen. Chest compression-only CPR circulates oxygen-poor blood and fails to address the person’s need for immediate ventilation. It is strongly discouraged in a drowned person. It should only be used temporarily if the rescuer is unable or unwilling to perform rescue breathing before the arrival of a barrier device, face mask, or bag-mask device or a person willing and able to perform rescue breathing.
Use Of The AED
During drowning, prompt initiation of rescue breaths and starting CPR are very important. Do not delay starting CPR while waiting for an AED to arrive. The AED should be attached as soon as available, and the prompts followed. Dry the person’s chest if feasible before applying the pads. Although the cardiac rhythm following drowning is usually non-shockable, the AED may be lifesaving in the small number of those drowned who have a shockable cardiac rhythm.
Defibrillation on a wet surface, for example, poolside, is not dangerous.
Oxygen Therapy
In the unresponsive person with abnormal breathing, oxygen should be used if available by mouth-to-mask, bag-mask, or positive pressure delivery system if the appropriate equipment and trained personnel with current training and certification are available. However, CPR should not be delayed while waiting for oxygen equipment to arrive.
Supplemental oxygen should be used in accordance with ANZCOR Guideline 9.2.10. The use of supplemental oxygen in drowning includes if the person has cyanosis (blue colouration of skin), breathing, or has been successfully resuscitated irrespective of their oxygen saturation level or whether pulse oximetry is available. Pulse oximeters may be unreliable if the person is wet or cold, so continue to administer oxygen until the ambulance arrives.
Medical Conditions Leading To Sudden Incapacitation In The Water
Not all water-related deaths are due primarily to drowning. Sudden incapacitation leading to swim failure, unconsciousness, and subsequent water in the airway can occur due to heart attacks, cardiac rhythm disturbances, seizures, hyperventilation, drugs and alcohol, dementia, frailty, decompression illness in scuba divers and other conditions causing loss of consciousness, e.g., low blood glucose levels in a person with diabetes. These conditions should be suspected incompetent swimmers found drowned unexpectedly.
Spinal Injuries Occurring In The Water
Spinal injury occurring with drowning is rare but should be suspected if the person dived into shallow water, is found in an area of dumping surf, rocks, or after an incident involving a boat or other aquatic craft. Remove the person from the water while minimising movement of the spine in any direction by manual in-line immobilisation, noting that speed of rescue and airway management takes priority over a possible spinal injury. Therefore, an unresponsive person who is not breathing normally should be removed from the water immediately by whatever means possible.
Hypothermia In Drowning Victims
There is no evidence that drowning in colder water has an increased survival rate than those in warmer water, and the temperature of the water should not alter the initial actions of rescuers. There are reports of people who had normal oxygen levels before they became hypothermic and were rescued from icy waters, making a full recovery even after extended periods of cardiac arrest. However, time underwater (submersion time) is the only variable that has been shown to affect survival rates. Hypothermia in Australia and New Zealand is more likely due to prolonged time in the water and ongoing cooling during resuscitation in a wet, open environment. If the person is unresponsive and not breathing, CPR should continue until an ambulance or rescue personnel take over.
In-Water Resuscitation
Remove the person from the water as soon as possible. Only deliver in water resuscitation if trained to do so, and immediate removal from the water is delayed or impossible. Rescue breaths in deep water requires a highly trained rescuer and a flotation aid. Chest compressions are ineffective in water and should never be attempted.
