The American Heart Association and the American Academy of Pediatrics have revised their guidelines for untrained bystanders and trained rescuers who need to perform resuscitation on both adults and children who have experienced drowning incidents.
The newly updated guidance reinforces the importance of carrying out cardiopulmonary resuscitation (CPR) along with rescue breaths as the initial action when responding to cardiac arrest due to drowning. This focused update comes from the Special Circumstances Guidelines developed by both organizations. While they have previously collaborated on neonatal guidelines, this marks their first joint initiative regarding resuscitation post-drowning. The updated recommendations were published today in the leading peer-reviewed journals of each organization, Circulation and Pediatrics. The Pediatrics article emphasizes child resuscitation after drowning and cites pediatric-related studies, whereas the Circulation article encompasses resuscitation for both adults and children.
Globally, drowning ranks as the third leading cause of death due to unintentional injury, with the World Health Organization estimating around 236,000 annual drowning fatalities. In the U.S., drowning is the leading cause of death for children aged 1-4 years, according to the CDC.
There are significant disparities in access to swimming lessons and other preventive measures, leading to inequalities; among individuals aged 17 and younger, drowning rates are notably higher among Black and American Indian or Alaska Native children.
“This focused update on drowning provides the latest evidence-based recommendations for resuscitating someone who has drowned, offering practical advice for healthcare practitioners, rescuers, caregivers, and families,” stated writing group Co-Chair Tracy E. McCallin, M.D., FAAP, associate professor of pediatrics in pediatric emergency medicine at Rainbow Babies and Children’s Hospital, Cleveland. “While we strive daily to reduce drowning risks through education and community initiatives, it is crucial to have emergency preparedness training available for those unfortunate events when drowning happens.”
The updated guidelines include:
- Individuals taken from the water without normal breathing or awareness should be considered in cardiac arrest.
- CPR, including rescue breaths alongside chest compressions, should be initiated immediately. Research indicates that those suffering cardiac arrest from non-cardiac causes, such as drowning, have improved survival rates when CPR includes rescue breaths rather than solely hands-only CPR, which is composed of calling emergency services and performing compressions.
Drowning typically escalates rapidly from respiratory arrest (difficulty breathing) to cardiac arrest, at which point the heart ceases to function properly, and blood circulation diminishes, leading to a lack of oxygen supply to the body.
“When performing CPR on someone who has drowned, our focus should be on restoring their ability to breathe, as well as reviving blood circulation,” emphasized writing group Co-Chair Cameron Dezfulian, M.D., FAHA, FAAP, senior faculty in pediatrics and critical care at Baylor College of Medicine, Houston.
“Cardiac arrest following drowning is typically caused by severe low oxygen levels in the blood,” Dezfulian added. “This is different from instances of sudden cardiac arrest from heart-related issues, where the person usually collapses with oxygen-rich blood.”
The updated advice for untrained rescuers and the public is:
- Perform CPR with both breaths and compressions for anyone in cardiac arrest after drowning. If a rescuer is untrained, unwilling, or unable to provide breaths, they can do chest compressions alone until professional help arrives.
- Only trained rescuers should administer in-water rescue breathing if it does not endanger their own safety. Trained individuals should also provide supplemental oxygen if accessible.
- Beginning CPR as early as possible is crucial since early action by lay responders significantly enhances outcomes following drowning.
- The guidelines suggest placing automated external defibrillators (AEDs) in public locations where swimming activities occur, such as pools and beaches. These devices can be used once the individual is out of the water but should not delay CPR initiation. If available, the AED should be connected to the patient to check for shockable rhythms while CPR is ongoing. Although most drowning-related cardiac arrests do not present with shockable rhythms, quick defibrillation following a primary cardiac event, such as a heart attack in water, leads to better outcomes. AEDs are safe and practical to use in water-based settings.
- All individuals requiring any form of resuscitation after drowning, including those needing only rescue breaths, should be taken to a hospital for further evaluation, monitoring, and treatment.
Along with the drowning resuscitation recommendations, the updated guidelines emphasize the Drowning Chain of Survival, which outlines the necessary steps to improve survival chances: prevention, recognition, and safe rescue.
Prevention
It is believed that over 90% of all drownings can be avoided. Research indicates that most infants drown in bathtubs, while many preschool-aged children drown in swimming pools. The American Heart Association and the American Academy of Pediatrics emphasize the importance of being aware of water safety and practicing it. A comprehensive review of preventive measures is beyond the scope of this guideline, but it is addressed in the American Academy of Pediatrics’ 2021 technical report on the Prevention of Drowning, as well as guidelines from the World Health Organization and the Wilderness Medical Society.
Recognition
Identifying someone in distress due to drowning can be challenging, as they may not be able to communicate or signal for help. Drowning incidents occur swiftly. Those in distress will quickly go under, lose consciousness, and may not be visible to anyone who is not looking for them.
Safe Rescue and Removal
The updated guidelines recommend that only properly trained rescuers, such as lifeguards, swimming instructors, or first responders, should provide in-water rescue breathing to an unresponsive individual who has drowned, provided it does not endanger their safety. Previous research has shown that this practice yields better survival results. An unconscious drowning victim, likely in cardiac arrest, should be taken out of the water while keeping them in a nearly horizontal position, ensuring their head stays elevated to maintain an open airway. If the individual is conscious, a vertical position may be safer to minimize the risk of vomiting.
In conclusion, “These updated guidelines are founded on the most current evidence available and are aimed at guiding trained rescuers and the public on how to effectively resuscitate individuals who have drowned. Drowning can lead to fatal outcomes. Our recommendations emphasize the delicate balance between the urgent need for swift rescue and resuscitation, while ensuring the safety of the rescuer,” stated Dezfulian.
The American Heart Association encourages everyone to participate in CPR training programs available through its online resources or local community centers. CPR education is provided for healthcare professionals, first responders, individuals, schools, and communities. Effective rescue breathing requires hands-on practice utilizing mannequins or other simulation methods.
This joint focused update was authored by a volunteer writing group representing the American Heart Association and the American Academy of Pediatrics. These updates to the current clinical guidelines were developed with insights from experts in the fields of drowning prevention, pediatrics, adult and pediatric critical care, anesthesiology, emergency medicine, EMS, and related areas. They are based on seven systematic reviews conducted by the International Liaison Committee on Resuscitation Basic Life Support Task Force, forming the basis for the revised treatment recommendations and best practice statements. This updated guideline supersedes the American Heart Association’s previous drowning recommendations issued in 2020 and complements the American Academy of Pediatrics’ 2021 technical report on the Prevention of Drowning and the associated 2019 policy statement. All other guidelines and algorithms published in the 2020 American Heart Association Guidelines for CPR and Emergency Cardiovascular Care remain the official clinical standards for resuscitation, with the exception of drowning-specific scenarios.
