Ventilation still needed as part of CPR used in drowning victims

An international consensus statement recently developed addresses how to do cardiopulmonary resuscitation (CPR) in drowning victims to reduce the risk of COVID-19 transmission from victims. The 13-page consensus was published in JAMA Open Network and was developed by experts from 17 countries, including Canada. There are about 500 fatal drownings in Canada annually, with the number of non-fatal drownings (those treated with lifesaving manoeuvres such as CPR and survived) still unknown. Globally, drowning ranks as the third leading cause of unintentional injury deaths and leads to over 350,000 fatalities annually. Estimates place the number of non-fatal injuries at over a million each year, according to Dr. Cody Dunne, coauthor of Resuscitation of Drowned Persons During the COVID-19 Pandemic. He is a PGY-3 resident in emergency medicine at the University of Calgary and member of both the International Lifesaving Federation’s Medical Committee and International Drowning Researchers’ Alliance. “The importance of this is that non-fatal drowning can still result in life-altering impairments in lung function and quality,” he said. Read: Sudden death in athletes reduced three-fold with bystander training Over the past two decades, pre-hospital CPR in general has moved away from ventilation and focused more on compression. But ventilation is still important in drowning victims—as well as in others who have respiratory causes for collapse such as children whose breathing stops due to anaphylaxis or severe asthma. “Drowning has a different mechanism for causing cardiac arrest than other forms of cardiac events. The lungs aren’t getting enough air and that induces the cardiac arrest, as opposed to someone having a heart attack or going into an abnormal rhythm,” Dr. Dunne said. Doing both compression and ventilation are priorities in the CPR algorithm. When COVID-19 appeared, how to do CPR safely became a big issue among rescuers. Early on in the pandemic, the American Heart Association produced revised guidelines incorporating safety measures, as did the Heart and Stroke Association. But they differ from the consensus statement because they don’t recommend ventilation for the vast majority of people, Dr. Dunne told the Medical Post in an interview. The consensus statement was developed through an extensive literature review, multiple consultations, surveys and a consensus process. The result was recommendations in four key areas: prevention and mitigation of the risks of becoming infected; resuscitation of drowned persons during the COVID-19 pandemic; organizational responsibilities; organizations unable to meet the recommended guidelines. Prevention and risk mitigation include factors such as public education around water safety, practicing public health measures such as social distancing and screening, and having appropriate personal protective equipment (PPE) on hand. As for resuscitation, most international and national resuscitation councils recommended against laypeople providing ventilation during CPR because of COVID. But the statement noted “in drowning, the arrest is secondary to hypoxia and reversal is critical for survival. As a result, ventilation is essential; compression-only CPR significantly reduces survival in drowning.” The consensus offers an algorithm for water rescue resuscitation. The first is to avoid mouth-to-mouth ventilation while still in the water. It’s better to get the victim onto a solid surface as quickly as possible. It then suggests calling emergency services, putting on PPE and getting a ventilation device such as a ventilation mask or a mask-bag device. For victims needing ventilation, and no ventilations devices are available, the statement suggests determining if there is a anyone who lives with the victim on site who has CPR training who can be guided through the ventilation process. “This is a risk mitigation step for the rescuer because household members would likely have the same infection status as the victim,” Dr. Dunne said The masks needed for mask-to-mouth ventilation are common equipment in community centres, first aid kits and in kits used by lifeguards, Dr. Dunne said. The masks are also available for the general public with CPR training who might carry them with them. Other factors relating to risk should also be considered, such as the prevalence of community infection, whether mitigation protocols such as facility screening are in place, and the age and health status of the rescuer (are they low risk themselves?). The statement is useful for various niche rescuers, rescue organizations and first aiders, Dr. Dunne said. “I think the message for doctors is that we can act as advocates for these organizations, ” he said. “We should advocate for these smaller organizations or niche responders, like lifeguards, so they’re both protected and have guidance on how to do their job safely while still helping their patients.” Dr. Amer Johri, an associate professor of medicine at Queen’s University said the statement will be helpful in his own work with athletes. He is a cardiologist who sees varsity athletes at the Queen's University Athletics and Recreation Center. Dr. Johri was not involved with the development of the consensus statement. However, he helped develop Canada’s first Guidelines to Cardiovascular Screening of Competitive Athletes and has an interest in CPR-related issues. “We’re concerned about CPR and AED (defibrillation) in athletes who have collapsed and what to do in that situation. There are quite a few athletes who have had COVID19. The virus is still in the community and we do have to consider there is a possibility of transmission of infection to a rescuer. This new guideline points out some very practical measures,” he said. Being cautious about opening up aquatic facilities and using public health such as limiting numbers and screening when needed makes sense. Making sure PPE is available at facilities, training rescuers on its used, and protocols for PPE decontamination and disposal are all worthwhile. He concurred that there has been a move away from mouth-to-mouth in water ventilation.

Ventilation still needed as part of CPR used in drowning victims

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