Drowning is different : ventilations, ventilations, ventilations.

This morning, all around the world, new guidelines for CPR are being published.  As a UK based organisation, Nile Swimmers aligns most closely with the guidelines from the European Resuscitation Council, although we do make slight modifications to make them more appropriate for LMICs.

This five-yearly event is always interesting, and there will be no prizes for guessing which one of  our team woke up at 06:30 to download them and read them!

There are no significant changes to the mechanics of the CPR that we have been teaching for the last five years.  However, there does seem to have been a slight shift in emphasis – and one that we are really pleased to see.

First, some highlights from the Summary of Changes:

Survival after an asphyxia-induced cardiac arrest is rare and survivors usually have severe neurological impairment. During CPR, early effective ventilation of the lungs with supplementary oxygen is essential.

and a little later it also says:

Submersion exceeding 10 min is associated with poor outcome. Bystanders play a critical role in early rescue and resuscitation. Resuscitation strategies for those in respiratory or cardiac arrest continue to prioritise oxygenation and ventilation.

To see statements like this in the Summary of Changes really highlights drowning in the minds of the CPR practitioners.  For too long, drowning was an aside in the guidelines, a small paragraph buried in the body of the main text.

It resonates closely with what we teach – a huge emphasis on good quality ventilations, and getting them in as early as possible.  Imagine how pleased I was to continue scrolling, and to see this diagram!

If that’s not going to make it clear to all CPR provider that drowning is a little bit different, then I don’t know what will.

The analogy that I use often when teaching (particularly in Sudan) is that of a car.

In a heart attack the engine has stalled, but there is still fuel (oxygen) in the tank, and so we need to switch off the car, and turn the key (AED) to start it again.

In drowning, the car has run out of fuel (oxygen), and it doesn’t matter how much we pump the accelerator or turn the key, we have to put fuel in the tank quickly (ventilations) before turning the key has any chance of working.

The part of that sequence that we modify is the use of an AED, and also calling for the emergency services.  This is why on every single course that we teach, we teach CPR.  There is no ambulance service, there are no AEDs, and we know that one of the WHO recommendations for reducing drowning is to train as many bystanders as possible in CPR.  Additionally, we give advice on when it is appropriate to stop CPR attempts, as the UK/European answer of “when the first responder takes over” is not really appropriate.

As America is still asleep, the AHA haven’t yet published their guidelines, we do hope (for our colleagues working in LMICs in South America) that the AHA place a similar emphasis on the CPR for drowning victims.

As I’ve read deeper into the documents, I did have to chuckle at the ERC description of “training in a resource limited setting”

There are many different techniques for teaching ALS and BLS in resource limited settings.  These include simulation, multi-media learning, self-directed learning, limited instruction and self-directed computer-based learning.  Some of these techniques are less expensive and require less instructor resources enabling wider dissemination of ALS and BLS training.

I wonder what they would think about us shaping “manikins” out of the sand & mud of the Nile?  We would certainly consider the use of multi-media or computers to be high resource.  There’s another blog post coming related to this soon.

It is also very pleasing to see the important detail around the problems of foam in the drowning casualty. We feel it is critically important to give people the clearest possible picture of what to expect if they ever do CPR (which in Sudan, given the number of drownings, is quite likely).

In some situations, massive amounts of foam caused by admixing moving air with water are seen coming out of the mouth of the victim. Do not try and attempt to remove the foam as it will keep coming. Continue rescue breaths/ventilation until an ALS provider arrives and is able to intubate the victim.

Regurgitation of stomach contents and swallowed water is common during resuscitation from drowning. If this prevents ventilation completely, turn the victim on their side and remove the regurgitated material using directed suction if possible.

What are your thoughts?  Comment below.