New Rescuer Guidelines Tackle Rise of Drowning Deaths in U.S.

Mouth-to-mouth CPR with chest compressions are still the priority when rescuing victims of drowning, according to a focused update of American resuscitation and emergency cardiovascular guidelines.

The American Heart Association (AHA) and American Academy of Pediatrics (AAP) released a more codified and elaborate list of recommendations that replaces existing drowning guidelines from 2020 and years earlier.

Trained rescuers and laypeople alike are now formally advised that:

• Anyone removed from the water without signs of normal breathing or consciousness should be presumed to be in cardiac arrest. Provide CPR — with rescue breaths and chest compressions — to all individuals in cardiac arrest following drowning after removal from the water. (Class I recommendation)
• If a person is untrained, unwilling, or unable to give breaths, they can provide chest compressions only until help arrives. (Class IIa)
• In both adults and children, automated external defibrillator (AED) use is reasonable in cardiac arrest even though shockable rhythms occur less commonly in the drowning process. (Class IIa)
• Importantly, CPR should not be delayed to obtain or apply an AED on drowned people. (Class III)
• Trained rescuers may find it reasonable to perform in-water rescue breathing on unresponsive adults and children only if it doesn’t compromise their own safety. (Class IIb)
• Supplemental oxygen should be provided by trained rescuers to all people with cardiac arrest after drowning. (Class I)

“CPR for cardiac arrest due to drowning must focus on restoring breathing as well as restoring blood circulation,” said writing group co-chair Cameron Dezfulian, MD, critical care specialist of Baylor College of Medicine in Houston, in a joint press release from AHA and AAP.

The present AHA-AAP drowning recommendations were published in two parts: a general publication addressing adult and pediatric victims in Circulation, and a separate paper specific to the resuscitation of children in Pediatrics.

Dezfulian and colleagues based their recommendations in part on recent systematic reviews from the International Liaison Committee on Resuscitation (ILCOR).

“These updated guidelines are based on the latest available evidence and are designed to inform trained rescuers and the public how to proceed in resuscitating people who have drowned. Drowning can be fatal. Our recommendations maximize balancing the need for rapid rescue and resuscitation, while prioritizing rescuer safety,” Dezfulian said.

In most cases, cardiac arrest following drowning progresses from initial respiratory arrest due to submersion-related hypoxia. Less commonly, the drowning event may have occurred after a primary cardiac event.

“[T]hus, it can be challenging to distinguish respiratory arrest from cardiac arrest because pulses are difficult to accurately palpate within the recommended 10-second window. Therefore, resuscitation from cardiac arrest attributable to this specific circumstance must focus on restoring breathing as much as it does circulation,” the writing group reasoned.

According to the CDC, drowning deaths are on the rise in the U.S. after decades of decline. Over 4,500 people died due to drowning each year from 2020-2022, 500 more per year compared to 2019. Drowning is the top killer of children age 1-4 years old in the nation; most infants drown in bathtubs, and the majority of preschool-aged children drown in swimming pools.

AHA and AAP say it is reasonable to implement public access to defibrillators in aquatic environments pending cost-effectiveness data (Class IIa recommendation).

Meanwhile, the guideline writing group acknowledged that many questions in drowning resuscitation remain unanswered. The ILCOR reports had identified few studies with sufficient rigor to inform best practices, and topics such as extracorporeal CPR and the necessity of drying the victim’s chest before applying an AED are among the important knowledge gaps.

“While we work on a daily basis to lower risks of drowning through education and community outreach on drowning prevention, we still need emergency preparedness training that can be used in tragic circumstances if a drowning occurs,” said writing group co-chair Tracy McCallin, MD, of Rainbow Babies and Children’s Hospital in Cleveland, in a statement.