To the Editor:
I read with interest the update by Schmidt et al
1
to the original Wilderness Medical Society practice guidelines2
for treatment and prevention of drowning. In the guidelines, based on extensive analysis of the literature on the subject, useful indications are given on the modalities and effectiveness of rescue interventions.I note that in the literature there are no reports of a possible modality of intervention easily achievable in children. I would suggest including this, based on a personal experience, even if limited to a single case.
Case Report
A child was found in a seawater pool, floating motionless, upper limbs open laterally, face up, open mouth at the water’s surface, and eyes open with a vague appearance.
He was promptly removed from the water and found to be atonic, unconscious, and apneic (pulses were not checked at that moment). He was immediately raised upside down by the ankles and held that way. He instantly emitted water, which ceased after a few seconds. The child (4.5 y, weight 19 kg) recovered promptly: he began to breathe, although dyspneic and coughing for several seconds. There was no vomit. Still atonic, but with a regular heartbeat, he was laid on a camp bed and regained consciousness, although he was hyporesponsive and slightly confused for several minutes. No other resuscitation maneuvers were necessary. A repetition of the upside-down maneuver, less than 2 min after the first one, did not produce any additional emission.
The child reported no consequences, with normal general and neurological examination.
It is not possible to know how long he was in the water; it is only known that he had been out of sight for several minutes. All available data indicated an accidental fall into the pool. It was confirmed that he did not have previous pathologies. The temperature of the pool water was estimated to be higher than 20°C (southern Sardinia, Italy, beginning of August; usually around 25°C).
It is estimated that the child emitted much more than 50 mL of water. The puddle on the floor did not allow a correct evaluation of the quantity of water.
Discussion
The maneuver was simple and the effect rapid, although success could have been favored by a short submersion time, with a limited period of hypoxia. However, the condition of the child when he was in water suggests no less than 1 to 2 min of submersion.
Water in the Airways
One objection to the use of the upside-down lifting maneuver could be that the water is rapidly absorbed into the blood so that airways may be empty. This is more likely to occur when some time passes between recovery of the person from the water and transport to a place where it is possible to start rescue maneuvers, during which time the mouth is out of the water. Instead, in the situation reported, the water may have continued to enter the child’s open mouth as he was pulled up.
I believe it is unlikely that the emitted water came partly from the stomach because this would require overcoming the lower esophageal sphincter. Without subdiaphragmatic pressure, this is difficult to initiate. In addition, the issuance of water was so immediate as to suggest a provenance from open routes. Likewise, the effect on the child’s condition was so rapid as to suggest prompt resumption of oxygenation. On the other hand, the amount of water emitted was estimated to be greater than what would have been contained in the airways above the larynx if the child had been in a laryngospasm condition.
In lifting upside down, the abdominal organs apply pressure on the diaphragm and then on the thoracic cage; it should be verified with further studies whether this can also cause a “squeezing” effect, albeit slight, on the lungs, which could facilitate the elimination of water or reduce edema.
Air Insufflation with Water in the Airways
It has been reported that “there is evidence that water does not obstruct ventilation… even when large amounts of water are present within the trachea and bronchi, it is possible to oxygenate patients.”
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However, it is difficult to imagine that air can pass without difficulty through a trachea and bronchi full of water, and in this condition the air pushes the water toward the lungs, impairing gas exchange. In results from experiments on sheep, the introduction of 1 to 3 mL of water per kilogram of body weight is sufficient to cause a “precipitous fall and a prolonged depression of arterial oxygen saturation.”5
In dog experiments, the survival rate was inversely proportional to the quantity of fluid aspirated6
and “the clinical picture is determined predominantly by the amount of water that has been aspirated.”7
There is consensus that introduction of air into the lungs through mouth-to-mouth or other methods of resuscitation leads to effective oxygenation.1
,2
This means that at least part of the alveoli are functioning because they were not previously filled with water or that the air blown can at least partially restore alveolar function. It seems logical that pushing more water into the trachea or bronchi toward the alveoli that have remained healthy can damage them, and pushing more water toward the damaged alveoli can accentuate their dysfunction. Therefore, a rapid elimination of water from the airways should be useful.Safety of The Upside-Down Maneuver
Overturning upside down is a playful maneuver that some parents do with their children. In a child without bone lesions, it is surely safe. However, even in the condition sometimes present in a drowning child, that is, a cervical fracture, a maneuver that is not carried out abruptly probably does not involve greater risks than the other movements the rescue involves, considering the weight of the head down carries out a traction that can extend and straighten the column.
Putting a child upside down delays mouth-to-mouth breathing for a few seconds, a delay that is probably irrelevant. It is a nontraumatic operation, aiming to eliminate as much liquid as possible from the airways. The upside-down maneuver could be considered an alternative to the abdominal thrust (Heimlich maneuver),
4
which is not recommended, as clearly expressed in guidelines,1
,2
both for the time it requires and for its roughness and possible adverse effects such as vomiting and gastric acid aspiration; it is certainly much less effective than using the simple force of gravity.Obviously, the upside-down maneuver can be implemented appropriately in relation to the weight and size of the child, which may be greater if more than 1 operator is providing assistance.
References
- Wilderness Medical Society clinical practice guidelines for the treatment and prevention of drowning: 2019 update.Wilderness Environ Med. 2019; 30: S70-S86
- Wilderness Medical Society clinical practice guidelines for the treatment and prevention of drowning.Wilderness Environ Med. 2016; 27: 236-251
- Drowning.N Engl J Med. 1993; 328: 253-256
- The use of the Heimlich maneuver in near drowning: Institute of Medicine report.J Emerg Med. 1995; 13: 397-405
- Ventilation and circulation after fluid aspiration.J Appl Physiol. 1961; 16: 35-40
- Effects of volume of aspirated fluid during chlorinated freshwater drowning.Anesthesiology. 1966; 27: 662-672
- Drowning.N Engl J Med. 2012; 366: 2102-2110
Article info
Publication history
Published online: June 05, 2020
Accepted:
February 19,
2020
Received:
November 20,
2019
Identification
Copyright
© 2020 Wilderness Medical Society. Published by Elsevier Ltd. All rights reserved.
