United States Lifeguard Standards Coalition Evidence Review

Transcription

1 United States Lifeguard Standards Coalition Evidence Review On the following pages, you will find a primary question (and in some cases ancillary questions), reviewed by the United States Lifeguard Standards Coalition (USLSC), the draft consensus recommendation of the USLSC, and the Scientific Review Forms (usually two) that detail the specific evidence upon which the consensus recommendation was based. In most cases, for each question, two independent investigators researched existing evidence, including scientific research and other material, related to the question. Each investigator then completed a Scientific Review Form, listing the evidence and an evidence summary. The level and quality of evidence was rated using a standardized evidence evaluation process. The evidence reviewed included, but was not limited to, the following: a. Population-based studies b. Epidemiological studies c. Case-control studies d. Historic research e. Case studies f. Large observational studies g. Review of past research summaries, and h. Extrapolations from existing data collected for other purposes The scientific reviews were presented to the entire USLSC. Each topic was presented, discussed and critiqued by the assembled experts until consensus was reached. You are invited to comment on this question (as well as the others) and particularly whether you believe that the evidence adequately supports the consensus recommendation. If you are aware of any additional evidence (e.g. scientific research) that was not considered by the Lifeguard Standards Coalition, please list that evidence in your comments. In any comments you choose to make, please be sure to cite the line number, if you are referring to specific wording of the item. Before commenting, please review the document in full. This includes an initial document, which contains the question or questions investigated and the consensus recommendation. This is followed, in most cases, by two Scientific Review Forms, which list the evidence that was considered in arriving at the consensus recommendation. Thank you for your time and consideration in reviewing this question. The deadline for comments is December 12, 2009.

2 US Lifeguard Standards Coalition AIRWAY Question Are there unique aspects of establishing and maintaining the upper airway during the process of resuscitation after drowning? Ancillary Question Are there unique aspects of establishing and maintaining upper airway management for in-water resuscitation? Introduction Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid. Drowning outcomes are classified as death, morbidity, or no morbidity. The drowning process is the continuum that begins when the victim s airway lies below the surface of the liquid, usually water, at which time the victim voluntarily attempts to hold his or her breath. This may be followed by an involuntary period of laryngospasm secondary to the presence of an irritant (ie, not air) in the oropharynx or larynx. This begins a cascade of hypoxia that most often results in the victim actively aspirating liquid and swallowing larger amounts of liquid into the gastrointestinal system. If there is no rescue and/or reverse of this cascade, the hypoxia increases and multisystem failure ensues. If the drowning process is stopped or reversed, the hypoxic changes can be reversed. However, hypoxic changes can continue despite rescue and resuscitation if reoxygenation is impaired. This can occur when there is no effective circulation or if oxygen cannot reach lung tissue because of upper airway obstruction or aspiration damage to the lower airway. Maintaining an open airway to allow oxygen to reach some effective lung tissue, and minimizing the aspiration obstruction of the airway improve resuscitation outcomes. The degree to which airway management problems impacts resuscitation and outcomes after rescue from the drowning process are unclear. It is also unclear if techniques to reduce regurgitation and subsequent aspiration of gastric fluids improve resuscitation outcomes. There are many reports of various techniques for upper airway management in the prehospital setting after rescue from the drowning process, which may imply that upper airway management after rescue from the drowning process is an important issue. Although there has been considerable debate and controversy about the techniques of upper airway management during and after rescue from the drowning process, there is little documentation of the upper airway challenges themselves. Evidence Summary The speed of relieving hypoxia during the drowning process has the greatest influence on outcome, and ensuring that a victim is brought to land should not delay attempts at in-water resuscitation (Orlowski and Spzilman, 2001; Golden et al, 1997.) In a report of 36 near-drownings at Miami Beach from January 1967 through December 1969, submersion victims were treated at the scene with suctioning the oronasopharynx,

3 US Lifeguard Standards Coalition establishing an airway, and assisting or controlling ventilation by personnel of the specially trained Fire Rescue Squad of Miami Beach. Treatment recommendations made based on expert opinion indicated the following: an airway should be established and artificial ventilation begun immediately, postural drainage and oronasal suction should be instituted whenever possible, if the patient is unconscious upon arrival, tracheal intubation should be performed immediately and then a nasogastric tube inserted to aspirate the stomach, but only after a cuffed tracheal tube is in place. This will prevent aspiration of stomach contents (Hasan, Avery, Fabian, and Sackner, 1971). In reports of prehospital care of 162 immersion resuscitation victims in Australia from 1973 to 1983, vomiting and regurgitation occurred in 86% of those who required CPR, in 68% of those who required expired-air resuscitation and in 50% of those with spontaneous respiration; obtaining and maintaining a clear airway was difficult in 54 of the victims (Manolios and Mackie, 1988). According to Pearn (1985), The unconscious (but breathing) victim must be nursed and transported in the coma position, for the airway is particularly likely to be blocked secondarily by regurgitation of large amounts of water and of stomach contents. Often the first sign of successful CPR is a convulsive abdominal diaphragmatic heave with a flood of vomitus or swallowed water. The International Life Saving Federation Medical Committee (1994) issued the following statement: This combination of hypoxia and a full stomach is the cause of the regurgitation that is very familiar to lifeguards and is an almost inevitable accompaniment of near drowning. The victim s position during rescue is a determinant of vomiting during the rescue or transport. More than 80% of resuscitation of drowning process victims results in vomiting (Szpilman, 2002). Szpilman and Handley (2006), consistent with the Basic Life Support Working Group on the ILCOR, recommend the following: The victim should be in as near a true lateral position as possible with the head dependent to allow free drainage of fluids. The position should be stable. Any pressure on the chest that impairs breathing should be avoided. It should be possible to turn the victim onto the side and return to the back easily and safely, having particular regard to the possibility of cervical spinal injury. Good observation of, and access to, the airway should be possible. The position itself should not give rise to any injury to the victim. From January 1995 to December 2000, in a retrospective selected group of waterfront resuscitation drowning victims in Brazil, in-water resuscitation provided the victim a 4.4 times better chance of survival (Szpilman, 2006). In summary, evidence from 9 retrospective observational case series and case review studies with the highest LOE of 3b, and 11 peer review consensus papers (LOE 4), upper airway management is a significant challenge in drowning process resuscitation. Early rescue

4 US Lifeguard Standards Coalition breathing and airway management, including in-water resuscitation, improve outcomes in drowning process resuscitation outcomes when performed by trained rescuers in open-water settings. Both outcome data and expert opinion support the concept that there are unique aspects of establishing and maintaining an upper airway during the drowning process resuscitation, and that early rescue breathing, including in-water resuscitation is safe, effective, and feasible for trained rescuers in open-water settings. It is extrapolated that this would also be a positive factor for drowning process resuscitation outcomes in pool settings. The drowning process creates a unique and challenging problem in upper airway management for victims, rescuers, and those providing resuscitation and medical care. Resolving any upper airway obstruction may be the most important step in reversing the hypoxic cascade, often complicated by regurgitation and vomiting, either spontaneously or as a result of triggers in the rescue, resuscitation, and transportation process. The evidence available suggests: Prevention of unintended immersion, aspiration, and drowning is most important. Most drowning process victims have upper airway management problems. Aspiration leads to acute and chronic complications in medical management of drowning. Reversing aspiration and subsequent hypoxia may have a significant impact on outcome. Early rescue breathing is a priority in reversing the hypoxic cascade and may prevent cardiac arrest. It is safe and effective to provide rescue breathing in shallow water. It may be helpful to provide rescue breathing in deep water if the conditions are safe; a single, trained rescuer is supported by a flotation device; or there are two or more trained rescuers. Reasonable assumptions include the following: Upper airway management is more challenging in the prehospital setting. Preventing aspiration is helpful in improving outcomes and reducing rescuer airway management. The upper airway management in an un-intubated unconscious victim may require the full-time attention of one rescuer. During resuscitation, the drowning process victim may benefit from airway drainage positioning and minimizing patient movements to reduce vomiting, regurgitation, and the consequent aspiration risk. Distractions, such as suspecting a spinal injury when the probability is very low, decreases focus on higher priorities. Consensus Recommendation Airway management awareness and skills should be standard in prehospital and hospital protocols for drowning process rescue and resuscitation in open-water, surf, and pool submersions. In addition, early rescue breathing, including in-water rescue breathing, is recommended as a standard in shallow water in all cases and in deep calm water with trained rescuers with flotation support. In all drowning process resuscitation, upper airway

5 US Lifeguard Standards Coalition management control and early rescue breathing is the highest priority. Standards Airway management awareness and skills must be included in prehospital and hospital protocols for drowning process rescue and resuscitation in open-water, surf, and pool submersions. Prevention of aspiration is beneficial. In basic life support for drowning resuscitation: o Earliest possible airway management and ventilation may be lifesaving in drowning resuscitation. o In-water resuscitation is recommended under the following appropriate circumstances: shallow water, deep calm water, trained rescuer with a flotation aid, or two or more trained rescuers. o Positioning, drainage and airway-clearing skills are needed by all lifeguards and aquatic rescue responders. o Activities that increase the risk of vomiting and regurgitation should be minimized. In advanced life support for drowning resuscitation: o Airway management control and rescue breathing (with assistance as necessary) is the highest priority in drowning resuscitation. o Nasogastric suction may be helpful to reduce regurgitation and may enhance respiratory function. Guidelines: Education of rescuers and resuscitation personnel who may respond to drowning patients should emphasize the challenges of airway management in drowning resuscitation. In-water resuscitation should not be attempted by a single rescuer without flotation support. In this case, the priority should be rescue to shore. Procedures or issues (eg, focusing on spinal injury in situations in which it is not likely) that distract rescuers and resuscitation personnel from the lifesaving attention to airway management should be identified and minimized in drowning resuscitation. For unconscious or recovering victims, or during transport of drowning victims: o The victim should be in as near a true lateral position as possible with the head dependent to allow free drainage of fluids. o The position should be stable. o Any pressure on the chest that impairs breathing should be avoided. o It should be possible to turn the victim onto the side and return to the back easily and safely, having particular regard to the possibility of cervical spinal injury. o Good observation of, and access to, the airway should be possible. o The position itself should not lead to any injury of the victim. Research Needs: The degree of airway management challenge and the impact on outcome is not known. It would be reasonable to create a point or line scale of the degree of difficulty for airway management in drowning resuscitation, such as the following example: Airway Management Difficulty Score 0 = no difficulty

6 US Lifeguard Standards Coalition = manual techniques for one occasion 2 = manual techniques for multiple times at intervals 3 = manual techniques continually 4 = mechanical or structural techniques for <5 minutes 5 = mechanical or structural techniques continually Prospectively designed research on the application of early expired air resuscitation on the drowning hypoxic cascade victim outcomes The impact of in-water resuscitation for the rescuer(s)

7 Unites States Lifeguarding Standard Coalition Scientific Review Form Author: Steve Beerman Question:Resuscitation, First Aid and Eduction #1 Organization Representing: ILS Date Submitted: April 29, 2007 first draft June second draft November 25, 2007 third draft Question and Sub-Questions: Are there unique aspects of establishment and maintaining upper airway management in the drowning process resuscitation? a. For in-water resuscitation, are there unique aspects of establishment and maintaining upper airway management and safe, effective and feasible rescue breathing in the drowning process resuscitation? Introduction/Background: Drowning is the process of experiencing respiratory impairment from submersion/immersion in liquid. Drowning outcomes will be classified as: death, morbidity, and no morbidity. The drowning process is the continuum that begins when the victim s airway lies below the surface of the liquid, usually water, at which time the victim voluntarily attempt to hold his or her breath. Breath-holding may be followed by an involuntary period of laryngospasm secondary to the presence of an irritant (not air) in the oropharynx or larynx. This begins a cascade of hypoxia which most often results in the victim actively aspirating liquid and swallowing larger amounts of liquid into the gastrointestinal system. If there is no rescue and/or reverse of this cascade the hypoxia increases and multisystem failure ensues. If the drowning process is stopped or reversed by removal of the liquid or removal of the victim from the liquid, the hypoxic changes may be reversed. Hypoxic changes can continue despite rescue and resuscitation if the re-oxygenation is impaired. This can occur when there no effective circulation or if there is obstruction of oxygen to the bronchi by upper airway obstruction or to the lower airway by aspiration damage. Maintaining an open airway to allow oxygen to reach some effective lung tissue, and minimizing the aspiration obstruction of that airway have been shown to improve resuscitation outcomes. Orlowski, Spzilman and other experts have proposed that the speed to relieve the hypoxia of the drowning process has the greatest influence on outcome. Golden et al stated that: landing a

8 casualty should never be delayed to enable attempts at in-water resuscitation. The ILS Medical Committee and Szpilman have stated that: The higher death rate resulting from cardiac arrest (33%-93%) versus respiratory arrest alone (0% - 44%) justifies the risk of attempting in-water resuscitation immediately. --- If the resucer cannot provide ventilation at the location where the victim is found, then the rescuer should immediately move to a position of safety. The degree to which airway management problems impacts resuscitation and outcomes after rescue from the drowning process in unclear. It is also unclear if techniques to reduce regurgitation and subsequent aspiration of gastric fluids improves resuscitation outcomes. There are many reports of various techniques for upper airway management in the pre-hospital setting after rescue from the drowning process. This may imply that there is an important issue in the management of the upper airway after rescue from the drowning process. In 1971, Drs Hasan, Avery, Fabian and Sackner reported on a series of 36 near-drowning in humans from Miami Beach during the period January 1967 through December They were focused on clinical features, arterial blood gas and serum electrolyte and Xray imaging observations after submersion. Their patients came to their emergency room by the Fire Rescue Squad of Miami Beach. They stated: in dealing with submersion victims, personnel of this specially trained team suction the oronasopharynx, insert airways and assist or control ventilation,--- at the scene In their treatment recommendations they made the following statements without data support (expert opinion) an airway should be established and artificial ventilation begun immediately, Postural drainage and oronasal suction should be instituted whenever possible, if the patient is unconscious upon arrival, tracheal intubation should be performed immediately and then a nasogastric tube inserted to aspirate the stomach, but only after a cuffed tracheal tube is in place. This will prevent aspiration of stomach contents. Drs. Nicholas Manolios and Ian Mackie reviewed a series of 162 Australian immersion resuscitation reports on pre-hospital care for the period They reported that vomiting and regurgitation in 86% of survivors who required CPR, in 68% of survivors who required expired-air resuscitation and in 50% of survivors with spontaneous respiration. They reported that in 13 patients, vomitus was responsible for the extreme difficulty that was experienced in maintaining a clear airway. Of 100 victims of drowning, who underwent resuscitation without success, the material in the mouth was as follows: clear (20), vomitus (41), copious froth and water (28), loose dentures (8) and sand (3). Difficulty in obtaining and maintaining a clear airway was experienced in 54 victims. Of the 20 victims who initially had only small amounts of saliva present and an otherwise clear airway, 11 victims regurgitated subsequently during the resuscitation procedure. The jaw was clenched in 8 victims initially but produced an airway problem in only 3 of these. In this case series, expired-air resuscitation was preformed in deep water on 14 of the 262 victims. There were 6 survivors, all requiring further resuscitation on the beach and 2 required CPR. In all 14 cases a flotation device in the form of a board, a rescue tube, a buoyant wetsuit or flippers (fins) were used. No data or comment on the airway management issues in this subgroup was made.

9 In 1985 Dr. John Pearn reviewed The Management of Near Drowning in the British Medical Journal (Nov 23, Vol 291). In that paper he outlined the hypoxic march. He stated that, The unconscious (but breathing) victim must be nursed and transported in the coma position, for the airways is particulary likely to be blocked secondarily by regurgitation of large amounts of water and of stomach contents. Often the first sign of successful CPR is a convulsive abdominal diaphragmatic heave with a flood of vomitus or swallowed water. In 1998, the International Life Saving Federation (ILS) Medical Committee produced a statement on the use of abdominal trusts in near drowning. In that evidenced based review, they stated that: This combination of hypoxia and a full stomach is the cause of the regurgitation that is very familiar to lifeguards and is an almost inevitable accompaniment of near drowning. Szpilman reported to the Congress on Drowning (Amsterdam 2002) that the victims position during rescue is a determinant of vomiting during the rescue or transport. Szpilman reports that more than 80% of resuscitation of drowning process victims results in vomiting. Szpilman and Handley, consistent with the Basic Life Support Working Group on the ILCOR, recommend: - The victim should be in as near a true lateral position as possible with the head dependant to allow free drainage of fluids. - The position should be stable. - Any pressure on the chest that impairs breathing should be avoided. - It should be possible to turn the victim onto the side and return to the back easily and safely, having particular regard to the possibility of cervical spine injury. - Good observation of, and access to, the airway should be possible. - The position itself should not give rise to any injury to the victim. Szpilman reported from a retrospective selected (January-1995 to December -2000) group of waterfront drowning process victim rescues that reported to the Drowning Resuscitation Center, Hospital and ICU in a Brazil community. In-water resuscitation provides the victim a 4.4 times better chance of survival. Therefore they recommend that lifeguards should be fully trained in this difficult procedure, though it is not always possible. There has been considerable debate and controversy about the techniques of upper airway management during and after rescue from the drowning process. There is very little documentation of the upper airway challenges themselves. There are a variety of medical devices to assist with the management of upper airway issues after rescue from the drowning process. Aquatic Lifesaving organizations teach drainage positions for victims being carried on a beach, for performing expired-air resuscitation on immersion victims and for the observation of recovery.

10 Evidence Identification and Review List the approach to gathering evidence. 1. COCHRANE 1. Database: EBM Reviews - Cochrane Database of Systematic Reviews <2nd Quarter 2007> Search Strategy: 1: (drowning or near-drowning).mp. 2.. MEDLINE (PubMed) Search ("Drowning"[MeSH] OR "Near Drowning"[MeSH]) AND ("Resuscitation"[MeSH] OR "Cardiopulmonary Resuscitation"[MeSH]) AND (upper airway OR breathing OR breath OR vomit* OR aspiration OR choking OR choke OR exudate) 92 Select 67 documents most unrelated to this issue. 3 Librarian Medline Resuscitation/adverse effects[mesh] AND drowning[mesh] 12citations Resuscitation[mesh] AND (drowning/complications[mesh] OR drowning/physiopathology[mesh]) 143 citations "drowning/epidemiology"[mesh] AND resuscitation[mesh] 61 citations Pubmed keywords drowning, near-drowning, aspiration, regurgitation, airway a lot of articles that are case study, reviews, and opinions about techniques and devices to assist with airway management. 4. AHA BLS Worksheets for Guidelines 2005 Szpilman, Wigginton, Idris 266/7 did a science evidence review of Airway and In-Water Resuscitation in Drowning. There is not new data in this review and the relavent papers are discussed below. Only one paper (Manolios & Mackie, 1988) has data on numbers of drowning process victims and the incidence of airway challenges in the pre-hospital resuscitation. Many papers quote this work. Many papers have provide expert opinion that is supported by that Australian data. There are no other papers that deal with this effect of this issue on resuscitation outcomes.. -Advanced Search to English, Human, Review articles with both words in the title - provides 12 articles none that address the issue directly and few that identify upper airway management after rescue from the drowning process as a problem. - Cochrane Collaborative Review Drowning, Airway - no results At the ILS WWS 2007(Porto, Portugal Sept 2007) David Szpilman presented theaha BLS Worksheet on Airway Issues and In-water resuscitation. That scientific review process used data quoted above. That review produced the following recommendations: -if submersion time is unknown or known to be less than 15 minutes -a non-breathing victim is found in water - bring face out of water and extend the neck to open the airway (Class 11a LOE 4)

11 -in shallow water check for breathing if absent then begin rescue breathing for one minute if breathing restored monitor and remove to land. -in deep water with 2 or more trained rescuers or with 1 trained rescuer with a floatation device check for breathing if absent begin rescue breathing for one minute. If breathing is not restored or there is no circulation, the rescuer should recover the victim to shore without further attempts at rescue breathing. (LOE 4) -short swim (<5 min) continue ventilation while proceeding to shore or stop Q1-2 minutes for one minute of ventilation. -long swim (>5 min) continue ventilation 1 additional minute while checking for signs of circulation (movement or reaction to ventilation) if present continue as per short swim, if not present proceed to shore without further ventilation. -Cardiac Compression in water is ineffective, slows rescue and may place the victim at increased risk of aspiration, and rescuer at risk of fatigue (LOE 5) Summary of Key Articles/Literature/Reports/Data Found and Level of Evidence (Please fill in the following table for articles that were used to create your recommendations and/or guidelines) Author(s) and Year published Full reference Summary of Article (if abstract available, first past abstract and Level of Evidence (Using table below) Manolios N, Mackie I Modell Orlowski Orlowski, Szpilman Fenner, Harrison, Williamson, Williamson Hasan, Avery, Fabian, Sackner Med J Aust 1988 Feb (4) 165-7, NEJM Jan 28, :253-6 Pediatr Clinics of NA 1987 Feb 34(1) Pediatr Clinis of NA, 2001 Jun 48(3) Med J of Australia 1995(Dec 4-18; 163(11-12) Chest, 1971; 59; then provide your summary Drowning and near-drowning on Australian beaches patrolled by lifesavers: a 10 year study, Drowning 4 Drowning, near-drowning and icewater submersion Drowning, Rescue, Resuscitation and reanimation Success of Surf Lifesaving Resuscitations in Queensland, Near-drowning in Humans: A case report of 36 patients 3b 4 4 3b 3b Szpilman Chest Sept 1997, 112/3 Near-Drowning and Drowning Classification A Proposal to 3b

12 Quan Watson, Cummings, Quan, Bratton, Weiss Dodd, Simon, McKeown, Patrick ILS Medical Committee Golden, Tipton, Scott Perkins Szpilman Soales AHA 2005 Guidelines ILCOR ILS Medical Committee Szpilman D Pearn J Stratify Mortality Based on the Analysis of 1,831 Cases Ann of Drowning Issues in resuscitation 4 Emerg Med Feb;22, Trauma, Oct Cervical Spine Injuries among 3b 2001, 51(4) Submersion Victims Anaesthesia 1995 Nov; 50(11) Brit Journal of Anaesthesia 1997, Resuscitation 65(2005) Resuscitation 2004 Oct;63(1): Circulation 2005 Dec 13 ;112 (24 supp) Pediatrics 2006 May 117(5) Brit Med Jour Nov Vol Congress on Drowning The effect of a cervical collar on the tidal volume of anesthetized adult patients. Statement on in-water resuscitation Immersion, near-drowning and drowning In-water resuscitation: a pilot evaluation In-water resuscitation is it worthwhile Guidelines 2005 see Worksheets 266/7 Szpilman, Wigginton, Idris International Liaison Committee on Resuscitation (ILCOR) consensus on science with treatment recommendations for pediatric and neonatal patients: Pedictric basic and advanced life support Statement on the use of Abdominal Thrusts in Near The Management of near drowning Drowning 3b 4 4 3c 3b

13 Szpilman D, Handley T Proceedings Handbook on Drowning Pg Level of Evidence Level 1a Level 1b Level 2 Level 3a Level 3b Level 3c Level 4 Level 5 Level 6 Level 1-6E Criteria Population based studies, randomized prospective studies Large non-population based epidemiological studies, meta-analysis or small randomized prospective studies Prospective Studies which can include, controlled, non-randomized, epidemiological, cohort or case-control studies Historic which can include epidemiological, non-randomized, cohort or case-control studies Case series: subjects compiled in serial fashion without control group, convenience sample, epidemiological studies, observational studies Mannequin, animal studies or mechanical model studies Peer-reviewed works which include state of the art articles, review articles, organizational statements or guidelines, editorials, or consensus statements Non-peer reviewed published opinions, such as textbooks, official organizational publications, guidelines and policy statements and consensus statements Common practices accepted before evidence-based guidelines or common sense Extrapolations from evidence which is for other purposes, theoretical analyses which is on-point with question being asked. Modifier E applied because extrapolated but ranked based on type of study.

14 Summary Table of Evidence Place all the evidence listed in the previous sections in one of the following three columns using the follow approach: 57. Place each article or report in one of the columns and in its own row 58. List articles with highest level of evidence first 59. In box place name of lead author and in parenthesis year published 60. In addition in each box put a one to two sentence summary of how the article either support, opposes or has no position with regard to the question(s) Question #1 Supportive of Recommendation Manolios N, Mackie I Modell Orlowski Orlowski, Szpilman Fenner, Harrison, Williamson, Williamson Hasan, Avery, Fabian, Sackner Szpilman Quan Watson, Cummings, Quan, Bratton, Weiss Dodd, Simon, McKeown, Patrick ILS Medical Committee Golden, Tipton, Scott Perkins AHA 2005 Guidelines ILCOR ILS Medical Committee Pearn J Szpilman D Szpilman D, Handley T Opposing Recommendation No Position Question # 1a re:in-water resuscitation Supportive of Recommendation Perkins ILS Medical Committee Opposing Recommendation Golden, Tipton, Scott No Position

15 Szpilman Textual Summary of Evidence: Please provide a textual summary of the all of the evidence reviewed and explain in detail how these lead to the guidelines, recommendations and/or options which you are proposing The Drowning Process creates a unique and challenging upper airway management problem for victims, rescuers and those providing resuscitation and medical care. Upper airway obstruction resolution may be the most important process in the reversal of the hypoxic cascade. Maintaining a functional upper airway is also challenging due to regurgitation and vomiting, spontateously or as a result of triggers in the rescue, resuscitation and transportation process. Until this is secured by the recovering patient or by cuffed intubation, it requires ongoing focused attention. The evidence available suggests: 1. Prevention of unintended immersion, aspiration and drowning is most important 2. A majority of drowning process patients will have upper airway management problems. 3. Aspiration provides acute and chronic complications to medical management of drowning. 4. Reversal of that problem may have a significant impact on outcome. 5. Early expired air ventilation is a priority to reverse the hypoxic cascade and may be cardiac arrest preventing 6. It is safe and effective to provide expired air ventilation in shallow water 7. It may be helpful to provide expired air ventilation in deep water if; 1. the conditions are safe for this 2. the single trained rescuer is supported by a floatation device. 3. there are two or more trained rescuers. The reasonable assumptions include: 1. The upper airway management is more challenging in the pre-hospital setting. 2. Preventing aspiration would be a beneficial objective to improve outcomes and reduce rescuer airway management. 3. The upper airway management in the un-intubated unconscious patient may require the full time attention of one rescuer. 4. Resuscitation of the Drowning Process patient may benefit from airway drainage positioning and a minimization of patient movements to reduce the vomiting, regurgitation and the consequent aspiration risk. 5. Distraction such as suspecting spinal injury when the probability is very low is distracting to the focus on higher priorities.

16 Preliminary Guideline Document Section: Place your suggested recommendations into one or more of the three categories listed below and then briefly summarize the issue, your overall recommendations including answers to the question which was addressed as we should included it in the final document Recommendations and Strength (using table below): Standards: 1. Airway management awareness and skills must be included in the pre-hospital and hospital protocols for drowning process rescue and resuscitation. 2. Prevention of aspiration is beneficial 3. In basic life support for drowning resuscitation: a. Earliest possible airway management and ventilation may be life saving in drowning resuscitation b. In-water resuscitation is recommended under appropriate circumstances. - shallow water - deep calm water - trained rescuer with a floatation aid - two or more trained rescuers c. Positioning, drainage and airway clearing skills are needed by all lifeguards and aquatic rescue responders. d. Activities that increase the risk of vomiting and regurgitation should be minimized. 4. In advanced life support for drowning resuscitation: a. Airway management control and early ventilation (with assistance as necessary) is the highest priority in drowning resuscitation. b. Nasogastric suction may be helpful to reduce regurgitation and may enhance respiratory function. Guidelines: 1. Education for rescuers and resuscitation personnel who may respond to drowning patients, have a special section of their support literature and education that provides emphasis to the challenges of airway management in drowning resuscitation. 2. In-water resuscitation for a singe rescuer without floatation support should not be taught or encouraged for rescuers. 3. Procedures and issues that distract rescuers and resuscitation personnel from the lifesaving attention to airway management should be identified and

17 minimized in drowning resuscitation. Ie spinal injury focus in low probability situations 4. For unconscious, or transporting or recovering victims from drowning: - The victim should be in as near a true lateral position as possible with the head dependant to allow free drainage of fluids. - The position should be stable. - Any pressure on the chest that impairs breathing should be avoided. - It should be possible to turn the victim onto the side and return to the back easily and safely, having particular regard to the possibility of cervical spine injury. - Good observation of, and access to, the airway should be possible. - The position itself should not give rise to any injury to the victim. Further Research Needs: 1. The degree of airway management challenge and the impact on outcome, is not known. To enhance our understanding it would be reasonable to create a point or line scale of the degree of difficulty for airway management in drowning resuscitation. This would allow research on this issue. a. Eg Airway Management Difficulty Score 0 = no difficulty 1 = manual techniques for one occasion 2 = manual techniques multiple times at intervals 3 = manual techniques continually 4 = mechanical or structural techniques for less than 5 minutes 5 = mechanical or structural techniques continually 2. Prospectively designed research on the application of early expired air resuscitation on the drowning hypoxic cascade victim outcomes. 3. Research is needed on the impact of in-water resuscitation for the rescuer(s). Guideline Definitions for Evidence-Based Statements Statement Definition Implication

18 Standard Guideline Option No recommendation A standard in favor of a particular action is made when the anticipated benefits of the recommended intervention clearly exceed the harms and the quality of the supporting evidence is excellent. In some clearly identified circumstances, strong recommendation standards may be made when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. A guideline in favor of a particular action is made when the anticipated benefits exceed the harms but the quality of evidence is not as strong. Again, in some clearly identified circumstances, recommendations may be made when high quality evidence is impossible to obtain but the anticipated benefits outweigh the harms. Options define courses that may be taken when either the quality of evidence is suspect or, level and volume of evidence is small or carefully performed studies have shown little clear advantage to one approach over another. No recommendation indicates that there is a lack of pertinent evidence and that the anticipated balance of benefits and harms is presently unclear. One should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present. One would be prudent to follow a recommendation but should remain alert to new information. One should consider the option in their decisionmaking. One should be alert to new published evidence that clarifies the balance of benefit versus harm