CIRCULATION

- While pulses may be difficult to identify due to hypothermia or hypotension, absence of a pulse necessitates initiation of Basic Life Support/Advanced Cardiac Life Support (ACLS) protocols. See Table 2 for CPR guidance in the drowning patient.
- Most common dysrhythmias are asystole and pulseless electrical activity. Defibrillation is not indicated with these rhythms. Attempts to attach an AED should not be made if it delays or interferes with compressions and ventilation.10,11,13
- Shockable rhythms (ventricular fibrillation or ventricular tachycardia) are present in <6% of patients and have a more positive prognosis.1
- Obtain IV access when able. Intraosseous access is an acceptable alternative if unable to obtain IV access. Administering ACLS medications through the endotracheal tube is discouraged in the drowning patient.10,11
- Many drowning patients will be volume depleted intravascularly and will have volume responsive hemodynamics. In patients who are mechanically ventilated or receiving positive pressure, hypotension may be more common as increased intrathoracic pressure reduces central venous return/preload. IV crystalloid should be considered if available. In the hypothermic patients, warmed IV fluids at 43°C (109°F) should be considered.16
- Use of IV fluids must be judicious given the increased risk for noncardiogenic pulmonary edema in these patients.
- Notably, many ACLS interventions, including pacing, atropine, lidocaine, and defibrillation, are ineffective with low core body temperatures. Antiarrhythmics should be withheld for core temperatures of < 30 °C (86 °F).
- Emphasis should be placed on chest compressions and ventilations to maintain perfusion.18