First aid for drowning Time is life! First aid for drowning focuses on the word “early”, and the rescue of drowning victims should be a race against time. It includes two steps: on-site first aid and initial resuscitation; further resuscitation in hospital (including emergency department and ICU). The key point of treatment is to implement effective cardiopulmonary cerebral resuscitation (CPCR) and adequate respiratory management, that is, the systemic and continuous nature of first aid and initial resuscitation from the accident scene to further treatment in the hospital is important, and on-site first aid and initial resuscitation are the most important. (a) On-site first aid and initial resuscitation of drowning Rapid and effective on-site first aid is the key to the success or failure of treatment. Some data show that if the resuscitator is trained in resuscitation, the survival rate of the patient can reach 70%, but only 40% in the opposite direction. Improving the restoration of effective ventilation and organizing escort to hospital are the main tasks of on-site first aid. 1, quickly remove the respiratory foreign body drowning from the water, the respiratory tract is often blocked by vomit, sediment, algae and other foreign bodies, so the fastest speed to make its respiratory tract, and immediately put the patient in a flat position, head back, lift the chin, pry open the mouth, pull out the tongue, remove foreign bodies in the mouth and nose, such as movable dentures should also be removed to avoid falling into the trachea; lift the tightly wrapped underwear, bras, belts, etc.. After the rapid removal of foreign bodies in the mouth and nose, if there is a heartbeat, it is customary to perform more water control treatment. 2, water control treatment which refers to the use of head low feet high position will be the lungs and stomach water discharge. The most common simple method is: quickly pick up the patient’s waist, so that his back to the top, head down, as soon as possible to pour out the lungs, trachea and stomach water; can also be placed on the abdomen of the rescuer kneeling thighs, so that the head drops, and then use the hand to flatten its back, so that the trachea and oropharynx water pour out; can also use small wooden stools, large stones, inverted iron pot and other things to do the cushion high thing. During this period, the resuscitation action must be agile, and the pouring time should not be too long (1 min is enough), in order to pour out the water in the mouth, pharynx and trachea as degree, if not much water is discharged, artificial respiration, chest cardiac compressions and other first aid measures should be taken immediately. Some authors believe that once the patient’s airway is open, mouth-to-nose breathing can be used instead of mouth-to-mouth breathing, and it is not necessary to remove the water that is mistakenly absorbed in the airway. Because even for wet drowning, most drowning patients only inhale a small amount of water by mistake, and it is quickly absorbed into the blood, leaving little residue, any attempt to remove water from the airway by methods other than suction is unnecessary and dangerous. Do not just discharge “lung water” and delay the resuscitation time! 3, artificial respiration and chest cardiac compressions first to determine the presence of breathing and heartbeat, the determination of breathing using the “3L” method: that is, facing the patient’s mouth and nose, listen carefully (Listen) breathing sounds; eye observation of its thoracic undulation activity (Look); facial sensory airflow (Feel). At the same time, the carotid artery can be touched to see if there is pulsation. If breathing has stopped, continuous artificial respiration should be carried out immediately, the method of prone pressure back method is more appropriate, conducive to the discharge of water in the lungs, but mouth-to-mouth or mouth-to-nose positive pressure blowing method is the most effective. If the drowning person still has a heartbeat, and more rhythmic, you can also simply do artificial respiration. If the heartbeat also stops, chest compressions should be done at the same time as artificial respiration. The ratio of chest compressions to artificial respiration is 30:2, and the number of chest compressions is 100 times/min. If chest compressions are not effective, electric defibrillation should be considered. Artificial respiration must be continued until the complete recovery of spontaneous breathing before stopping, at least insist on 3-4 hours, do not give up lightly. If the heartbeat and respiration are not restored after short-term resuscitation, resuscitation should be continued on the way to the hospital. Mask pressure ventilation often causes water in the stomach to be mistakenly sent into the airway, and should not be used. After arriving at the hospital, tracheal intubation and pressure artificial respiration should be used, and FiO2 should be increased to more than 70%. Patients can often vomit when chest compressions or respiratory therapy is performed, which further complicates maintaining the patient’s airway open. A 10-year study in Australia showed that vomiting occurred in 2/3 of patients who received respiratory care and 86% of patients who required chest compressions. In this case, the patient’s head should be turned to the side and vomit should be removed with fingers, clothing, and suction. If there may be spinal cord injury, the head, neck and torso should be kept rotated as a whole along the long axis of the body, and vomit should be removed. 4, rewarming is urgently needed to correct the serious effects caused by hypothermia, so that the patient’s body temperature gradually returns to 34-36 ℃, but the rewarming speed should not be too fast. Specific methods include hot water bath method, warm Ringer’s fluid enema, extracorporeal circulation rewarming method, etc. However, there are also views that natural rewarming is better, in order to use the beneficial effect of subfreezing to reduce the oxygen consumption of brain tissue. 5.Emergency medication can be repeated intravenous push epinephrine 0.5mg – 1mg, if found ventricular fibrillation and no defibrillator can be intravenous push amiodarone 300 mg or lidocaine 50mg – 100mg, also can be used at the same time Nicosamide 0.375g, Lopressor 3mg – 6mg, if necessary, high dose repeated application to help respiratory recovery. 6.After the first aid at the scene, even if the drowned person’s voluntary heartbeat and respiration have been restored, he still needs to be sent to hospital for further observation for 24~48 hours due to the presence of hypoxia. (2) Emergency room treatment After the drowned person is sent to the emergency room, patients with clear consciousness, normal chest X-ray, no obvious hypothermia, hypoxia and acidosis do not need special treatment, but before leaving the hospital, several hours of observation and monitoring are required to exclude the possibility of further deterioration of arterial blood gas and acid-base imbalance. If the arterial blood gas analysis is normal at 4 to 6 hour intervals, the patient should be discharged home. At the same time, attention should be paid to the so-called “second drowning”, i.e., cerebral edema, pneumonia, ARDS, hemolytic anemia, ARF, or DIC after 24 to 48 hours. Patients who leave the hospital and go home should be advised to come to the hospital immediately for follow-up if any related discomfort occurs. 1.Actively implement cardiopulmonary cerebral resuscitation (CPCR) to effectively improve ventilation and ventilatory function and correct tissue hypoxia If the patient’s voluntary heartbeat and respiration are not restored after on-site resuscitation, regular cardiopulmonary cerebral resuscitation (CPCR) should still be performed upon arrival at the emergency room, regardless of how long the patient has been drowning, and do not give up resuscitation lightly. If the patient is still unconscious, he should be intubated immediately and mechanically ventilated with intermittent positive pressure control breathing (IPPB) or end-expiratory positive pressure breathing (PEEP) to administer oxygen to re-expand the atrophied alveoli, which can improve and enhance oxygenation. Tracheotomy should be considered if the tracheal tube is left in place for more than 48 hours. Immediate electrical defibrillation if ventricular fibrillation occurs. Artificial cardiac pacing may be considered for cardiac arrest and direct cardiac massage with open chest if necessary to establish effective blood circulation. Closely observe the changes of body temperature, respiration, ECG, blood pressure and other vital signs of the patient at any time. 2. Prevention and control of intracranial hypertension and cerebral edema and protection of brain tissue (1) Coma or cardiac arrest and respiratory arrest are generally associated with intracranial hypertension. Continuous increase of intracranial pressure (ICP) over 2.0~2.7kpa can reduce cerebral blood flow and aggravate the ischemic damage of damaged brain tissue. Rapid intravenous infusion of 20% mannitol 125-250ml or tachyzoate intravenous injection and albumin drip can be used not only for dehydration and prevention of cerebral edema, but also for the prevention and treatment of pulmonary edema that often occurs in drowning. IV adrenocorticotropic hormone, such as dexamethasone 10mg – 20mg or hydrocortisone succinate has a good effect on the prevention and treatment of cerebral edema that occurs after cardiac arrest, and can reduce intravascular hemolysis. However, one should be alert to the fact that rapid sedation of mannitol can induce or aggravate pulmonary edema. In addition, hyperbaric oxygen chamber therapy can also be used to improve blood oxygen tension, increase blood oxygen diffusion, and increase the oxygen content of blood and tissues, which has a better effect on tissue hypoxia caused by drowning, especially cerebral hypoxia. For those with impaired consciousness, drugs that promote brain tissue metabolism and protect brain cells, such as coenzyme A, cytochrome C, adenosine triphosphate, energy combination, naloxone, FDP, etc., can be given; and keep blood sugar below 11.1mmol/L. (2) Cerebral hypothermia treatment Since Williams et al. reported in 1985 that hypothermia was effective in treating cerebral hypoxia in cardiac arrest, clinical and experimental studies at home and abroad have confirmed that hypothermia can reduce post-ischemic brain damage.