united states lifeguard standards coalition evidence...

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 (eg 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

US Lifeguard Standards Coalition

SUCTION 1

Question 2 Is suction safe effective and feasible in the drowning process resuscitation 3

4 Introduction 5 Several methods to remove water debris and vomitus from the upper respiratory system 6 have been introduced debated and included in drowning process resuscitation protocols over 7 time In the drowning process upper abdominal thrusts pose a greater risk of precipitating 8 gastroesophageal regurgitation and subsequent aspiration Upper abdominal thrusts do not 9 expel sufficient water from the airway or lungs to assist in resuscitation In addition upper 10 abdominal thrusts may delay and complicate the start of effective CPR Postural drainage 11 before first ventilation and other means of removing fluid and vomitus have also been 12 debated in recent decades 13 14 But what about suction Suction is used regularly in prehospital emergency medicine by 15 paramedics and physicians to maintain airways in trauma patients Should lifeguards be using 16 suction in the field too We explored whether suction should be recommended during 17 resuscitation of drowning victims ie whether it is safe and effective and can be used 18 successfully 19 20 Evidence Summary 21 Identifying information on suctioning is difficult because there is a little scientific literature 22 on early resuscitation measures by lifeguards and literature on suctioning of submersion 23 victims is extremely scarce Because of this lack of specific evidence we examined literature 24 on submersion victims and resuscitation with any mention of suctioning in the articles on 25 resuscitation or submersion incidents 26 27 The literature generally refers to suctioning in a neutral or positive manner as a common and 28 standard protocol in emergency medicine and airway management The theoretical basis for 29 suctioning a submersion patient would be to assist in establishing the airway by removing 30 either aspirated fluid (or vomitus) from the airway or lungs or debris that is blocking the 31 airway 32 33 Safety There is no evidence indicating that suction is unsafe to use on drowning victims 34 during early resuscitation efforts or any part of the rescue and resuscitation process 35 36 Effectiveness The effectiveness of suction in submersion victims has not been well studied 37 38 Removing aspirated fluid from the lungs 39 There is a general consensus that little if any fluid can be expelled from the lungs by 40 drainage techniques including suctioning abdominal thrusts or postural drainage this is 41 because after just a few minutes of submersion water is absorbed into the circulation 42 (Harries 1986 Mills-Senn 2000 Braun [Advanced Cardiac Life Support guidelines] 1997 43 DeNicola 1997 Modell 1996) According to the latest American Heart Association 44 guidelines (2005) there is ldquono need to clear the airway of aspirated water because only a 45


modest amount of water is aspirated by the majority of drowning victims and is rapidly 46 absorbed into the central circulation so it does not act as an obstruction in the tracheardquo 47 48 Removal of vomitusdebris from the airway or lungs 49 In some patients the airway is blocked by vomitus or particulate matter making 50 resuscitation difficult (Manolios 1988) In these cases although techniques vary the vomitus 51 or debris should be removed if it interferes with airway management (American Heart 52 Association 2005 Auerbach 2007 Orlowski 2001 Ornato 1986 Cahill 1968) Although 53 there is no hard evidence on whether lifeguards can effectively implement suction as part of 54 the rescue protocol for those victims who vomit it is well stated in the literature that in 55 prehospital rescue efforts suction is an option for removal of vomitus and debris blocking the 56 airway 57 58 Feasibility The feasibility of suction at the drowning process resuscitation scene has not 59 been well studied 60 61 Timing of start of resuscitation in relation to suction or fluid draining from the airway 62 There is general consensus that resuscitation should begin before attempting to remove fluids 63 from the airway or lungs (Ibsen 2002 Orlowski 2001) According to Orlowski (2001) 64 victims can even be ldquooxygenated and ventilated effectively through copious pulmonary 65 edema fluid The first priorities are adequate oxygenation and ventilationrdquo 66 67 It is clear based on this evidence that the protocol for resuscitation should remain A-B-C 68 (airway breathing circulation) not S-A-B-C (suction airway etc) However research is 69 needed to determine whether lifeguards should adopt suction as part of standard airway 70 protocol 71 72 Consensus Recommendation 73 Evidence is insufficient to indicate whether suction is safe or not safe for submersion and 74 drowning victims if used by lifeguard personnel in any aquatic environment The use of 75 suctioning in prehospital care may continue as recommended by the American Heart 76 Association 77 78 Evidence from 11 review articles and guidelines ranging from LOE 4 to LOE 5 indicate that 79 when suction is performed by prehospital personnel on submersion victims that have 80 regurgitated or vomited or that have an airway blockage the airway can be better controlled 81 However this evidence does not specify the effectiveness of suction as used by lifeguards 82 83 There is consensus that for submersion and drowning victims who vomit or regurgitate 84 during the drowning process resuscitation suction may be used to clear the airway (Orlowski 85 and Szpilman Quan Carli Ornato Cahill Auerbach Minkler and the American Heart 86 Association) Therefore it should be an option that suction be used by lifeguards (as is done 87 by prehospital rescue personnel) to clear the airway in submersion and drowning victims in 88 whom vomitus or debris makes airway access difficult 89

90 91


Standards 92 Guidelines 93 Options 94

Training lifeguards on manual and powered suctioning equipment should be 95 considered 96

The use of suction in submersion victims should be considered if the airways are 97 blocked by vomitus or debris or if establishing an airway is difficult 98

No Recommendations 99 There are no recommendations as to whether or not suction should be mandated 100

in the drowning resuscitation process 101

Unites States Lifeguarding Standard Coalition Scientific Review Form

Author Farhad Madani

Organization Representing City of Austin and NRPA

Question Is suction safe effective and feasible in the drowning process resuscitation

Date Submitted November 26 2007

Question and Sub-Questions This should include the major question originally planned and any changes which occurred during the review process Please also list any original sub-questions and the changes and those added during the review process Is Suction safe effective and feasible in the drowning process resuscitation Suctioning Drowning Endotracheal Suctioning Airway suctioning Drowning Resuscitation Water in airway Fluids in upper airway Immersion injury Laryngeal chemoreflex Pharyngeal suction IntroductionBackground Provide any relevant background on the subject and the need to address this question During a drowning process rescuers are sometimes faced with airways obstruction by fluids in upper airway making it difficult for the rescuer to apply essential rescue breathing procedures In addition the materials that remain in the airway may be forced into the trachea and eventually into the lungs This will cause complications ranging from severe pneumonia to a complete airway obstruction Evidence Identification and Review List the approach to gathering evidence This should include any electronic databases searched with the terms used and numbers of articles found and reviewed Also list any reports prior evidence reviews analyzed andor position papers evaluated MEDLINE (pubmedgov) Critical Care Journal Circulation and Google Three Hundred twenty one (321) articles were retrieved using search engines such as MEDLINE (pubmedgov) Critical Care Journal Circulation and Google and about

seventeen (17) articles pertaining to some kind of suctioning procedures were selected as evidence However No articles were found regarding suctioning related to the drowning process There were numerous articles were found speaking to the Endotracheal suctioning on emergency care patients

Summary of Key ArticlesLiteratureReportsData Found and Level of Evidence (Please fill in the following table for articles that were used to create your recommendations andor guidelines) Author(s) and Year published

Full reference

Summary of Article (if abstract available first past abstract and then provide your summary)

Level of Evidence

Mark Harries July 12 1986

BMJ Drowning and Near Drowning volume 293 pages 122-124

Drowning process poses numerous problems during resuscitation including Survival after prolonged submersion to secondary drowning dry drowning and pulmonary and cerebral oedema ldquoData collected from actual resuscitation attempts indicate that in around two thirds of them rescuers experience difficulty in clearing the upper respiratory tract of waterldquo

4

Jerome H Modell January 28 1993

NEJM Drowning volume 328253-256J Modell JH Moya F Effects of volume of aspirated fluid during chlorinated fresh water drowning Anesthesiology 196627662-672

ldquoThe first step in treatment is to retrieve the victim from the water and if he or she has apnea and no pulse to initiate artificial ventilation and circulation as soon as possible An abdominal-thrust maneuver has been recommended3738 no controlled

experimental studies have demonstrated its superiority as the

initial therapy for patients who have nearly drowned however39 In one study in animals no increase in the amount of water drained from the lungs could be demonstrated with abdominal thrusts as compared with gravitational drainage Furthermore arterial oxygen tension intrapulmonary shunting of blood and the amount of water in the lung after treatment with mechanical ventilation did not differ significantly among animals that underwent gravitational drainage abdominal thrust or no active measures to remove water from the lungs40

In other studies

of animals fresh water

was aspirated and rapidly absorbed from

the lungs and little residual

water could be recovered after three

to five minutes even by direct suction

10 Furthermore an abdominal thrust may lead to regurgitation and pulmonary aspiration of gastric contents as well as to delay in restoring adequate ventilation and

6

circulation4142 I agree with the

American Heart Associations recommendation that an abdominal thrust should not be used routinely in victims of submersion but rather should be reserved for cases in which obstruction of the airway with a foreign body is suspected or when the patient does not respond to mouth-to-mouth ventilation41rdquo

Mark Harries 2003

BMJ 20033271336-1338 (6 December) doi101136bmj32774271336

Clinical review

ABC of resuscitation

Near drowning

ldquoResuscitation Circulatory arrest should be managed in a unit in which facilities are available for bypass and extracorporeal rewarming This will determine the target hospital Although patients can be intubated at the scene if required practical difficulties mean that venous or arterial canulation is better left until arrival in hospital Continuous chest compression should be applied without rewarming throughout transportation

The role of procedures that are intended to drain water from

the

lungs and airways is controversial Placing the patients

head down in

the lateral position probably recovers water from

only the

stomach Aspiration of gastric contents is a constant

hazard and is

one of the reasons for attempting to intubate

unconscious patients at an

early stage ldquo

4

Will Boggs MD

2007

NEW YORK (Reuters Health) May 29 2007

Radiology 2007243862-868

Multidetector CT (MDCT) findings can aid in the determination of cause of death after possible drowning according to a report in the June issue of Radiology

MDCT complements autopsy by providing an anatomic assessment before dissection and provides a mechanism to preserve anatomic information in forensic investigation Dr Angela D Levy from Armed Forces Institute of Pathology Washington DC told Reuters Health

Dr Levy and colleagues described MDCT virtual autopsy findings in comparison with those of autopsy findings in 37 drowning subjects and in 14 subjects who died of sudden

4

cardiac death

Drowning and cardiac death groups had fluid in the sinuses the authors report but only subjects in the drowning group had high-attenuation sediment in the airways or sinuses

Subjects in the drowning group but not in the cardiac death group also showed frothy airway fluid and high-attenuation sediment in the distal trachea andor main bronchi the results indicate

Findings in the lungs and pleural space did not differentiate the two groups the researchers note with both showing pulmonary ground-glass opacity

Nearly 90 of the drowning subjects had gastric distention and many had evidence of high-attenuation sedimentation in the stomach findings not present in the cardiac death control group

In the absence of frothy fluid or sediment multidetector CT is nonspecific but may provide anatomic findings that support the diagnosis of drowning in the appropriate scenario when all other causes of death have been excluded the investigators write Furthermore multidetector CT virtual autopsy may be useful as a pre-autopsy triage tool in mass casualty scenarios or may add additional anatomic information to a cause of death rendered by external examination or limited autopsy

Our future projects are focused on the utility of MDCT in areas that are difficult to assess with routine dissection Dr Levy said

American Heart Association 2000

Circulation Part 6 Advanced Cardiovascular Life Support Section 3 Adjuncts for Oxygenation Ventilation and Airway Control

ldquoSuction Devices Both portable and installed suction equipment should be available for

resuscitative emergencies The portable unit should provide vacuum and flow adequate for pharyngeal

5

ECC Guildelines

suction It should be fitted with large-bore nonkinking suction tubing and semirigid pharyngeal tips Several sterile suction catheters of various

sizes should be available for suctioning through tracheostomy tubes along with a nonbreakable collection bottle and a supply of sterile water for cleaning tubes and catheters

The installed suction unit should be powerful enough to provide

an

airflow of gt40 Lmin at the end of the delivery tube and

a vacuum of gt300

mm Hg when the tube is clamped The amount

of suction should be

adjustable for use in children and intubated

patients Hand-powered

suction units lack the problems associated

with electric pumps and

have had considerable anecdotal clinical

success although no formal

evaluations have been published

An additional set of rigid pharyngeal suction tips (tonsil suction tips) and sterile curved tracheal suction catheters of various sizes should be available For tracheal suction a Y-piece or T-piece or a lateral opening should lie between the suction tube and the source of the on-off suction control The suction yoke collection

bottle water for rinsing and suction tube should be readily accessible to the attendant in charge of the airway Suction apparatus must be designed for easy cleaning and subsequent decontaminationrdquo


(Circulation 2005112IV-133 ndash IV-135) Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 103 Drowning 5Modell JH Davis JH Electrolyte changes in human drowning victims Anesthesiology

ldquoRescue Breathing The first and most important treatment of the drowning victim is the immediate provision of ventilation Prompt initiation of rescue breathing increases the victimrsquos chance of survival10

Rescue breathing is usually performed when the unresponsive victim is in shallow water or out of the water If it is difficult for the rescuer to pinch the victimrsquos nose support the head and open the airway in the water mouth-to-nose ventilation may be used as an alternative to mouth-to-mouth

5

ventilation Untrained rescuers should not try to provide care while the victim is still in deep water Management of the drowning victimrsquos airway and breathing is similar to that recommended for any victim of cardiopulmonary arrest There is no need to clear the airway of aspirated water

because only a modest

amount of water is aspirated by the majority

of drowning victims and it

is rapidly absorbed into the central

circulation so it does not act as an obstruction in the trachea

511 Some

victims aspirate nothing because they develop laryngospasm

or

breath-holding512 Attempts to remove water from the breathing

passages by any means other than suction (eg abdominal thrusts or the Heimlich maneuver) are unnecessary and potentially dangerous11 The routine use of abdominal thrusts or the Heimlich maneuver for drowning victims is not recommendedrdquo Vomiting by the Victim During Resuscitation The victim may vomit when the rescuer performs chest compressions or rescue breathing In fact in a 10-year study in Australia two thirds of victims who received rescue breathing and 86

of victims who required compressions and ventilations vomited13 If vomiting occurs turn the victimrsquos mouth to the side and remove the vomitus using your finger a cloth or suction If spinal cord injury is possible logroll the victim so that the head neck and torso are turned as a unit

John Pearn 1985

BMJ Volume 291 The Management of near drowning

ldquoFirst aid for the apparently drowned is standard though disquieting reports persist that many medical graduates feel inadequate in the field when expected to give expired air resuscitation and external cardiac compression Cardio pulmonary resuscitation uses

4

the same technique whether it is undertaken at the rescue site or in the emergency room while intubation monitors defibrillators ventilators and other hardware are being coordinated The airway must be cleared initial breaths given the carotid pulse checked and (if absent) combined external cardiac compression and expired air resuscitation administeredrdquo

Suzanne M Shepherd MD MS DTMampH James Martin MD July 19 2005

Medicine from webMD Submersion Injury Near Drowning

Abstract Drowning is defined as death secondary to asphyxia while immersed in a liquid usually water or within 24 hours of submersion The classic image of a victim helplessly gasping and thrashing in the water rarely is reported A more ominous scenario of a motionless individual floating in the water or quietly disappearing beneath the surface is more typical

Near drowning connotes an immersion episode of sufficient severity to warrant medical attention that may lead to morbidity and death

ldquoPathophysiology The principal physiologic consequences of immersion injury are prolonged hypoxemia and acidosis

After initial gasping and possible aspiration immersion stimulates hyperventilation followed by voluntary apnea and a variable degree and duration of laryngospasm This leads to hypoxemia Depending upon the degree of hypoxemia and resultant acidosis the person may develop cardiac arrest and central nervous system (CNS) ischemia Asphyxia leads to relaxation of the airway which permits the lungs to take in water in many individuals (wet drowning) although most patients aspirate less than 4 mLkg of fluid Approximately

4

10-20 of individuals maintain tight laryngospasm until cardiac arrest occurs and inspiratory efforts have ceased These victims do not aspirate any appreciable fluid (dry drowning)

Robert E St Johns 2004

Critical Care Nurse Vol 24 No2 April 2004 pages 93-97

ldquoSuctioning frequency should always be based on clinical need and not on a fixed schedule in order to decrease the potential of complications associated with suctioning (eg hypoxemia arrhythmias increased mean arterial blood pressure and intracranial pressure tracheal tissue damage) Hyper oxygenation before and after suctioning should be performed to decrease the occurrence of arterial desaturation associated with suctioning Hypoxemia can usually be avoided by using either manual resuscitation bags with supplemental oxygen or ventilator-based methods of hyper oxygenationrdquo

4

Olshaker JS 1992

Near Drowning Emerg Med Clinics North America 1992 10339-350

The first step in resuscitation of the near drowning victim is to initiate ventilation and circulation(Literature review)

2b

Orlowski JP Szpilman D 2001

Drowning Rescue resuscitation and reanimation Pediatr Clin North Am 2001 Jun 48(3)627-46

Abstract Several myths about drowning have developed over the years This article has attempted to dispel some of these myths as follows 1 Drowning victims are unable to call or wave for help 2 Dry drownings probably do not exist if there is no water in the lungs at autopsy the victim probably was not alive when he or she entered the water 3 Do not use furosemide to treat the pulmonary edema of drowning victims may need volume 4 Seawater drowning does not cause hypovolemia and freshwater drowning does not cause hypervolemia hemolysis or

4

hyperkalemia 5 Drowning victims swallow much more water than they inhale resulting in a high risk for vomiting spontaneously or on resuscitation No discussion of drowning would be complete without mentioning the importance of prevention Proper pool fencing and water safety training at a young age are instrumental in reducing the risk for drowning Not leaving an infant or young child unattended in or near water can prevent many of these deaths especially bathtub drownings Also crucial is the use of personal flotation devices whenever boating Proper training in water safety is crucial for participation in water recreation and sporting activities including SCUBA diving The incidence of pediatric drowning deaths in the United States has decreased steadily over the past decade perhaps as a result of increased awareness and attention to drowning-prevention measures

Australian Resuscitation Council 2006

Adult advanced life support Australian Resuscitation Council Guidelines 2006 Emergency Medicine Australasia 18 (4) 337ndash356

ldquoEndotracheal intubation remains the gold standard for airway maintenance and airway protection in CPR If the victim is unconscious and has no gag reflex a trained operator should perform intubation at the first appropriate opportunity and ventilate with 100 oxygen In addition to providing optimal isolation and potency of the airway intubation allows ventilation with 100 oxygen and suctioning of the airway and also provides possible access for the delivery of some drugs However if Endotracheal intubation is attempted ongoing CPR must be maintained and attempts at intubation should not interrupt cardiac compressions for more than 20 secondsrdquo

5

Modell JH 1986

Near Drowning Circulation 1986 74 (supp IV) 27-28

The first step in resuscitation of the near-drowning victim is to initiate ventilation and circulation The Heimlich should only be performed if the patient cannot be ventilated

4

Michael Verive 2007

Near Drowning Last Updated February 16 2007

Abstract Submersion injuries are a significant cause of death and disability in children second only to accidental trauma At least one third of survivors sustain moderate to severe neurologic

4

sequelae Although no uniform classification for submersion injuries exists drowning is usually defined as death from asphyxia within 24 hours of submersion in water Near drowning refers to survival (even if temporary) beyond 24 hours after a submersion episode Submersion injuries may be further classified as cold-water or warm-water injuries Warm-water drowning occurs at water temperatures of 20degC or higher and cold-water drowning occurs at water temperatures of less than 20degC Some references include very-cold-water drowning which refers to submersion in water at temperatures of 5degC or less Additional classification may include the type of water in which the submersion occurred such as fresh-water and salt-water submersion injury The distinction between fresh-water and salt-water submersion injury however is primarily academic as initial treatment is not affected by water type Most patients have fluid aspiration of less than 4 mLkg Fluid aspiration of at least 11 mLkg is required for alterations in blood volume to occur and aspiration of more than 22 mLkg is required before significant electrolyte changes develop Ingestion rather than aspiration is more likely to cause clinically significant electrolyte imbalances including hyponatremia from ingestion of large volumes of fresh water (especially in children) Increased airway resistance secondary to plugging of the patients airway with debris as well as release of inflammatory mediators that result in vasoconstriction may impair gas exchange Ventilator-associated lung injury (VALI) can further compromise noncompliant edematous lung tissue Newer modes of ventilation including high-frequency oscillatory ventilation and airway pressure release ventilation can help support ventilation and oxygenation with less risk of VALI than that associated with older

methods of ventilation

Simcock 1986

Treatment of near Drowning a review of 130 cases Anesthesia 1986 41643-648

Many patients had no evidence of aspiration of fluids

3a

Minkler Limmer Mistovich and william 2007

Beyond the Basics Airway MANAGEMENT EMS respondercom March 6 2007

ldquoEndotracheal intubation is the gold standard for airway control Correct placement of an endotracheal tube allows for effective ventilation exhalation deep tracheal suctioning and in some cases medication administration Endotracheal intubation does not have any limitations as to the patients age weight height or prior activities (eating medical conditions etc) Most commonly used endotracheal tube sizes are 75 to 85 for adult males and 70 to 80 for adult females Tubes can generally be found in the range of 20 (premature infants) to 100 (extremely large adults) Endotracheal tubes should be selected based on the largest size possible that will not cause trauma during insertion A factor that is particularly important during insertion is use of a laryngoscope and associated blades Blades are usually a Macintosh (curved) or Miller (straight) but other blades do exist A common problem is many providers insistence upon using a blade that works for them Laryngoscope blade selection is based on the patient not the provider with curved blades used for shorter fatter necks and straight blades for longer more anterior tracheas The well-prepared provider will have both immediately available during the procedure in case a different view is needed Some commercially available options for intubation include specialty blades such as the Viewmax and Grandview while other options like the Howland lock alter a standard blade setup These devices are designed to change and in many cases improve your view of the trachea to allow for more successful intubationsrdquo

3b

Orlowski JP 1987

Vomiting as a complication of the Heimlich maneuver

Vomiting after the Heimlich maneuver can cause serious complications

2

JAMA 1987 258512- 513

The first step in resuscitation of the near-drowning victim is to initiate ventilation and circulation The Heimlich maneuver should be reserved for those cases with documented airway obstruction

Level of Evidence

Criteria

Level 1a Population based studies randomized prospective studies Level 1b Large non-population based epidemiological studies meta-analysis or small randomized

prospective studies Level 2 Prospective Studies which can include controlled non-randomized epidemiological cohort or

case-control studies Level 3a Historic which can include epidemiological non-randomized cohort or case-control studies Level 3b Case series subjects compiled in serial fashion without control group convenience sample

epidemiological studies observational studies Level 3c Mannequin animal studies or mechanical model studies Level 4 Peer-reviewed works which include state of the art articles review articles organizational

statements or guidelines editorials or consensus statements Level 5 Non-peer reviewed published opinions such as textbooks official organizational publications

guidelines and policy statements and consensus statements Level 6 Common practices accepted before evidence-based guidelines or common sense

Level 1-6E 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

Summary Table of Evidence Place all the evidence listed in the previous sections in one of the following three columns using the follow approach

73 Place each article or report in one of the columns and in its own row 74 List articles with highest level of evidence first 75 In box place name of lead author and in parenthesis year published 76 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) Supportive of Recommendation

Opposing Recommendation No Position

Mark Harries 1986 ldquoData collected from actual resuscitation attempts indicate that in around two thirds of them rescuers experience difficulty in clearing the upper respiratory tract of waterldquo L4

Jerome H Modell 1993 In other studies of animals fresh water was aspirated and rapidly absorbed from the lungs and little residual water could be recovered after three to five minutes even by direct suctioning L6

Mark Harries 2003 The role of procedures that are intended to drain water from the lungs and airways is controversial Placing the patients head down in the lateral position probably recovers water from only the stomach Aspiration of gastric contents is a constant hazard and is one of the reasons for attempting to intubate

unconscious patients at an early stage L4

Will Boggs MD 2007 Drowning and cardiac death groups had fluid in the sinuses the authors report but only subjects in the drowning group had high-attenuation sediment in the airways or sinuses Subjects in the drowning group but not in the cardiac death group also showed frothy airway fluid and high-attenuation sediment in the distal trachea andor main bronchi the results

indicateL4

American Heart Association 2000 ldquoSuction Devices Both portable and installed suction equipment should be available for resuscitative emergencies The portable unit should provide vacuum and flow adequate for pharyngeal suction L5

American Heart Association 2005 Attempts to remove water from the breathing passages by any means other than suction (eg abdominal thrusts or the Heimlich maneuver) are unnecessary and potentially dangerous The routine use of abdominal thrusts or the Heimlich maneuver for drowning victims is not recommended L5

John Pearn1985 ldquoThe airway must be cleared initial breaths given the carotid pulse checked and (if absent) combined external cardiac compression and expired air resuscitation administeredrdquo L4

Suzanne M Shepherd James Martin 2005 After initial gasping and possible aspiration immersion stimulates hyperventilation followed by voluntary apnea and a variable degree and duration of laryngospasm This leads to hypoxemia Depending upon the degree of hypoxemia and resultant acidosis the person may develop cardiac arrest and central nervous system (CNS) ischemia Asphyxia leads to relaxation of the airway which permits the lungs to take in water in many individuals (wet drowning) although most patients aspirate less than 4 mLkg of fluid Approximately 10-20 of individuals maintain tight laryngospasm until cardiac arrest occurs and inspiratory efforts have ceased These victims do not aspirate any appreciable fluid (dry drowning) L4

Robert E St Johns 2004 Suctioning frequency should always be based on clinical need and not on a fixed schedule in order to decrease the potential of complications associated with suctioning (eg hypoxemia arrhythmias increased mean arterial blood pressure and intracranial pressure tracheal tissue damage) L4

Olshaker JS 1992 The first step in resuscitation of the near drowning victim is to initiate ventilation and circulation(Literature review) L2b

Orlowski JP Szpilman D 2001 Drowning victims swallow much more water than they inhale resulting in a high risk for vomiting spontaneously or on resuscitation L4

Australian Resuscitation Council 2006 ldquoEndotracheal intubation remains the gold standard for airway maintenance and airway protection in CPR If the victim is unconscious and has no gag reflex a trained operator should perform intubation at the first appropriate opportunity and ventilate with 100 oxygen In addition to providing optimal isolation and potency of the airway intubation allows ventilation with 100 oxygen and suctioning of the airway and also provides possible access for the delivery of some drugs L5

Modell JH 1986 The first step in resuscitation of the near-drowning victim is to initiate ventilation and circulation The Heimlich should only be performed if the patient cannot be ventilated L4

Michael Verive 2007 Most patients have fluid aspiration of less than 4 mLkg Fluid aspiration of at least 11 mLkg is required for alterations in blood volume to occur and aspiration of more than 22 mLkg is required before significant

electrolyte changes develop Ingestion rather than aspiration is more likely to cause clinically significant electrolyte imbalances including hyponatremia from ingestion of large volumes of fresh water (especially in children) L4

Simcock1986 Many patients had no evidence of aspiration of fluids L3a

Minkler Limmer Mistovich and william 2007 ldquoEndotracheal intubation is the gold standard for airway control Correct placement of an endotracheal tube allows for effective ventilation exhalation deep tracheal suctioning and in some cases medication administration L3b

Orlowski JP 1987 Vomiting after the Heimlich maneuver can cause serious complications The first step in resuscitation of the near-drowning victim is to initiate ventilation and circulation The Heimlich maneuver should be reserved for those cases with documented airway obstruction L2

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 andor options which you are proposing While there is some evidence indicating the effectiveness of using suctioning techniques on the critical care patients there is no evidence to support suctioning as a tool for lifeguards during the drowning process In addition many articles are supporting endotracheal intubation for ventilation and suctioning and this is an advance skill that belongs to EMTs not Regular lifeguards however this can be used on the beach or water park setting with certified EMTs

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 Use of suctioning device must perform by a Certified Emergency Medical Technician (EMT) to clear the upper airway for drowning victim with a lot of fluids and froth Guidelines There is not sufficient evidence to create guidelines Options No Recommendations

Guideline Definitions for Evidence-Based Statements Statement Definition Implication Standard 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

One should follow a strong recommendation unless a clear and compelling rationale for an alternative approach is present

Guideline 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

One would be prudent to follow a recommendation but should remain alert to new information

Option 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

One should consider the option in their decision-making

No recommendation

No recommendation indicates that there is a lack of pertinent evidence and that the

One should be alert to new published evidence that

anticipated balance of benefits and harms is presently unclear

clarifies the balance of benefit versus harm

Attach Any Lists Tables or Summaries Created As Part Of This Review (Please include any tables lists of items or procedures and tables which you created as part of the review that would be helpful for final analysis or publication in the final document)


Author Peter Chambers PhD DO

Organization Representing USLA

Question Resuscitation First Aid and Education Is suction safe effective and feasible in the drowning process resuscitation

Date Submitted October 31 2007

Question and Sub-Questions This should include the major question originally planned and any changes that occurred during the review process Please also list any original sub-questions and the changes and those added during the review process Is suction safe effective and feasible in the drowning process resuscitation IntroductionBackground Provide any relevant background on the subject and the need to address this question Methods to remove water debris and vomitus from the upper respiratory system have been introduced debated included and then dropped from drowning process resuscitation protocols over time The Heimlich maneuver was one of these which proved ineffective and potentially dangerous to patients Postural drainage prior to first ventilation and other means of removing fluid and vomitus have also been debated in the recent decades But what about suction This question seeks to unveil whether suction is recommended during resuscitation of drowning victims and if it is safe and effective and has the ability to be used successfully Evidence Identification and Review List the approach to gathering evidence This should include any electronic databases searched with the terms used and numbers of articles found and reviewed Also list any reports prior evidence reviews analyzed andor position papers evaluated A comprehensive literature search was completed searching the following resources and databases Academic Search Premier Cochrane Database of Systematic Reviews EMBASE MEDLINE (PubMed) MD Consult Business Source Premier textbook resources and through research websites such as Agency for Healthcare Research and Quality Clinical Practice Guidelines (National Guidelines Clearinghouse) Academic Search Premier Suction [and] resuscitation (0)

Resuscitation [and] drowning (2) Suction [and] drowning (0) Suctioning (237) limited by ldquomedical carerdquo (10) Suctioning [and] pre-hospital care (0) Suctioning [and] emergency care (0) Suction [and] lifeguardlife guard (0) Suction [and] water rescue (0) Suction [and] airway (2) Business Source Premier Suctioning unit (0) Suction [and] manualpowered (0) Cochrane Database of Systematic Reviews Suction (69) Drowning (14) Lifeguardlife guard (0) Upper airway [and] drainage (1) Pre hospital care (4) Resuscitation (129) EMBASE Suction drainage (755) Airway (16700) Suction [and] airway (6) MD Consult ndash includes e-textbooks Suction [and] resuscitation (349) Suction [and] resuscitation [and] drowning (13) PubMedMedline Suctioning [and] pulmonary edema (52) Suctioning [and] aspiration (2697) Limited to English child adolescent and adult (1421) Limited to submersion (0) Submersion [and] aspiration (32)

limited to English child adolescent and adult (12) submersion [and] suction (9) respiratory aspiration (83) advanced trauma life support guidelines (72) prehospital emergency care [and] suction (79)

Summary of Key ArticlesLiteratureReportsData Found and Level of Evidence (Please fill in the following table for articles that were used to create your recommendations andor guidelines) After reviewing more than 900 articles on drowning resuscitation and pre-hospital care I have chosen the following articles to use in creating my recommendations Author(s) and Year published

Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125

Abstract Assesses problems of near drowning situation on resuscitation measures Controversy on use of abdominal thrusts Impact of resuscitation on chances of survival and brain damage Difficulty on making cardiac arrest diagnosis on drowning scene Summary The human body has been known to recover after long periods of submersion Harries states that in fresh cadavers water has been able to be expelled from the stomach but not the lungs which is why many rescuers do not focus on drainageextraction of fluid in the upper airway

5

Mills-Senn P 2000

httpwwwuslaorgPublicInfo libraryHeimlich_Article_Mills-Senn_033000pdf

Summary of suction-related findings After 3 minutes of submersion water is quickly absorbed into circulation Drainage or suction will thus not produce significant fluid

5

Auerbach 2007

Wilderness Medicine text Mosby 2007 5th edition Chapter 68 Submersion incidents

Excerpts and summary Drainage of lungs dates back to the 17th century and has been controversial ever since The Heimlich maneuver has no place in the resuscitation efforts of submersion victims Four groups of submersion victims four groups (1) the asymptomatic patient (2) the symptomatic patient (3) the patient in cardiopulmonary arrest and (4) the obviously dead or still-submerged patient In category 3 victim if ldquocopious drainage from lungs or stomach persists suction through endotracheal tube pass nasogastric tube apply abdominal thrusts once ET tube is in place and copious drainage persists and sodium bicarbonate ordered on advice of physician or according to protocolrdquo ldquoSuctioning is the primary action to optimize the clearance of secretions

5

vomitus or foreign debrisrdquo Nasogastric tube preferred over endotracheal tube for suctioning


EEC Guidelines Part 6 Part 6 Advanced Cardiovascular Life Support Section 3 Adjuncts for Oxygenation Ventilation and Airway Control Circulation 2000102I-95

Guidelines for emergency resuscitation are covered Excerpt ldquoBoth portable and installed suction equipment should be available for resuscitative emergencies The portable unit should provide vacuum and flow adequate for pharyngeal suctionhellipThe amount of suction should be adjustable for use in children and intubated patients Hand-powered suction units lack the problems associated with electric pumps and have had considerable anecdotal clinical success although no formal evaluations have been publishedrdquo

5

Braun R Krishel S 1997

Environmental Emergencies Emergency medicine clinics of North America 1997 15(2)451 -76

Referencing the 1992 ACLS guidelines state ldquoThere is no need to clear the airway of aspirated water aspiration of freshwater or saltwater is believed to be minimalrdquo

4

DeNicola LK Falk JL Swanson ME Gayle MO Kissoon N 1997

Submersion injuries in children and adults Crit Care Clin 1997 Jul13(3)477-502

ldquoManeuvers to empty the lungs of water such as the Heimlich maneuver or other postural drainage techniques are of unproven benefit and CPR should not be delayed in order to perform these techniquesrdquo

4

Harries M 2003

Near Drowning BMJ 2003 Dec 6327(7427)1336-8

ldquoThe role of procedures that are intended to drain water from the lungs and airways is controversial Placing the patients head down in the lateral position probably recovers water from only the stomach Aspiration of gastric contents is a constant hazard and is one of the reasons for attempting to intubate

unconscious patients at an early stagerdquo

4

Ibsen LM Koch T

Submersion and asphyxial injury Crit

States scene response of a submersion victim should be as

4

2002 Care Med 2002 Nov30(11 Suppl)S402-8

follows ldquoAt the scene mouth-to-mouth breathing of an apneic victim should be attempted even while the victim is in the water and the victim should be removed from the water as quickly as possible No attempts to drain water from the lungs should be made before pulmonary resuscitation begins The Heimlich maneuver should not be performed except when airway obstruction is suspected Once the victim is on solid ground chest compressions should be begun if there is no palpable pulse Further advanced life-support measures such as endotracheal intubation defibrillation or intravenous or intraosseous medications or fluids should be undertaken as indicated if personnel capable of performing such interventions are presentrdquo

Modell JH 1993

Drowning N Engl J Med 1993 Jan 28328(4)253-6

The first step in treatment is to retrieve the victim from the water and if he or she has apnea and no pulse to initiate artificial ventilation and circulation as soon as possible In one study in animals no increase in the amount of water drained from the lungs could be demonstrated with abdominal

thrusts as compared with gravitational drainage Furthermore arterial oxygen tension intrapulmonary shunting of blood and the amount of water in the lung after treatment with mechanical ventilation did not differ significantly among animals that underwent gravitational drainage abdominal thrust or no active measures to remove water from the lungs In other studies

of animals fresh water was aspirated and rapidly absorbed from the lungs and little residual water could be recovered after three to five minutes even by direct suction

4

Modell JH 1966

Effects of volume of aspirated fluid during chlorinated fresh water drowning Anesthesiology 1966 27662-672

Summary of conclusions In dogs that survived the freshwater aspiration of 1cc ndash 32 cc blood pressures and electrolytes returned to normal fairly quickly The volume of fluid aspirated was not directly related to blood volume In treating humans Modell places emphasis first in the treatment and correction of acidosis and arterial hypoxemia then on electrolyte balance

3c


Drowning Rescue resuscitation and reanimation Pediatr Clin North Am 2001 Jun48(3)627-46

ldquoNo attempts to drain fresh or salt water from the lungs should be made before pulmonary resuscitation is begun In freshwater drowning victims water has moved rapidly out of the lungs and into the vascular system and in seawater drowning victims noncardiogenic pulmonary edema fluid continually is produced Any delay in instituting pulmonary resuscitation exacerbates hypoxia Airway patency should be assessed but the airway usually does not need to be cleared of any debris or vomitus If debris or vomitus is detected the finger-sweep maneuver or suctioning to clear the oropharynx is neededrdquo ldquoIn seawater drownings suctioning pulmonary edema fluid from the airway may be necessary if its presence interferes with effective ventilation Once the victim is intubated frothy pulmonary edema fluid and water can be suctioned from the airway but most important victims can be oxygenated and ventilated effectively even through copious pulmonary edema fluid The first priorities are adequate oxygenation and ventilationrdquo

4

Quan 1993

Drowning issues in resuscitation Annals of emergency medicine 1993 22(2 Pt 2) 366-9

Abstract Submersion injury is so often lethal because it inflicts severe hypoxia To prevent hypoxic end-organ damage to the heart and brain the goals of resuscitation are immediate ventilation and oxygenation Issue 1 Should submersion victims receive the Heimlich maneuver The pathophysiologic assumptions for this intervention are that water in the airway is obstructive thus precluding ventilation and that aspiration of water is the major injury Anecdotal

4

case reports describe improved ventilation of some victims who failed prior ventilatory efforts However animal and human studies support that aspirated water is rapidly absorbed does not preclude ventilation and intubation and is best treated rapidly with positive pressure ventilation With inadequate data to support benefit from the Heimlich maneuver and concern that the Heimlich maneuver would delay initiation of ventilation basic life support procedures are recommended in managing the airway of the submersion victim Issue 2 What is the role of prehospital care Outcomes of submersion victims treated with rapid aggressive prehospital care show that the window for medical intervention for the submersion victim is in the prehospital setting not in the emergency department or intensive care unit The submersion victim should be provided advanced cardiac life support including intubation as needed as soon as possible Other summary points Aspirated fluid amounts in a submersion victim are likely minimal Seattle medics indicate that they successfully intubate 98 of submersion patients Rapid ventilation is key to survival



ldquoEndotracheal intubation remains the gold standard for airway maintenance and airway protection in CPR If the victim is unconscious and has no gag reflex a trained operator should perform intubation at the first appropriate opportunity and ventilate with 100 oxygen In addition to providing optimal isolation and patency of the airway intubation allows ventilation with 100 oxygen and suctioning of the airway and also provides possible access for the delivery of some drugs However if endotracheal intubation is attempted ongoing CPR must be maintained and attempts at intubation should not interrupt cardiac compressions for more than 20 secondsrdquo

5

Kozak RJ Ginther BE Bean WS 1997

Difficulties with portable suction equipment used for prehospital advanced airway procedures

ABSTRACT INTRODUCTION Airway management is the highest priority for prehospital personnel While different modalities for airway management are under investigation

2

Prehosp Emerg Care 1997 Apr-Jun1(2)91-5

endotracheal intubation remains the standard for definitive airway protection Currently airway adjuncts such as portable suction remain relatively unstudied OBJECTIVE To identify utilization and complications associated with portable suction equipment used by prehospital medical personnel METHODS Fifty-one paramedics serving a Level I urban trauma center were anonymously surveyed to determine types of equipment used maintenance and utilization patterns difficulties encountered and training received with that equipment RESULTS The paramedics reported carrying suction equipment to the scene of medical aid calls less than 25 of the time Once on scene suction equipment is utilized during 50 of advanced airway procedures Half of the paramedics reported complications affecting patient care at least once during their careers due to equipment malfunction Ninety-eight percent of the paramedics reported having some type of training with the suction equipment for prehospital advanced airway procedures CONCLUSIONS The results of this study suggest that suction equipment is carried to the scene infrequently and when employed is often found to be functioning suboptimally Suggestions for improvement and further investigation are provided


2005 Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 4 Adult Basic Life Support Circulation 2005 112(suppl IV) IV-19-

Summary This overview of American Heart guidelines most current and in practice in the United States and the group that the International Liaison Committee on Resuscitation coordinates with on creating the international guidelines ldquoAlthough there are theoretical

4

IV-34 Part 103 - Drowning

differences [between salt water and fresh water drowning] that have been reported in laboratory conditions these have not been found to be clinically significantrdquo Here are the initial rescue steps referenced in the updated guidelines 1) Get the victim out as fast as possible Cervical spine stabilization is not needed unless circumstances leading to submersion indicate that trauma is likely Cervical collars and spine immobilization techniques may make airway issues more complicated 2) Most important to initiate rescue breathing as quickly as possible Only trained rescuers should attempt rescue breathing in deep water 3) There is ldquono need to clear the airway of aspirated water because only a modest amount of water is aspirated by the majority of drowning victims and is rapidly absorbed into the central circulation so it does not act as an obstruction in the tracheahellipAttempts to remove water from the breathing passages by any means other than suction are unnecessary and potentially dangerousrdquo 23 of victims who receive chest compressions or rescue breathing vomit If vomiting occurs turn the victimrsquos mouth to the side and remove the vomitus using your finger a cloth or suctionhelliprdquo

Minkler MA Limmer DD Mistovich JJ and Krost WS 2007

Beyond the Basics Airway Management EMS Emergency Medical Services

Summary This recent publication terms suction units as one of the most important pieces of equipment in pre-hospital care They focus on correct

5

January 200762-69 use and adequate training ldquoSuction can make the difference between an airway that is relatively easy to immediate control and a complete respiratory arrestrdquo Use the 15 second rule when suctioning then stop and reevaluate the airway

Carli P Hapnes SA and Pasqualucci V 1992

Airway management and ventilation A Statement for the Advanced Life Support Working Party of the European Resuscitation Council Resuscitation 1992 24(3)205-210

Summary Endotracheal intubation best primary mode for airway control and ventilation because it prevents aspiration of vomitus Complication to ET tube is airway trauma and repeated unsuccessful attempts which may result in hypoxia and aspiration Training is mandatory CPR efforts should not cease for more than 30 seconds to attempt a trach tube insertion Suction devices should be available for advanced respiratory care ldquoRapid endotracheal suction (10 seconds) after preoxygenation is mandatory to avoid occurrence of severe hypoxemia

4

Ornato JP 1986

The Resuscitation of near drowning victims JAMA 1986 256(1) 75-7

Summary notes Aspirated fresh or salt water contains impurities that may cause pulmonary insult although 15 of drowning victims maintain tight laryngospasm until death and do not aspirate at all Ventilation should be started immediately before victim removed from water if possible If there is evidence of upper airway obstruction by particulate matter matter should be removed with suction or abdominal thrust There is cause for concern in using the Heimlich in this population Supplemental oxygen given as soon as possible

4

Cahill JM 1968

Drowning the problem of nonfatal submersion and the unconscious patient The Surgical Clinics

Summary notes Gastric contents found in bronchial tube in patients Two expired immediately following vomiting and one had severe respiratory problems

4

of North America 1968 48(2) 423-30

after vomiting Ventilate as quickly as possible ldquoEfforts to drain the lungs are not recommended but the upper airway should be cleared of any solid materialrdquo ldquoSuction of the stomach is advisable to prevent further vomiting and aspirationrdquo

Manolios N 1988

Drowning and near-drowning on Australian beaches patrolled by life-savers a 10 year study 1973-1988 1988 148(4) 165-7 170

ldquoVomiting andor regurgitation occurred in 86 of survivors who required cardiopulmonary resuscitation in 68 of survivors who required expired-air resuscitation and in 50 of survivors with spontaneous respiration while they were kept in lateral positionrdquo In some patients ldquovomitus was responsible for the extreme difficulty that was experienced in maintaining a clear airwayrdquo ldquoThe material found in 100 victims at initial resuscitation was clear vomitus froth and water loose dentures and sandrdquo 11 regurgitated during resuscitation Rational for ldquocarrying immersion victims to beach face down then placing them on their side for assessment to prevent inhalation of regurgitated materialrdquo ldquoAirway obstruction is a problem in 54 of casesrdquo

4

Bierens JJ 1990

Submersion in the Netherlands prognostic indicators and results of resuscitation Annals of emergency medicine 1990 19(12) 1390-5

Aspiration of water or gastric contents is a frequent complication in submersion victims 37 of patients in this study that had aspiration died

3a

Level of Evidence

Criteria

Level 1a Population based studies randomized prospective studies

Level 1b Large non-population based epidemiological studies meta-analysis or small randomized prospective studies

Level 2 Prospective Studies which can include controlled non-randomized epidemiological cohort or case-control studies

Level 3a Historic which can include epidemiological non-randomized cohort or case-control studies Level 3b Case series subjects compiled in serial fashion without control group convenience sample









Kozak (1997) Suction is infrequently carried to EMS scenes and functions suboptimally at times Suggesting suction is underutilized (Level 2)

Bierens (1990) Aspiration of water and gastric contents is a frequent complication in submersion victims(Level 3a)

Modell (1966) Canine experiment in which the volume fluid aspirated was not directly related to hypoxemia or acidosis Modell emphasized that in freshwater aspiration blood pressure and electrolytes returned to normal relatively quickly (Level 3c)

Braun (1997) There is no need to clear the airway of aspirated water aspiration is believed to be minimal (Level 4)

DeNicola (1997) Maneuvers to empty lungs (Heimlich) and postural drainage techniques are unproven benefit and CPR should not be delayed in order to perform these techniques (Level 4)

Harries (2003) Procedures to drain lungs of fluid is controversial Aspiration is constant hazard and one of the reasons for early intubation

(Level 4) Ibsen (2002) No attempts to

drain water from lungs should be made before resuscitation begins Advanced ACLS including intubation can be performed if indicated by a trained professional (Level 4)

Modell (1993) Initiate ventilation immediately Fresh water rapidly absorbed and little residual water could be recovered after 5 minutes even with direct suction (Level 4)

Orlowski and Szpilman (2001) No attempts to drain fresh or salt water from the lungs should be made before beginning pulmonary resuscitation Delay in resuscitation worsens hypoxia Airway patency should be assessed and if debris or vomitus is detected suctioning is needed ldquoIn seawater drownings suctioning pulmonary edema fluid from the airway may be necessary if ithellipinterferes with ventilationrdquo Once intubated frothy pulmonary edema fluid and water can be suctioned (Level 4)

Quan (1993) The submersion victim should be provided ACLS including intubation as needed as soon as possible (Level 4)

American Heart Association (2005) There is no need to first try to clear the airway of aspirated water Attempts to remove water from breathing passages by anything other than suction is unnecessary and potentially dangerous

However 66 of victims vomit If vomit occurs turn the victimrsquos mouth to the side and remove vomitus using finger cloth or suction (Level 4) Carli (1992) Article referring to general emergency situations and resuscitation -- Suction devices should be available for advanced respiratory care Rapid endotracheal suction (10 seconds) after preoxygenation is mandatory to avoid occurrence of severe hypoxemia (Level 4)

Ornato (1986) If there is evidence of upper airway obstruction by particulate matter matter should be removed with suction (Level 4)

Cahill (1968) ldquoThe upper airway should be cleared of any solid materialrdquo (Level 4)

Manolios (1988) ldquoVomitus was responsible for the extreme difficulty that was experienced in maintaining a clear airwayrdquo (Level 4)

Harries (1986) Fresh human cadavers have expelled from water from the stomach but very little has been expelled from the lungs which is why many rescuers do not focus on drainage or extraction of fluid from the upper airway (Level 5)

Mills (2000) After three minutes of submersion water is quickly absorbed into circulation Drainage or suction will not produce significant fluid (Level 5)

Auerbach (2007) In

submersion patients in cardiopulmonary arrest ldquoif copious drainage from lungs or stomach persists suction through endotracheal tuberdquohelliprdquosuction is the primary action to optimize the clearance of secretionsrdquo (Level 5) Australian Resuscitation

Council (2006) Endotracheal intubation is the gold standard for airway management and airway protection during CPR Intubation allows for ventilation and suctioning as required

Minkler (2007) On suction utilized in standard EMS proceduremdashldquoSuction can make the difference between and airway that is easy to control and complete respiratory arrestrdquo Use the 15 second rule when suctioning Stop re-evaluate the airway (Level 5)

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 andor options that you are proposing SAFETY There is no evidence indicating that suction is unsafe to drowning victims during early resuscitation efforts or during any part of the rescue and resuscitation process More research is needed In Kozak (1997) half of the paramedics surveyed reported complications affecting patient care at least once during their careers due to equipment failure or malfunction It is unsure at this time given the evidence in the Kozak article if this is equipment failure or user failure as the malfunctions were not defined clearly This study also showed that in standard emergency care (not involving submersion injuries) suction was not often carried to the scene and when it was (lt 25 of the time) it was only used 50 of the time

Education and training There is no literature on any aspect of suction utilization training for lifeguards If suction is to be carried to the scene for use on submersion victims adequate training on the suctioning equipment should be provided to lifeguards and proper maintenance of said equipment should be maintained EFFECTIVENESS The effectiveness of suction in submersion victims is understudied Evidence currently suggests that suction is effective when regurgitation or vomiting occur after ventilation begins The American Heart Associationrsquos current basic life support guidelines for submersion victims endorse the use of suction ldquoif vomiting occursrdquo and others support the use of suction in instances where airway maintenanceaccess is a problem (Orlowski amp Szpilman Quan Carli Ornato Cahill Auerbach Minkler) Studies papers and guidelines that refer to suction in a supportive manner (Orlowski amp Szpilman Quan Carli Ornato Cahill Auerbach Minkler and the American Heart Association) use single statements about suction use in this population The tone of these statements is that of fact and that suction is currently a standard protocol in airway management Other evidence indicates that it is important to begin resuscitation efforts through immediate ventilation rather than trying to suction or remove water or other fluids from the airway (Auerbach Braun DeNicola Ibsen Orlowski Quan Australian Resuscitation Council American Heart Association Mikler Ornato Cahill) with one (Ornato) stating that ventilation should begin even before the victim is removed from the water FEASIBILITY The feasibility of suction at the drowning process resuscitation scene is understudied However there is evidence suggesting this is currently a successful option in drowning process resuscitation for clearing vomitus than not given the statements about use of suction in the drowning resuscitation process (Orlowski amp Szpilman Quan Carli Ornato Cahill Auerbach Minkler the American Heart Association Australian Resuscitation Council and Manolios)

Preliminary Brief Evidence Summary and Guideline Document Section Please provide a brief summary of the evidence from the previous section using the template language below and summarize the recommendation also using the template language Then place each of the recommendations in the table at the end Descriptions of how to determine the strength of the recommendations are listed below Safety There is insufficient evidence to make a statement guideline or option that suction is safe or not safe for submersion and drowning victims Until evidence is presented in the literature that indicates there is a safety issue with suctioning in this population its use in prehospital care should continue as recommended by the American Heart Association Evidence from one study with a low evidence level does indicate that emergency personnel should be trained on suctioning equipment and usage Effectiveness Evidence from eleven review articles and guidelines ranging from Evidence Level 4 to Evidence Level 5 indicate that when suction is performed by pre-hospital personnel for submersion victims that have regurgitated or vomited airway management is able to be controlled However this evidence does not specify the effectiveness of suction as used by lifeguards There is consensus by Orlowski amp Szpilman Quan Carli Ornato Cahill Auerbach Minkler and the American Heart Association that for submersion and drowning victims who vomit or regurgitate during the drowning process resuscitation suction can and should be used to clear the airway Therefore it should be an option that suction be used by lifeguards to clear the airway in submersion and drowning victims who have vomitus or debris making airway access difficult during lifeguard initiated pre-hospital resuscitation Recommendations and Strength (using table below) Standards Guidelines

Options One should consider the option of training lifeguards on manual and powered suctioning equipment One should consider the option of using suction in submersion victims if their airways are blocked by vomitus or debris and establishing an airway is difficult No Recommendations There are no recommendations as to whether or not suction should be mandated in the drowning resuscitation process








No recommendation

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 be alert to new published evidence that clarifies the balance of benefit versus harm


SUCTION 1

Question 2 Is suction safe effective and feasible in the drowning process resuscitation 3

4 Introduction 5 Several methods to remove water debris and vomitus from the upper respiratory system 6 have been introduced debated and included in drowning process resuscitation protocols over 7 time In the drowning process upper abdominal thrusts pose a greater risk of precipitating 8 gastroesophageal regurgitation and subsequent aspiration Upper abdominal thrusts do not 9 expel sufficient water from the airway or lungs to assist in resuscitation In addition upper 10 abdominal thrusts may delay and complicate the start of effective CPR Postural drainage 11 before first ventilation and other means of removing fluid and vomitus have also been 12 debated in recent decades 13 14 But what about suction Suction is used regularly in prehospital emergency medicine by 15 paramedics and physicians to maintain airways in trauma patients Should lifeguards be using 16 suction in the field too We explored whether suction should be recommended during 17 resuscitation of drowning victims ie whether it is safe and effective and can be used 18 successfully 19 20 Evidence Summary 21 Identifying information on suctioning is difficult because there is a little scientific literature 22 on early resuscitation measures by lifeguards and literature on suctioning of submersion 23 victims is extremely scarce Because of this lack of specific evidence we examined literature 24 on submersion victims and resuscitation with any mention of suctioning in the articles on 25 resuscitation or submersion incidents 26 27 The literature generally refers to suctioning in a neutral or positive manner as a common and 28 standard protocol in emergency medicine and airway management The theoretical basis for 29 suctioning a submersion patient would be to assist in establishing the airway by removing 30 either aspirated fluid (or vomitus) from the airway or lungs or debris that is blocking the 31 airway 32 33 Safety There is no evidence indicating that suction is unsafe to use on drowning victims 34 during early resuscitation efforts or any part of the rescue and resuscitation process 35 36 Effectiveness The effectiveness of suction in submersion victims has not been well studied 37 38 Removing aspirated fluid from the lungs 39 There is a general consensus that little if any fluid can be expelled from the lungs by 40 drainage techniques including suctioning abdominal thrusts or postural drainage this is 41 because after just a few minutes of submersion water is absorbed into the circulation 42 (Harries 1986 Mills-Senn 2000 Braun [Advanced Cardiac Life Support guidelines] 1997 43 DeNicola 1997 Modell 1996) According to the latest American Heart Association 44 guidelines (2005) there is ldquono need to clear the airway of aspirated water because only a 45



90 91















Full reference


Level of Evidence




4






In other studies







6



Mark Harries 2003


Clinical review


Near drowning



the


head down in


only the


hazard and is



early stage ldquo

4

Will Boggs MD

2007


Radiology 2007243862-868




4

cardiac death











5

ECC Guildelines




an


a vacuum of gt300
















5







511 Some


or




John Pearn 1985



4








4





4

Olshaker JS 1992



2b




4





5

Modell JH 1986



4

Michael Verive 2007



4



Simcock 1986



3a




3b

Orlowski JP 1987



2

JAMA 1987 258512- 513


Level of Evidence

Criteria

















indicateL4

























No recommendation















Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125


5

Mills-Senn P 2000



5

Auerbach 2007



5





5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation





90 91















Full reference


Level of Evidence




4






In other studies







6



Mark Harries 2003


Clinical review


Near drowning



the


head down in


only the


hazard and is



early stage ldquo

4

Will Boggs MD

2007


Radiology 2007243862-868




4

cardiac death











5

ECC Guildelines




an


a vacuum of gt300
















5







511 Some


or




John Pearn 1985



4








4





4

Olshaker JS 1992



2b




4





5

Modell JH 1986



4

Michael Verive 2007



4



Simcock 1986



3a




3b

Orlowski JP 1987



2

JAMA 1987 258512- 513


Level of Evidence

Criteria

















indicateL4

























No recommendation















Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125


5

Mills-Senn P 2000



5

Auerbach 2007



5





5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation

















Full reference


Level of Evidence




4






In other studies







6



Mark Harries 2003


Clinical review


Near drowning



the


head down in


only the


hazard and is



early stage ldquo

4

Will Boggs MD

2007


Radiology 2007243862-868




4

cardiac death











5

ECC Guildelines




an


a vacuum of gt300
















5







511 Some


or




John Pearn 1985



4








4





4

Olshaker JS 1992



2b




4





5

Modell JH 1986



4

Michael Verive 2007



4



Simcock 1986



3a




3b

Orlowski JP 1987



2

JAMA 1987 258512- 513


Level of Evidence

Criteria

















indicateL4

























No recommendation















Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125


5

Mills-Senn P 2000



5

Auerbach 2007



5





5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation





Mark Harries 2003


Clinical review


Near drowning



the


head down in


only the


hazard and is



early stage ldquo

4

Will Boggs MD

2007


Radiology 2007243862-868




4

cardiac death











5

ECC Guildelines




an


a vacuum of gt300
















5







511 Some


or




John Pearn 1985



4








4





4

Olshaker JS 1992



2b




4





5

Modell JH 1986



4

Michael Verive 2007



4



Simcock 1986



3a




3b

Orlowski JP 1987



2

JAMA 1987 258512- 513


Level of Evidence

Criteria

















indicateL4

























No recommendation















Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125


5

Mills-Senn P 2000



5

Auerbach 2007



5





5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation



cardiac death











5

ECC Guildelines




an


a vacuum of gt300
















5







511 Some


or




John Pearn 1985



4








4





4

Olshaker JS 1992



2b




4





5

Modell JH 1986



4

Michael Verive 2007



4



Simcock 1986



3a




3b

Orlowski JP 1987



2

JAMA 1987 258512- 513


Level of Evidence

Criteria

















indicateL4

























No recommendation















Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125


5

Mills-Senn P 2000



5

Auerbach 2007



5





5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation



ECC Guildelines




an


a vacuum of gt300
















5







511 Some


or




John Pearn 1985



4








4





4

Olshaker JS 1992



2b




4





5

Modell JH 1986



4

Michael Verive 2007



4



Simcock 1986



3a




3b

Orlowski JP 1987



2

JAMA 1987 258512- 513


Level of Evidence

Criteria

















indicateL4

























No recommendation















Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125


5

Mills-Senn P 2000



5

Auerbach 2007



5





5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation









511 Some


or




John Pearn 1985



4








4





4

Olshaker JS 1992



2b




4





5

Modell JH 1986



4

Michael Verive 2007



4



Simcock 1986



3a




3b

Orlowski JP 1987



2

JAMA 1987 258512- 513


Level of Evidence

Criteria

















indicateL4

























No recommendation















Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125


5

Mills-Senn P 2000



5

Auerbach 2007



5





5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation










4





4

Olshaker JS 1992



2b




4





5

Modell JH 1986



4

Michael Verive 2007



4



Simcock 1986



3a




3b

Orlowski JP 1987



2

JAMA 1987 258512- 513


Level of Evidence

Criteria

















indicateL4

























No recommendation















Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125


5

Mills-Senn P 2000



5

Auerbach 2007



5





5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation







4

Olshaker JS 1992



2b




4





5

Modell JH 1986



4

Michael Verive 2007



4



Simcock 1986



3a




3b

Orlowski JP 1987



2

JAMA 1987 258512- 513


Level of Evidence

Criteria

















indicateL4

























No recommendation















Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125


5

Mills-Senn P 2000



5

Auerbach 2007



5





5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation







5

Modell JH 1986



4

Michael Verive 2007



4



Simcock 1986



3a




3b

Orlowski JP 1987



2

JAMA 1987 258512- 513


Level of Evidence

Criteria

















indicateL4

























No recommendation















Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125


5

Mills-Senn P 2000



5

Auerbach 2007



5





5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation





Simcock 1986



3a




3b

Orlowski JP 1987



2

JAMA 1987 258512- 513


Level of Evidence

Criteria

















indicateL4

























No recommendation















Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125


5

Mills-Senn P 2000



5

Auerbach 2007



5





5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation



JAMA 1987 258512- 513


Level of Evidence

Criteria

















indicateL4

























No recommendation















Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125


5

Mills-Senn P 2000



5

Auerbach 2007



5





5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation












indicateL4

























No recommendation















Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125


5

Mills-Senn P 2000



5

Auerbach 2007



5





5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation























No recommendation















Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125


5

Mills-Senn P 2000



5

Auerbach 2007



5





5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation















Full reference


Level of Evidence

Harries M 1986

BMJ 71286 293 (6539) 122-125


5

Mills-Senn P 2000



5

Auerbach 2007



5





5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation







5




4




4

Harries M 2003




4

Ibsen LM Koch T



4



Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation





Modell JH 1993





4

Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation



Modell JH 1966



3c




4

Quan 1993



4





5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation







5




2






4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation








4






5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation








5





4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation







4

Ornato JP 1986



4

Cahill JM 1968



4



Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation





Manolios N 1988



4

Bierens JJ 1990



3a

Level of Evidence

Criteria































Auerbach (2007) In















No recommendation
































Auerbach (2007) In















No recommendation

















No recommendation



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