Posted in January 2000 on the Corporate site for American Red Cross:
AMERICAN RED CROSS
ADVISORY COUNCIL ON FIRST AID AND SAFETY
Use of the Heimlich Maneuver First in Near-drowning Victims (See Disclaimer)
Question: After removing a victim of near-drowning from the water, what is the first step a rescuer
should be trained to do?
Overview: The American Heart Association (AHA) Guidelines for Cardiopulmonary Resuscitation (CPR)
and Emergency Cardiac Care (ECC) state that if a victim is not breathing, the rescuer should
initiate CPR immediately. If the ventilation efforts do not make the victim's chest rise, the
rescuer should attempt to clear the airway by using age-appropriate methods for relief of foreign
body airway obstruction. These AHA CPR/ECC guidelines are supported by the American Academy of
Pediatrics, the American College of Cardiology, the American College of Emergency Physicians and the
Institute of Medicine of the National Academy of Sciences.
Despite consensus on these guidelines, Henry J. Heimlich MD, who developed the maneuver to relieve
choking victims, contends that in cases of near-drowning the Heimlich maneuver should be the first
procedure attempted, before CPR. Dr. Heimlich contends that water gets into and obstructs the airway
of near-drowning victims and that his maneuver will relieve this obstruction.
Review Process: The titles and abstracts of 117 citations were retrieved using a computerized search
of the National Library of Medicine Medline database from 1966 to 1999. MeSH heading combinations of
"drowning" or "near-drowning" with "Heimlich maneuver" were used as search parameters. The abstracts
of all citations were reviewed and those that appeared to be appropriate were selected for review of
the complete reference. Manual search of the reference lists from these articles was also conducted
for additional citations that might be relevant. This process resulted in the review of 27 citations
of which 18 (all class III) were found to discuss the role of the Heimlich maneuver in
near-drowning.
Scientific Foundation: Heimlich states that near-drowning victims aspirate large amounts of water
and that the water causes obstruction of the airway. He advocates that the safest and most
effective method for removing water from the lungs of a near-drowning victim is the
subdiaphragmatic abdominal thrust (Heimlich maneuver). He states that this maneuver should be the
first step in the management of the near-drowning patient and should be repeated until no water or
fluid flows from the patient's mouth. In order to minimize the risk of aspiration (which he
believes to be low since the patient is not breathing and will not inhale any vomitus), the head of
the patient should be turned to one side or on a sloping shore the patient can be placed in a head
down position. Heimlich cites several anecdotal case reports, including one involving an aspirated
piece of vegetable, to support his opinion.,
There is no scientific literature available supporting the concepts that near-drowning victims
aspirate large volumes of water, that aspirated water obstructs the airway of near-drowning
victims, that the water must be removed immediately upon rescue of the patient, or that the
Heimlich maneuver (abdominal thrust) is an effective and safe method for removing aspirated water
from the airway and lungs.
Modell in a review article reported that 15% of near-drowning patients have no evidence of any water
aspiration. The remaining 85% do aspirate some water, up to 22 milliliters per kilogram of body
weight, although he stresses that in many cases the amount is much less than the 22
ml/kg. He points out that one would expect electrolyte abnormalities in patients who have aspirated
large amounts of water. In actuality, these changes are rarely found, thus suggesting that
aspiration of large amounts of water does not occur. Modell recommends immediate airway control
and initiation of ventilation and correction of hypoxemia. Simcock also reported that many
patients of near-drowning did not have any signs of aspiration of water, including some who
appeared apneic when removed from the water.
Rosen, chairing an expert committee for the Institute of Medicine (IOM), could find no evidence that
water aspiration in fact causes obstruction or prevents efforts to ventilate patients. The IOM panel
recommended that the current ECC guideline of establishing an airway and ventilation be the
priority. Quan, in a study of submersion victims, reported no finding of airway fluid to impair
paramedics' ability to intubate nor any difficulty in ventilating patients once intubated.,
The sequence of events which occurs following water aspiration into the lungs includes laryngospasm,
fluid shifts across the pulmonary alveolar membrane, destruction of surfactant, atalectasis,
intrapulmonary shunting, and pulmonary edema formation. Weinstein et al point out the final
pathophysiologic result of near drowning is hypoxemia. As was stated in the IOM report 8, there is
no evidence in any study that removing water from the lungs will alter this sequence of events.
Numerous other authorities have also recommended that obtaining an airway, ventilating the patient
and correcting hypoxemia are the immediate treatment priorities.11,12,13,14,15
Weinstein et al point out that no study has demonstrated that the Heimlich maneuver can result in
the removal of significant amounts of fluids from the lungs of these patients.11 He also raises the
concern that an abdominal thrust may cause vomiting. This could interfere with efforts to ventilate
the patient or may result in aspiration and further deterioration of the pulmonary status. Others
have also echoed the concerns about inducing regurgitation or vomiting.13 Finally Weinstein also
voices the concern that efforts to perform the Heimlich maneuver delay the establishment of an
airway, ventilation and correction of hypoxemia.
The recommendation by Heimlich that the victim's head be turned to the side to facilitate drainage
of fluid expelled as a result of performing the Heimlich maneuver has also raised concerns about the
potential for exacerbation of a possible cervical spine injury in some patients.8
Summary: The available scientific evidence supports the position that victims of near-drowning
should first have a patent airway secured, ventilation initiated, and hypoxemia corrected. If
efforts to ventilate the patient suggest obstruction of the airway, the Heimlich maneuver may be
performed in an attempt to clear the obstruction.
Recommendation Strength:
Standards: There is no evidence to support a treatment standard.
Guidelines: There is no evidence to support a treatment guideline.
Options: The first step after removing a victim of near-drowning from the water should be to obtain
an airway, initiate ventilation and correct hypoxemia. If the patient cannot be ventilated,
suggesting a tracheal obstruction, the Heimlich maneuver may be performed to attempt to clear the
obstruction.
