Don’t use compression only CPR for drowning victims

Compression-only CPR has improved bystander participation and patient survival for OOCA. Advertisements on television and in print media have done a good job of increasing layperson awareness of this modality. And for many patients, it’s the right thing to do. But only if the etiology of their cardiac arrest is cardiac in nature. As is explained in this short little “article in press” that’s actually a letter to the editor, this can ignore the true cause of arrest in drowning victims and decrease their chance of survival.

In drowning victims, it’s primarily respiratory in nature, and they absolutely need ventilations. But how many of the ads for CCPR are that nuanced? I certainly haven’t seen any, and I would imagine many of the rest of you haven’t either. The major societies (ECR and AHA) are certainly aware of it, as their guidelines strongly urge proper use of respiratory support.

European Resuscitation Council Guidelines for Resuscitation 2015 (2,4)

Most cardiac arrests of non-cardiac origin have respiratory causes, such as drowning (among them many children) and asphyxia. Rescue breaths as well as chest compressions are critical for successful resuscitation of these victims.

“Most drowning victims will have sustained cardiac arrest secondary to hypoxia. In these patients, compression-only CPR is likely to be ineffective and should be avoided.

American Heart Association (AHA) 2010

CPR for drowning victims should use the traditional A-B-C approach in view of the hypoxic nature of the arrest

The first and most important treatment of the drowning victim is the immediate provision of ventilation.

And since preventable drowning deaths can be due to improperly or not-at-all performed bystander CPR, this gap between the guidelines and the layperson needs to be closed by education. Anticipatory guidance for parents with pools, people who take part in watersports, and lifeguards can help, but really there needs to be a public campaign for CPR for drowning that’s similar to that of cardiac arrest of coronary artery disease. 

Specifically, any instructional materials need to address the dreaded mouth foam that can appear during resuscitation, as this is a major deterrent for anyone performing mouth to mouth.

So yeah, maybe we can dial back on the CCPR a bit, and focus on getting patients the best care available specific to their process.


  • Schmidt A, Szpilman D, Berg I, Sempsrott J, Morgan P. A call for the proper action on drowning resuscitation. Resuscitation. 2016 Aug;105:e9-e10. [PMID 27234851]
  • European Resuscitation Council Guidelines for Resuscitation 2015
  • Spencer B, Chacko J, Sallee D; American Heart Association. The 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiac care: an overview of the changes to pediatric basic and advanced life support. Crit Care Nurs Clin North Am. 2011 Jun;23(2):303-10 [PMID 21624692]

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EBM Gone Wild

Wilderness Medicine

Emergency physician with interests in wilderness and prehospital medicine. Medical Director of the Texas State Aquarium, Padre Island National Seashore, Robstown EMS, and Code 3 ER | EBM gone Wild | @EBMGoneWild |


  1. In the light of the pandemic, etc. would any of us be prepared to give 2 rescue breaths to a complete stranger? This conundrum has been toying in my head for quite a while now. Any thoughts?

  2. I encountered this dilemma when a surfer washed ashore sans surf board with unknown injuries, length without oxygen, etc. I was doing chest compressions only, and it wasn’t the foam or vomit that deterred me from giving rescue breaths, but the fear of COVID. I was in close proximity to his mouth/nose and would have been at risk regardless. It was a tricky situation because I knew what I had to do for the man to have the highest chance of survival but I also worried the entire time. In retrospect, I should have just done the rescue breaths. I was exposed anyway.

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