The Use of the Heimlich Maneuver in Near Drowning

Peter Rosen, Michael Stoto, and Jim Harley

Editors

Committee on the Treatment of Near-Drowning Victims

Division of Health Promotion and

Disease Prevention

JNSTITUTE OF MEDICINE
Washington, D.C. 1994

August 1994
Institute of Medicine 2101 Constitution Avenue, N.W. Washington, DC 20418 I w-

NOTICE: The project mat is the subject of this report was approved by the Governing Board of the
National Research Council, whose members are drawn from the councils of the National Academy 1 pet
of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of
the committee responsible for the report were chosen for their special competencies and with regard .
for appropriate balance. | Ro;
This report has been reviewed by a group other than the authors according to procedures ^
approved by a Report Review Committee consisting of members of the National Academy o f , gm
Sciences, the National Academy of Engineering, and the Institute of Medicine. |
The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to^ ^
enlist distinguished members of the appropriate professions in the examination of policy matters ^
pertaining to the health of the public. In this, the Institute acts under the Academy's 1863 i Sol
congressional charter responsibility to be an adviser to the federal government and its own initiative A
in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of j J^J
the Institute of Medicine.
Support for this study was provided by the Institute of Medicine.

Additional copies of this report are available from:

Division of Health Promotion and Disease Prevention

Institute of Medicine _ f ! Ins
2101 Constitution Avenue, N.W. | ,
Washington, DC 20418 | Mic

Copyright 1994 by the National Academy of Sciences. All rights reserved.

IJ l Cv
L.
I Die
The serpent has been a symbol of long life, healing, and knowledge among almost all cultures J j ym
and religions since the beginning of recorded history. The image adopted as a logotype by the f
Institute of Medicine is based on a relief carving from ancient Greece, now held by the ^
Staatlichemusseen in Berlin.

In:

_X
 f ^ C O M M n T E E ON THE TREATMENT OF NEAR-DROWNING VICTIMS

7 Peter Rosen* (Cforir), Director, Emergency Medicine Residency ^ f ^ ^ ^ . ^

>f ! of Clinical Medicine and Surgery, Division of Emergency Medicine, Umversity of
d | California, San Diego
Roger Barldn, Chairman, Department of Pediatrics and Newborn Medicine, and
s Director, Pediatric Emergency Services, Rose Medical Center, Denver
Susan McHenry, State Director of Emergency Medical Services, Virginia Department of
Health, Richmond
Harvey Meislin, Director, Arizona Emergency Medical Research Center,
University of Arizona Health Sciences Center, Section of Emergency Medicine
Solbert Permutt, Department of Pulmonary and Critical Care, Johns Hopkins Umversity
School of Medicine
T.ircfmianan Sathvavagiswaran, Chief Medical Examiner-Coroner, Los Angeles County
Department of Coroner
Robert Van Citters, Professor of Medicine, Professor of Physiology
and Biophysics, and Dean Emeritus, School of Medicine, Umversity of Washington

Institute of Medicine Staff

Michael Stoto, Director, Division of Health Promotion and Disease Prevention

Cynthia Abel, Program Officer
Linda DePugh, Administrative Assistant
Diana Johnson, Project Assistant . , .. . -u-,^ .
Jim Harley, Staff Consultant, Department of Pediatric Emergency Medicme, Children s
Hospital and Health Center, San Diego ;
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 HOUSTON ACAUbMY OF MEDICINE
TEXAS MEOICAL CENTER U6RARY

Contents

Executive summary 1

Introduction 3

Historical Background 3

Methodology 5

Results I 6
Proposition 1 6
Proposition 2 7
Proposition 3 8
Proposition 4 10

Conclusions and Recommendations 12

Appendix A: Workshop Agenda 15

Appendix B: Workshop Participants 16

Appendix C: Summary of Henry Heimlich's Presentation 17

Appendix D: Summary of Edward Patrick's Presentation 18

Appendix E: Summary of Eric Spletzer's Presentation 19

Appendix F: Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiac Care

(American Heart Association) 20

References 23

v
 Executive summary

The application of the Heimlich maneuver as the initial and perhaps only
step for opening the airway in all near-drowning victims has been proposed by
Henry Heimlich and Edward Patrick. This is contrary to current resuscitation
guidelines for the treatment of near-drowning victims established by the
Emergency Cardiac Care (ECC) Committee of the American Heart Association.
To help resolve this difference, the Institute of Medicine (IOM) convened an
expert committee to determine when the Heimlich maneuver should be used in the
treatment of near-drowning victims, if at all. During its deliberations, the IOM
Committee on the Treatment of Near-Drowning Victims met with Dr. Heimlich
and his colleagues and considered literature reviews of clinical and basic research
on drowning, scientific articles on pertinent pathophysiological states involving
fluid in the airways, and its own clinical experience.

The committee concludes that, although the Heimlich maneuver is useful

for the removal of aspirated solid foreign bodies, there is no evidence that death
from drowning isfrequentiycaused by aspiration of a solid foreign body that is
not effectively treated by the current ECC recommendations. The committee
further finds mat the evidence is insufficient to support the proposition that the
Heimlich maneuver is useful for the removal of aspirated liquid. Moreover,
because mere is no evidence to support Heimlich's hypothesis that substantial
amounts of water are aspirated by near-drowning victims or that such aspirated
liquid causes brain damage and death, the committee finds that the available
evidence does not support routine use of the Heimlich maneuver in the care of
near-drowning victims.

The committee also has a series of concerns about the routine use of the
Heimlich maneuver for treatment of near drowning, because of: (a) the amount of
time it would take to repeat this maneuver until the patient is no longer expelling
water (as recommended by Heimlich) and how long this would delay the initiation
of artificial ventilation; (b) possible complications of the Heimlich maneuver,
especially if Ihe near drowning is associated with a cervical fracture; and (c) the
prospect of teaching rescue workers a different protocol than mat which is taught
at present for resuscitating victims of cardiopulmonary arrest from all causes other
man near drowning.

The committee therefore concludes that given the present state of basic
science and clinical knowledge about near drowning, the current ECC
recommendations for establishment of the airway and ventilation should not be
changed. These recommendations state that an abdominal thrust should be
performed only after ventilation has been shown to be ineffective and then only to
remove a solid foreign body.

1
 Introduction

Drowning is the second leading cause of accidental death among children

and young adults in the United States. In 1989, mere were 4,600 accidental
drowning deaths, 1,200 among children (0-14 years of age) and 900 among young
adults (15-24 years of age).1 Preventing death from drowning requires the
establishment of adequate ventilation. Current resuscitation guidelines for the
treatment of near-drowning victims established by the Emergency Cardiac Care
(ECC) Committee of the American Heart Association (AHA) are focused on
opening the airway and the early administration of artificial respiration for
apnea.2 The ECC recommends mouth-to-moulh respiration followed by efforts to
open the airway, including abdominal thrusts, if the airway is obstructed.

The application of the Heimlich maneuver as the initial and perhaps only
step for opening the airway in all near-drowning victims has been proposed by
Henry Heimlich and Edward Patrick.3-4'5,6,7,8 According to Heimlich,
"Evacuation of water from the lungs by pulmonary compression should be the first
step in resuscitating a drowning person. . . . The subdiaphragmatic pressure
[Heimlich maneuver] should be performed and repeated until no water flows from
the mourn. In the event that spontaneous respiration does not occur, standard
resuscitative methods should then be used immediately."5 The Heimlich-Patrick
method for treating submersion victims is first to perform the Heimlich maneuver
to remove fluid, followed by mouth-to-mouth resuscitation and chest compressions
(CPR), if necessary.8
To help resolve these differences in recommendations regarding the
treatment of drowning, in 1993 the Institute of Medicine (LOU) convened an
expert committee to determine when the Heimlich maneuver should be used in the
treatment of near-drowning victims, if at all.

Historical Background

Methods used for resuscitating drowning victims before the 1900s included
back slapping, shaking, placing burning coals on the victim, insufflating tobacco
smoke into the lungs and rectum, and burying the victim up to the neck in horse
dung. The controversy concerning the role of manual compression with or
without ventilation by lung insufflation in drowning resuscitation is quite old. In
1829, Leroy-d'Etiolles argued that insufflation should not be taught to laypeople
because of the danger of overinflation of the lungs when given by untrained

3
 THE USE OF THE HEIMUCH MANEUVER IN NEAR DROWNING

people. He recommended mat the thorax and abdomen be compressed in the

supine position to simulate expiration followed by a period of relaxation to
simulate inspiration.9

In the first half of the twentieth century, artificial manual respiration

became the norm. In 1958, Safar compared the accepted Holger-Nielsen method
of artificial manual respiration (extension of a prone victim's arms in inspiration
and pressure on the scapulae in expiration) to mouth-to-mouth ventilation. The
tidal volume exchanged with the manual method was less than the dead air space.
Mouth-to-mouth respiration was much more effective.10 Soon after Safaris
study, mouth-to-mouth resuscitation became the standard technique for drowning
resuscitation, and attempts to drain water from the lungs were no longer
recommended.8,11 The current ECC recommendations call for "immediate
ventilation and rescue breathing," with use of the Heimlich maneuver only in
cases in which "the rescuer suspects that foreign matter is obstructing the airway
or the victim does not respond appropriately to mouth-to-mouth ventilation."2

Heimlich introduced the abdominal thrust technique for resuscitation of f

food-choking victims in 1974 and requested that anytime the maneuver was used, |
a report of the results be sent to him. By 1975, he had collected over 162 case g
reports. There were 5 unanticipated reports of the Heimlich maneuver being used |
to resuscitate near-drowning victims, and afterward Heimlich recommended that %
the technique be used for near-drowning victims.12 y

At the 1985 AHA National Conference on Standards for Cardiopulmonary

Resuscitation and Emergency Cardiac Care, after extensive review and discussion
of clinical, research, and anecdotal data related to the efficacy of the Heimlich
maneuver, the procedure was recommended for use with drowning only if foreign
body aspiration was suspected or if mouth-to-mouth ventilation was unsuccessful. -1
The ECC Committee also recommended mat further investigations be undertaken
to determine the need for, timing, and risk of using subdiaphragmatic thrusts in
the resuscitation of drowning patients.13 In 1992, the ECC Committee reviewed
these recommendations and left them unchanged, resulting in the guidelines ;
summarized in the Introduction and Appendix F.2

For more than 40 years, the National Research Council has provided |
scientific advice to the American National Red Cross. In 1989, the Committee to %
Advise the American National Red Cross moved to the IOM Division of Health f
Promotion and Disease Prevention. In February 1991, the IOM released a brief |
report in response to a request from the Red Cross to address three specific |
aquatic issues: (1) wet versus dry lungs, (2) the Heimlich maneuver, and (3) in- |
water rescue breathing. The report concluded, among other things, that the j
Heimlich maneuver should not be used prior to executing the airway, breathing, |
and circulation (ABCs) assessment and correction measures on near-drowning |
victims. The report recommended that abdominal thrusts be performed only on \

3
\
THE USE OF THE HEIMLICH MANEUVER IN NEAR DROWNING 5

near-drowning victims on land, when the rescuer suspects airway obstruction after
ABC measures have been attempted and proven unsuccessful.14 After its
completion, Heimlich challenged the report, and a review committee of the
National Academy of Sciences suggested mat the committee's study process was
not adequately suited to the task. IOM President Kenneth I. Shine therefore
decided mat a new committee should be appointed to review this issue.

In response, the IOM Division of Health Promotion and Disease

Prevention assembled a committee to review and evaluate the available scientific
literatmVon the treatment of near-drowning victims. The charge to the committee
was to determine when the Heimlich maneuver should be used in the treatment of
near-drowning victims, if at all. The committee convened a workshop on
November 20, 1993, at the Academy's Arnold and Mabel Beckman Center in
Irvine, California, to address the appropriateness of immediately using the
Heimlich maneuver on all near-drowning victims. The workshop consisted of
several brief presentations followed by interactive discussions among participants
and committee members (see the appendixes). Letters from other experts on
resuscitation were solicited by IOM staff and made available to the committee and
the workshop participants.

Methodology

To guide its deliberations, the committee considered the following four

propositions:

1. Death from drowning is frequently caused by aspiration of a solid

foreign body mat is not effectively treated using die current ECC
recommendations.

2. The Heimlich maneuver is useful for the removal of aspirated solid

foreign bodies.

3. Death from drowning, when no foreign body is aspirated, is caused by

aspiration of liquid mat prevents ventilation and oxygenation.

4. The Heimlich maneuver is useful for the removal of aspirated liquid.

The committee used three types of information in reaching its conclusions:

(1) literature reviews of clinical and basic research on drowning, (2) selected
scientific articles on pertinent pathophysiological states involving fluid in the
airways, and (3) the clinical experience of the panelists, workshop participants,
and consultants.
 THE USE OF THE HEMLLCH MANEUVER IN NEAR DROWNING

The primary charge to the committee was to analyze the scientific and
medical literature published on the Heimlich maneuver and its use in drowning
resuscitation. Literature reviews were performed by workshop presenters as well
as by the committee staff. A comprehensive literature search was performed
using MEDLINE. The staff also examined the reference lists in articles mat
Heimlich and Patrick had published on the subject, as well as those in other
scientific and review articles.

Results

The committee found no valid controlled clinical research studies that

directly examined any of the four propositions. Indeed, very little information on
the circumstances of drowning exists.15 The available indirect data are discussed
below in conjunction with the analysis of the four propositions.

Proposition 1
Death from drowning is frequently caused by aspiration of a solid foreign
body that is not effectively treated using the current ECC recommendations.

Although mud, sand, and aquatic vegetation may be aspirated by someone

drowning in natural fresh water or salt water,16 the committee is not aware of
evidence that such bodies frequently interfere with mouth-to-mouth ventilation.

Gordon and Terranova report the case of a 2-year-old boy who arrived at
an emergency department pulseless and apneic after a cold-water near
drowning.17 He was given mouth-to-mouth respirations prior to arrival and
vomited just outside of the emergency department. He was intubated but no air
would pass through the tube with ventilation. The Heimlich maneuver was
performed three times and a large piece of celery was expelled from the trachea.
The child was then successfully ventilated. This case illustrates that near-
drowning victims can have airways obstructed by solid objects after vomiting
secondary to drowning.

Reporting on a series of ocean drownings in Australia, Manolios and

Mackie noted a high incidence of both vomitus as well as seaweed and sand in the
tracheas and bronchi of drowning victims, but the authors do not indicate whether
these foreign bodies contributed to the deaths of these individuals.18 Moreover,
it is not easy to extrapolate data from this population of ocean swimmers to those
who drown in swimming pools or calm water.

In Los Angeles County, where there are 130 to 135 drowning deaths per
year, no evidence of obstructing foreign bodies was found in a 2-year period
regardless of whether the victims had gone to a hospital emergency department
THE USE OF THE HEIMLICH MANEUVER IN NEAR DROWNING

before being autopsied. (Sathyagiswaran, L. January 3, 1994. Memorandum to

Michael Stoto.)

Conclusion The committee is aware of no scientific evidence of a

substantial incidence of solid foreign body obstruction of the trachea or a main
stem bronchus in drowning cases. Thus, based on a literature review and the
clinical experience of the committee members and consultants, the committee finds
no evidence to support Proposition 1, that death from drowning is frequently
caused by aspiration of a solid foreign body mat is not effectively treated using the
current ECC recommendations.

Proposition 2
The Heimlich maneuver is useful for the removal of aspirated solid foreign
bodies.
The committee did not review the literature or experimental evidence on
the efficacy of the Heimlich maneuver in the removal of solid foreign bodies
because it is outside of the scope of this investigation into near drowning.
However, the committee members' clinical experience does indicate that the
Heimlich maneuver is useful when treating choking victims, that is, when the
aspirated body is large enough to block the passage of air into the lungs.

Heimlich was queried as to the incidence of complications of the maneuver

and was asked if mere was a higher risk of complications if the maneuver was
performed on unconscious victims versus those who still had some ability to flex
their abdominal musculature in response to the maneuver. He stated that the only
complications of which he was aware were from an incorrect performance of the
abdominal thrust, and that it was his conclusion that the maneuver was actually
safer when used with unconscious victims.

Review of the literature revealed case reports of injuries due to abdominal

thrusts, but there was no evidence to indicate whether or not such injuries resulted
from incorrect performance of the maneuver, nor were there data concerning the
relative danger of an abdominal thrust in unconscious versus conscious choking
victims. Serious complications that have been noted when the Heimlich maneuver
was used on choking victims include: (1) stomach rupture,19 (2) aortic valve
rupture,20 (3) diaphragmatic rupture,21 (4) esophageal rupture,22 (5) jejunal
rupture,20 (6) mesenteric laceration,23 (7) thrombosis of an aortic abdominal
aneurysm,24 (8) pneumomediastinum,25 and (9) retinal detachment26 Six
patients have been reported to have died from complications of this procedure.1'
Vomiting and abdominal tenderness are less serious complications of the
procedure.27 One potential complication that has not been reported is the
manipulation of a cervical spine injury, a concomitant injury found in many near-
drowning victims. If a cervical spine injury is suspected, it would be very
difficult to perform the Heimlich maneuver safely, and turning the head to the side
 THE USE OF THE HEIMLICH MANEUVER IN NEAR DROWNING

(if thought to be necessary for the success of the maneuver) would greatly
endanger the integrity of spinal cord function.

Conclusion The committee concludes that Proposition 2 is true, mat is,

that the Heimlich maneuver is useful for the removal of aspirated solid foreign
bodies. There is concern, however, about the risks associated with using mis
procedure, especially on unconscious victims who might have cervical spine
injuries.

Proposition 3
Death from drowning, when no foreign body is aspirated, is caused by
aspiration of liquid that prevents ventilation and oxygenation.

Much of the debate centers on the use of the Heimlich maneuver centers
around the pathophysiology of drowning. Heimlich's view, which the committee
considered, is summarized in his statement that "you cannot get air into the lungs
until the water is out."8 When a person drowning in water can no longer suppress
inspiration, gasping occurs and water enters the mouth and pharynx. Exactly how
much water enters the lungs is a matter of controversy. Heimlich and his
colleagues state that it is a large amount, and that air cannot reach me alveoli
because of airway obstruction with water. Others state that only a small amount
of water enters and that it is rarely enough to impede ventilation.

Modell estimates that 85 percent of patients who survive near drowning

aspirate 22 ml of water per kilogram of body weight or tew.28 This estimate is
based on postmortem chloride measurements that were extrapolated from known
changes in serum chloride levels in dogs who had 22 cc/kg of water placed in
their lungs.29 Heimlich cites this study to support the use of subdiaphragmatic
thrusts, arguing mat 100- to 150-lb individuals would have up to 1,000-1,500 ml
of water in their lungs.5 Modell wrote that Heimlich has misinterpreted his
study.30 He also stated that in the 118 drowning victims he studied, there were
not significant amounts of water in the trachea, and that he is "convinced that
significant blockage of the airway by free water is uncommon."30 Modell also
finds that it is unusual for near-drowning victims to have substantial changes in
serum electrolyte concentrations.31 He interprets this to mean that either only a
small amount of fluid is aspirated or the fluid is rapidly redistributed.32

Harries wrote that it is unusual to aspirate more than 200 cc of fluid.33

The clinical argument against a large amount of fluid being present in the airway
is that the majority of near- drowning victims can be ventilated without evidence
of airway obstruction.34

The sequence of events in drowning starts with breath-holding and panic,

followed by a period of increasing air hunger and reflex inspiratory efforts that
force the victim to swallow and inhale.35 Peripheral airway resistance increases,
THE USE OF THE HEIMLICH MANEUVER IN NEAR DROWNING

laryngospasm may occur, reflex pulmonary vasoconstriction leads to pulmonary

hypertension, lung compliance decreases, fluid shifts across the alveolar
myembrane, surfactant may be destroyed or altered, and pulmonary edema forms.
Alteration or destruction of surfactant, if it occurs, leads to atelectasis, which in
turn leads to intrapulmonary shunting. All of these changes lead to hypoxia,
which is the cause of death and cerebral morbidity in almost all cases of
submersion injury.36 While it clearly would be advantageous to prevent these
changes from occurring, no published studies demonstrate that removal of water
from the lungs will stop this chain of events.

Physiological studies in animals provide a limited amount of information

on drowning pathophysiology but must be viewed with some skepticism given the
marked anatomical and physiological differences between small animals and
humans. Emergency resuscitation of drowning victims requires adequate alveolar
ventilation to restore normal blood oxygen levels rapidly;10 therefore, a clear path
from die mouth to the alveoli is a prerequisite for effective ventilation. Karpovich
reported that fluid and foam obstruction of the airway did affect survival in
rats,37 but this has not been confirmed by Modell or in other postmortem
observations in humans.

In 1909, Emerson showed that the application of positive airway pressure

prevented death in experimentally induced pulmonary edema in rabbits.38 Barach
et al. later showed that positive airway pressure brought about dramatic alleviation
of symptoms in patients with pulmonary edema.39 Following the work of
Ashbaugh et al. in 1969, continuous positive-pressure breathing became one of the
principal methods of treating pulmonary edema in critically ill patients.40

A recent study by Tutuncu and colleagues of partial liquid ventilation with

perfiuorocarbon (PFC) in animals with acute respiratory failure is also relevant to
Proposition 3. Tutuncu and colleagues began by producing acute respiratory
failure in rabbits by repeated lung lavage with warm saline to achieve an arterial
Po, below 100 mrnHg.41 After this, one group of rabbits had PFC (a liquid of
high density, low surface tension, and high solubility for oxygen) added into the
lungs in three consecutive doses of 6 ml/kg at 5-minute intervals through an
endotracheal tube. This is an amount estimated to equal the rabbits' normal lung
volume at functional residual capacity, and thus was a significant amount of liquid
to be added to the lungs. The result of the addition of PFC to the lungs, in
conjunction with continuous positive-pressure ventilation, was that respiratory
distress was markedly improved. This study used two control groups of rabbits,
one in which 18 ml/kg of normal saline was instilled through the endotracheal
tube, and another in which no liquid was used. Although the authors wanted to
show mat it is not the liquid per se that caused the improvement, the important
result with respect to the treatment of near drowning is that mere were no
significant differences between the two control groups. This indicates that despite
a large difference between the two control groups in the amount of water in the
 THE USE OF THE HEIMLICH MANEUVER IN NEAR DROWNING
J
i
4

!i

lungs, intermittent positive-pressure ventilation was essentially equally effective. \

These results are incompatible with Heimlich's idea that "you cannot get air into I
the lungs until the water is out."8
t

Conclusion Based on the literature cited, the committee concludes mat

there is likely to be some aspiration of water during drowning. Except for a small i
percentage of victims (less than 10 percent), water can be found in the trachea and
bronchi of drowned victims.28 There is, however, considerable debate as to how i
much water is aspirated. In no study has a significant electrolyte change been f
found, whether drowning has occurred in fresh or salt water. A review of the "
.;
research literature, as well as the clinical literature, finds no evidence of .)
absorption of seawater from ocean drownings, although there does appear to be }
movement of water into the bronchi to dilute the concentrated seawater that was
aspirated.28 The literature is not clear on whether this is merely an osmotic fluid J
shift or whether the victim had developed pulmonary edema from the combination 1
of hypoxia and hypertonicity. f'
"ft
*;J

A substantial body of basic and clinical scientific literature, including the \

studies cited above, indicates that even when large amounts of water are present
within the trachea and bronchi, it is possible to oxygenate patients. Although
mere is limited evidence in the clinical literature to demonstrate the effectiveness
of positive-pressure ventilation and end-expiratory ventilation in near drowmng,
mere is evidence that water does not obstruct ventilation.
4

Heimlich and his colleagues cite several case reports to indicate that
ventilation could not occur until the water in a drowning victim's trachea and
bronchi had been removed by abdominal thrusts (see the next section), but the f.
details of those case reports are incomplete and a full interpretation of these cases -
is impossible.

The clinical and pathological experience of the committee members, as

well as their review of the scientific literature, does not indicate a substantial '
incidence of fluid interfering with ventilation in near-drowning victims. Thus the
committee finds that the available evidence is insufficient to support Proposition 3,
mat death from drowning, when no foreign body is aspirated, is caused by
aspiration of liquid that prevents ventilation and oxygenation.

Proposition 4
The Heimlich maneuver is useful for the removal of aspirated liquid.

Very few research studies have been performed to examine the efficacy of
using the Heimlich maneuver in the resuscitation of near-drowning victims, and no
controlled studies have been done of either the Heimlich maneuver or other
resuscitation methods.
V7ATG THE USE OF THE HEIMLICH MANEUVER IN NEAR DROWNING 11

Heimlich uses an analogy of a straw and a glass of water to explain why

the Heimlich maneuver works to expel water.3 The anatomy of the lungs and
trachea are more complex than a rigid straw allows, thus this analogy does not
seem to be appropriate.

Ruben and Ruben studied the flow of water from the lungs in nine people
soon after they died (of causes not related to drowning).42 One liter of 1 percent
saline was instilled through an endotracheal tube into the lungs. Forceful anterior
chest and abdominal compressions were applied. The result was less than a S
percent return of fluid. A second liter of fluid was instilled into the lungs and
similar results were obtained. They conclude that "when more than a small
amount of water flows from the mouth of a drowning patient, subjected to
artificial respiration, it comes from the stomach." They also state that
"mechanical efforts to drain the lungs are of no practical use; and trying to do so,
before beginning artificial respiration, only means wasting valuable time."

Werner studied the effect of gravitational drainage and abdominal thrusts

after seawater near drowning in dogs.43 Three groups of five dogs were
intubated and asphyxiated, and 30 cc/kg of artificial seawater was instilled into the
lungs. The control group was drained in a horizontal position. The second group
was drained by gravity with 30 of Trendelenburg. The third group was given
four abdominal thrusts. After 1 minute more fluid had drained from the gravity
and abdominal thrust groups, but there was no difference among the groups after
10 minutes. Furthermore, there was no difference in oxygenation or acidosis
among the three groups.

Heimlich reported details of five cases in which the Heimlich maneuver

was used to resuscitate near-drowning victims.8 These were case reports by
people who had responded to his request to tell of instances in which the Heimlich
maneuver had been used. In two of the cases artificial respiration was not
effective initially. After the Heimlich maneuver was used and water flowed from
the mouth, the victim was able to be ventilated and survived. In no instance was
there any determination of whether the water came from the lungs or the stomach.

Patrick reports a case of a 2-year-old boy who had been submerged for 20
minutes. He was given mouth-to-mouth resuscitation for 20 minutes.44 He was
men intubated but could not be ventilated. No breath sounds were heard with
bagging. Patrick applied the Heimlich maneuver several times and substantial
amounts of fluid came through the endotracheal tube. The victim was then able to
be ventilated and survived to be discharged from the hospital. There was,
however, significant brain damage, and he died about 4 months after the drowning
episode.

Orlowski described the case of a 10-year-old submersion victim who

vomited and aspirated the vomit after the Heimlich maneuver was performed.
 THE USE OF THE HEJML1CH MANEUVER IN NEAR DROWNING

The poor outcome in mis patient was attributed to mis complication (the boy died
7 years later).27 Heimlich has argued that this was not a gastric aspiration because
the pH of the fluid was 7.5, despite the fact that Orlowski stated that it looked and
smelled like gastric contents.

Based on an analysis of submersion cases from Ohio, Indiana,

Pennsylvania, and West Virginia reported to him during the spring and summer of
1993, Patrick reported to the committee mat seven out of eight nonbreathing near-
drowning victims without a pulse survived without complications after the
Heimlich-Patrick method was used, whereas only two out of seven survived after
only mouth-to-mouth ventilation was used. Although Patrick labeled mis as a
"prospective study," all of the data on these cases were gathered after Patrick was
notified of each case. Patrick did not develop a consistent method of responding
to the drowning episode or of determining the validity of the data presented.
Anecdotal information obtained retrospectively is obviously fraught with
tremendous limitations in terms of generalizing these observations. Thus these
data are not equivalent to those from a randomized trial in which the populations
treated with each maneuver can be assumed to be comparable.43

Furthermore, in the analysis he presented to the committee, Patrick did not

consistently differentiate between cases with and without a detectable pulse at the
time that resuscitation was begun, which a priori would be a strong confounding
factor. Patrick also was not able to identify how many of the survivors on whom
the Heimlich maneuver had been performed had also had initial mouth-to-mouth
ventilation attempted, with performance of the abdominal thrust only after
ventilation was found to be impossible (the current ECC recommendation).

It has been shown that the Heimlich maneuver causes vomiting, but so
does mouth-to-mouth ventilation, and according to the Australian study, vomiting
is common among drowning victims.18

Conclusion In summary, there is no experimental evidence that an

abdominal thrust removes a substantial volume of aspirated fluid, and there is no
evidence mat near-drowning victims cannot be ventilated adequately without use of
the Heimlich maneuver. The committee therefore concludes that the available data
are insufficient to resolve whether or not Proposition 4, that the Heimlich
maneuver is useful for the removal of aspirated liquid, is true.

Conclusions and Recommendations

The committee concludes that although the Heimlich maneuver is useful

for the removal of aspirated solid foreign bodies, there is no evidence mat death
from drowning is frequently caused by aspiration of a solid foreign body that is
USE OF THE HEIMLICH MANEUVER IN NEAR DROWNING

not effectively treated by the current ECC recommendations. The committee

further finds mat the evidence is insufficient to support the proposition that the
Heimlich maneuver is useful for the removal of aspirated liquid. Moreover,
because there is no evidence to support Heimlich's hypothesis that substantial
amounts of water are aspirated by drowning victims and that such aspirated fluid
causes brain damage and death, the committee finds mat the available evidence
does not support routine use of the Heimlich maneuver in the care of near-
drowning victims.

The committee has a number of concerns about the changes Heimlich and
colleagues have suggested for the present ECC guidelines for treatment of near
drowning. First, whereas the correct performance of a single abdominal thrust
need not be excessively time-consuming, it is not known how much time it would
take to repeat this maneuver until the patient is no longer expelling water (as
recommended by Heimlich), and how long mis would delay the initiation of
artificial ventilation. In drowning situations, even a short delay in restoration of
breathing can cause brain damage and death. Furthermore, it is not clear to the
committee that the Heimlich maneuver is as easily or quickly applied to an
unconscious near-drowning victim as it is to a conscious choking person. Second,
the committee is concerned that beginning resuscitation in all cases with an
abdominal thrust would inhibit rescue workers from performing timely artificial
ventilation because of the natural reluctance to perform mouth-to-mouth ventilation
on a person who has vomited as a result of an abdominal thrust. While the
incidence of vomiting is large in all near-drowning victims, as well as in patients
receiving mouth-to-mouth ventilation, it is also significant in victims who have
received an abdominal thrust Third, there is concern about possible
complications of the Heimlich maneuver, especially that the incidence of
complications may be greater in unconscious victims. Fourth, injuries from
cervical fractures are common in diving accidents and surf drownings, and turning
a victim's head to avoid aspiration of vomitus prior to performing the abdominal
thrust could greatly endanger the victim's life or spinal cord integrity. Heimlich
has recommended omission of the head turn, but if this is not done, the committee
cannot understand why the expelled liquid or solid foreign body would not be
reaspirated. Fifth, the committee is also concerned about teaching rescue workers
a different protocol man that which is taught at present for resuscitating victims of
cardiopulmonary arrest from all causes other man near drowning. The committee
feels that given the wide variety of workers who deliver cardiopulmonary
resuscitation, it is important to have a simple, constant system that can be applied
in any prehospital care situation. Complicating the simple system currently taught
could, in the committee's judgment, lead to more harm man good-that is, more
injuries and deaths man lives saved.

The committee therefore concludes that given the present state of basic
science and clinical knowledge about drowning, the current ECC recommendations
for establishment of the airway and ventilation should not be changed. These
 THE USE OF THE HEIMLICH MANEUVER IN NEAR DROWNING

recommendations state mat an abdominal thrust should be performed only after

ventilation has been shown to be ineffective, and men only to remove a solid
foreign body. Although there are no randomized trials of mouth-to-mouth
resuscitation, the ECC recommendations are based on an extensive review of
physiological, clinical, and anecdotal data, using established standards for
scientific evidence.

The committee is concerned about the absence of valid data on the efficacy
of the Heimlich maneuver in near-drowning cases. Obtaining such data would
require prospective randomization in a defined population to ensure mat the test
groups are similarly sampled and, in particular, mat no group has a higher
incidence of victims lacking respirations or a pulse. Such as study should include
the entire population at risk, not just cases chosen retrospectively after hearing
about an episode. Given the lack of evidence for the effectiveness of the use of
the Heimlich maneuver in near-drowning situations and ethical concerns about
doing research without a person's or surrogate's informed consent, it is hard to
imagine a research methodology for such a study that would or should be
approved by a human studies committee.

However, while the effectiveness of the Heimlich maneuver in altering the

clinical course in recovery of pulmonary functions after near drowning in humans
is difficult to study in a controlled trial, its effectiveness can be studied in animals.
The major characteristics of near drowning can be produced in anesthetized
experimental animals, and even larger amounts of fresh water or seawater can be
instilled into the airways man might be present in near drowning in humans. If
the animal studies showed that the clinical course was improved and the recovery
of pulmonary function was accelerated with the application of abdominal thrusts as A
proposed by Heimlich, a stronger case could be made for consideration of a
change in the current ECC guidelines. A review of the literature reveals only one ;
such study, which concluded that more fluid could be drained initially with
abdominal thrusts, but that after 10 minutes the total amount of fluid drained was
the same whether abdominal thrusts or gravity was used, and mat the thrusts
produced no significant effect on oxygenation over the 6 hours of study.43 This
one study, of course, is not definitive, but before current standards are changed,
some supportive evidence of improvement as a result of using the modified
procedures in animal experiments should be required.

T
 Appendix A

WORKSHOP AGENDA

INSTITUTE OF MEDICINE
Committee on the Treatment of Near-Drowning Victims
November 20. 1993

NAS Beckman Study Center

Irvine, California

10:00 a.m. Welcome and Introductory Remarks

Peter Rosen, Chairman
Michael Stoto, Director, Division of Health
Promotion and Disease Prevention

10:10 a.m. Literature Review on Research Related to the Treatment of

Near-Drowning Victims
Jim R. Harley, Children's Hospital and Health
Center, San Diego

10:30 a.m. Rationale for Established Guidelines

Lawrence D. Newell, American National Red
Cross
Linda Quan, American Heart Association

11:00 a.m Use of Heimlich Maneuver on Near-Drowning

Victims
Eric Spletzer, The Heimlich Institute Foundation
Henry Heimlich, The Heimlich Institute
Foundation
Edward A. Patrick, The Patrick Institute

12:30 p.m. Questions and Answers

 1

Appendix B

WORKSHOP PARTICIPANTS

Roy E. Clason, Director of External Communication, Healm and Safety,

American National Red Cross, Washington, D.C.

Jim R. Harley, Department of Pediatric Emergency Medicine, Children's

Hospital and Health Center, San Diego, California

Henry Heimlich, President, The Heimlich Institute Foundation, Inc.,

Cincinnati, Ohio

Lawrence D. Newell, Senior Associate, Health and Safety, American

National Red Cross, Washington, D.C.

Edward A. Patrick, President, The Patrick Institute, Cincinnati, Ohio

Linda Quan, Emergency Services, Children's Hospital and Medical Center,

Seattle, Washington

Eric Spletzer, The Heimlich Institute Foundation, Inc., Cincinnati, Ohio

 Appendix C

SUMMARY OF HENRY HEIMLICH'S PRESENTATION

Spletzer's review of all drowning reports from 1930 to 1993 found no

study showing that mouth-to-mouth/cardiopulmonary resuscitation (m-to-m/CPR)
increases survival for drowning victims without first draining water from the
lungs. The Heimlich maneuver removes fluid and other foreign substances from
the airway and alveoli in 10 to 15 seconds, which resuscitates drowning
victims.43,44

Bystander CPR did not improve outcome in drowning, yet it doubled

survival in ventricular fibrillation (cardiac arrest victims have no water in the
lungs). In the presence of lifeguards, 42 percent of pediatric submersion victims
in Seatde public swimming pools died. They use m-to-m/CPR only.46,47

American Heart Association (AHA) Guidelines, 1986 to 1993, recommend

using the Heimlich maneuver for drowning to remove foreign matter from the
airway and "if the victim does not respond appropriately to mouth-to-mouth
ventilation." The American Red Cross instructs to use the Heimlich maneuver
after the chest does not rise with two breams. No instructions are given as to
when to stop m-to-m if the chest rises, which can occur as water is pushed deeper
into the airway. Paramedics often continue m-to-m/CPR for 25 minutes, even
though there is neither response nor recovery; hypoxic brain damage results.

It takes 173 ml of fluid (a half cup) to fill and completely obstruct the
tracheobronchial tree. Salt water is never absorbed. Fresh water is never
absorbed from the tracheobronchial tree, and its absorption from the alveoli ceases
after cardiac arrest. Consequently, absorption of water does not relieve hypoxia.

Laypersons are first on the scene in the vast majority of drownings. A

minuscule fraction of 248,000,000 Americans are trained in CPR; 90 percent of
those trained cannot perform m-to-m/CPR properly a year later. AHA
instructions to use m-to-m/CPR, therefore, are of little practical value. The
Heimlich maneuver is widely known. Children have learned the maneuver
watching a 1-minute TV demonstration and have used it successfully. The
maneuver is repeated, at most two to four times, until fluid is no longer expelled
from the mouth, which takes 10 to 15 seconds.

Risk/benefit ratio: 87 percent of pulseless drowning victims survive with

the Heimlich maneuver; 28 percent with m-to-m/CPR. M-to-m delays ventilation
due to water in the lungs, increasing hypoxia deaths. CPR injuries caused death
in 17 percent of cases, most done by physicians in hospitals. Heimlich maneuver
injuries are rare. Eighty-six percent vomit with danger of aspiration after m-to-
18 THE USE OF THE HEIMUCH MANEUVER IN NEAR DROWNINGTHE

m/CPR; 2.9 percent vomit with maneuvers. M-to-m raises fear of

contagion. *****

The Heimlich maneuver clears the airway as A of the ABC's:

1. Perform the Heimlich maneuver as the initial step in treating near-

drowning victims until water no longer flows from the mourn. Two to four
Maneuvers over a period of 10 to IS seconds are sufficient. The maneuver can be
performed standing in shallow water or with the victim in the supine position on
the shore.

2. If recovery is not immediate, perform CPR, if necessary.

Appendix D

SUMMARY OF EDWARD PATRICK'S PRESENTATION

The Heimlich-Patrick method for treating submersion victims8,45-46 is to

first perform the Heimlich maneuver to remove fluid followed by mouth-to-mouth
and chest compressions if necessary. Research supports three categories of
submersion victims at the scene: those with cardiac output (a pulse) and
respirations who need neither mouth-to-mouth nor the Heimlich-Patrick method;
those victims with a pulse having absorbed fresh water for whom mouth-to-mouth
may deliver oxygen to the circulation; those without a pulse and thus water is in
the respiratory tract, requiring the Heimlich-Patrick method.

In support of mis hypothesis, Patrick and Hess presented IS verified,

serious freshwater submersions analyzed at the Patrick Institute. Analysis
indicates mat 7 out of 8 (87 percent) of nonbreathing submersion victims without a
pulse survived without complications using the Heimlich-Patrick method while
only 2 out of 7 (28 percent) survived without complications using mouth-to-mouth.
One of the Heimlich-Patrick's was where mouth-to-mouth with chest compressions
failed but a succeeding Heimlich maneuver was successful.

Manolios and Mackie18 support the hypothesis: mouth-to-mouth survivals

when breathing and pulse present = 90/96 (94 percent), when breaming absent
and pulse present = 46/47 (98 percent), while when breathing and pulse absent =
26/119 (22 percent). Quan47 also supports the hypothesis: with mouth-to-mouth
without a pulse, survival is 8/38 (21 percent). Biggart and Bonn50 support the
hypothesis: quality survival without any treatment when mere is a pulse and
spontaneous respiration = 14/14 (100 percent), while with mouth-to-mouth for no
pulse or respiration = 4/27 (15 percent).
1NG THE USE OF THE HEIMLICH MANEUVER IN NEAR DROWNING 19

Further evidence mat unabsorbed fluid in the lungs causes hypoxia is

provided by: Karpovich,37 Halmagyi,51 Safar,10 the 1961 Stavanger
symposium,52 Swarm and Karpovich,53 Gordon and Raymond,54 Haimson,55
Fuller,56-57*58 Holden,59 Copeland,60-61 Ohmann et al.,62 Biggart and
Bohn,50 Gee,63 and Giartsen.64

Evidence the Heimlich-Patrick method removes water blocking the airway

is provided by Patrick44 using a planned protocol, Rubin and Rubin,42 and Werner
et al.43 During the turmoil of saving a victim of a serious submersion, it is
difficult for the first responders to measure a pulse. The Heimlich-Patrick method
safely resolves the problem.

Analysis of verified submersions using Statistical Pattern Recognition (with

a feature list consisting of over SO variables) must continue-estimating outcome
probabilities in terms of selected sets of independent variables.

Appendix E

SUMMARY OF ERIC SPLETZER'S PRESENTATION

In 90 percent of drownings, the penultimate event is an inhalative gasp

flooding the lungs with fluid. Eight-five percent of drowning victims aspirate up
to 10 ml of fluid per pound of bodyweight (1.5 L in a ISO-lb adult); IS percent
aspirate more.32 It takes 173 ml of fluid to completely fill and block the adult
tracheobronchial tree.65

The nature of the aspirated fluid determines its fate. Salt water is not
absorbed and draws fluid into the lungs;66'67 fresh water is rapidly absorbed into
the bloodstream from the alveoli until cardiovascular circulation ceases. Fluid
absorption from the alveoli does not remove fluid from the trachea, bronchi, or
bronchioles.

Hypoxia, the reason for drowning death, is caused by a combination of

reflex terminal airway closure, changes in pulmonary surfactant activity, and/or
blockage of the air passages. Of these causes of hypoxia, only airway blockage
can be treated in the field.

Emergency resuscitation of the drowning victim requires adequate alveolar

ventilation to rapidly restore normal blood oxygen levels;10 therefore, a clear path
from the mouth to the alveoli is a prerequisite for effective ventilation.
20 THE USE OF THE HEIMLICH MANEUVER IN NEAR DROWNING

Karpovich37 reported mat the sole difference between rats that survived drowning,
and those mat died, was that the airways of nonsurvivors were always blocked
with fluid and foam. Experimentally, intermittent positive-pressure breathing
(mouth-to-mouth) has been shown to reoxygenate only after drainage of the
lungs.67-68-69-70
The only rapid, efficient methods of removing fluid from the lungs are
endotracheal suctioning, Trendelenburg gravity drainage with endotracheal
intubation, and the Heimlich maneuver. The latter two methods have been shown
to remove alveolar fluid.43,44 Patrick showed that the Heimlich maneuver expels
lung fluid that could not be removed by endotracheal suctioning. Both suctioning
and gravity drainage require endotracheal intubation; for rescuers to use these
techniques, special equipment and advanced training are needed. The Heimlich
maneuver (which takes 10 to 15 seconds to expel intrapulmonary fluids) is
available to anyone, even lay rescuers, with minimal training (1 minute).
Complications of the Heimlich maneuver are infrequent and usually due to
improper application of the technique.

The sole basis for current "no drainage" recommendations is a 1962 study
which showed postural drainage is ineffective for removing fluid from the lungs.42
Subsequent development of new drainage methods, shown experimentally to be
efficacious, obviate "no drainage" recommendations. Solid foreign body airway
obstruction is readily recognized and treated. Fluid obstruction does not preclude
chest movement during attempted ventilation, but still prevents oxygenation. To
avoid unwarranted delay in providing effective ventilation, expulsion of water
from the lungs, using the Heimlich maneuver, should be the first step in drowning
resuscitation.

Appendix F

GUIDELINES FOR CARDIOPULMONARY RESUSCITATION

AND EMERGENCY CARDIAC CARE (AMERICAN HEART
ASSOCIATION)

Near Drowning
The most important consequence of prolonged underwater submersion
without ventilation is hypoxemia. The duration of hypoxia is the critical factor in
determining the victim's outcome. Therefore, restoration of ventilation and
perfusion should be accomplished as rapidly as possible.

T"
USE OF THE HEIMLICH MANEUVER IN NEAR DROWNING

Basic Life Support Rescue from the Water

When attempting to rescue a near-drowning victim, the rescuer should get

to the victim as quickly as possible, preferably with some conveyance (boat, raft,
surfboard, or flotation device). The rescuer must always be aware of personal
safety in attempting a rescue and should exercise caution to minimize danger.

Rescue Breathing

Initial treatment of the near-drowning victim consists of rescue breaming

with the mouth-to-mouth technique. Rescue breathing should be started as soon as
the victim's airway can be opened and protected and the rescuer's safety can be
ensured. This is usually when the victim is in shallow water or out of the water.

Appliances (such as a snorkel for the mouth-to-snorkel technique or

buoyancy aids) may permit specially trained rescuers to perform rescue breaming
in deep water. However, rescue breathing should not be delayed for lack of such
equipment if it can otherwise be provided safely. Untrained rescuers should not
attempt to use such adjuncts.

In a diving accident, neck injury should be suspected. The victim's neck

should be supported in a neutral position (without flexion or extension), and the
victim should be floated supine on a back support before being removed from the
water. If the victim must be turned, the head, neck, chest, and body should be
aligned, supported, and turned as a unit to the horizontal, supine position. If
artificial respiration is required, rescue breaming should be provided with the head
maintained in a neutral position; that is, jaw thrust without head tilt or chin lift
without head tilt should be used.

Immediate ventilation and rescue breathing should be initiated if the

submersion victim is not breathing. Management of the airway and ventilation of
the submersion victim are similar to those of any victim in cardiopulmonary
arrest. There is no need to clear the airway of aspirated water. However,
rescuers may need to remove debris, gastric contents, or other foreign materials
using standard techniques for obstructed airways. Usual airway management with
adjuncts, such as bag-mask ventilation and intubation, can be accomplished in the
near-drowning victim.5,48 At most only a modest amount of water is aspirated by
the majority of bom freshwater and seawater drowning victims, and it is rapidly
absorbed from the lungs into the circulation.29 Furthermore, 10 percent to 12
percent of victims do not aspirate at all because of Iaryngospasm or bream-
holding.29,30 An attempt to remove water from the breathing passages by any
means other than suction is usually unnecessary and apt to be dangerous because it
may eject gastric contents and cause aspiration.30
 THE USE OF THE HEIML1CH MANEUVER IN NEAR DROWNING

A Heimlich maneuver delays initiation of ventilation and breaming. Its

value is not proven scientifically and is supported only by anecdotal evidence, and
its risk-benefit ratio is untested. Therefore, a Heimlich maneuver should be used
only if the rescuer suspects that foreign matter is obstructing the airway or if the
victim does not respond appropriately to mouth-to-mouth ventilation. Then, if
necessary, CPR should be reinstituted after the Heimlich maneuver has been
performed.3,6,44 The Heimlich maneuver is performed on the near-drowning
victim as described in the treatment of foreign-body airway obstruction
(unconscious supine), except mat in near drowning the victim's head should be
turned sideways unless cervical trauma is suspected.

Chest Compressions

Chest compressions should not be attempted in the water unless the rescuer
has had special training in techniques in in-water CPR, because the brain is not
perfused effectively unless the victim is maintained in the horizontal position and
the back is supported. It is usually not possible to keep the victim's body
horizontal and the head above water in position for rescue breathing.

After removal from the water, the victim must be immediately assessed for
adequacy of circulation. The pulse may be difficult to appreciate in a near-
drowning victim because of peripheral vasoconstriction and a low cardiac output.
If a pulse cannot be felt, chest compressions should be started at once.

Advanced Cardiac Life Support

The near-drowning victim in cardiac arrest should be given advanced

cardiac life support (ACLS) including intubation without delay. Every submersion
victim, even one who requires only rninimal resuscitation and regains
consciousness at the scene, should be transferred to a medical facility for follow-
up care. It is imperative that the monitoring of life support measures be
administered if it is available in the transport vehicle, since pulmonary injury may
develop up to several hours after submersion. Although survival is unlikely in
victims who have undergone prolonged submersion and require prolonged
resuscitation,3 successful resuscitation with full neurological recovery has occurred
in near-drowning victims with prolonged submersion in extremely cold
water.71,12,73 Since it is often difficult for rescuers to obtain an accurate time
of submersion, attempts at resuscitation should be initiated by rescuers at the scene
unless there is obvious physical evidence of death (such as putrefaction, dependent
lividity, or rigor mortis). The victim should be transported with continued CPR
to an emergency facility where a physician can decide whether to continue
resuscitation. Aggressive attempts at resuscitation in the hospital should be
continued for the victim of cold water submersion.
i
THE USE OF THE HEIMLICH MANEUVER IN NEAR DROWNING 23

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