The Heimlich controversy in near-drowning resuscitation.

As a result of renewed media exposure, the Heimlich controversy has once more reared its head, creating a confusing message for life-guards and other rescue personnel regarding the appropriate resuscitation procedures when confronted with a near-drowning incident. The purpose of this article is to give our readers the necessary information to make a sound decision.

According to Dr. Henry Heimlich, "Drowning victims die when their lungs fill with water. Air can't get into water-filled lungs. Heimlich maneuvers remove the water from the lungs in four to six seconds. Pressing upward on the diaphragm jump-starts breathing. Many drowning victims have been saved by rescuers performing the Heimlich maneuver, even after CPR failed."

Ellis and Associates has advanced this concept by endorsing the Heimlich maneuver as the first step for saving drowning victims, even though this protocol is contraindicated by the Resuscitation Standards advocated by the American Heart Association and the American Red Cross.

Heimlich advocates that given the low complication rate associated with the Heimlich maneuver and the inability of rescuers to readily determine if a drowning victim's airway is blocked by fluid, the Heimlich maneuver should be applied as the first step. The maneuver should be performed until water no longer flows from the mouth, which usually occurs after two to four applications (four to six seconds).

There have been numerous reported cases that state that the Heimlich maneuver worked when all other life-saving measures had failed. In fact, a Patrick Institute study found that in a series of unconscious, non-breathing drowning victims, 87 percent survived when the Heimlich maneuver was performed, whereas only 27 percent survived when cardiopulmonary resuscitation (CPR) was performed without the maneuver. According to University of Houston professor John Hunsucker, in a study conducted for the National Pool and Waterparks Association, in 27 drowning incidents reported by NPWPA-trained lifeguards, 24 victims responded by breathing from the Heimlich procedures alone, and only three required CPR after the Heimlich was administered. The application of the Heimlich maneuver as the initial and, perhaps, only step for opening the airway in all near-drowning victims is contrary to current resuscitation guidelines for the treatment of such 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. 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 concluded that although the Heimlich maneuver is useful for the removal of aspirated solid foreign bodies, there is no evidence that death from drowning is frequently caused by aspiration of a solid foreign body that is not effectively treated by the current ECC recommendations. The committee further found that the evidence is insufficient to support the proposition that the Heimlich maneuver is useful for the removal of aspirated liquid. Also, because there 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 found that the available evidence does not support routine use of the Heimlich maneuver in the care of near-drowning victims.

The committee also had a series of concerns regarding the routine use of the Heimlich maneuver for treatment of near-drowning victims, 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 the near drowning is associated with a cervical fracture; and (c) the prospect of teaching rescue workers a different protocol than that which is taught at the present time for resuscitating victims of cardiopulmonary arrest from all causes other than drowning.

The committee concluded 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.

Gerald M. Dworkin is an aquatics-safety and water-rescue specialist for Lifesaving Resources, Inc., in Harrisville, New Hampshire.