fluid may appear in the endotracheal tube, suctioning
can disturb oxygenation and should be
balanced against the need to ventilate and oxygenate.35,36
Providers of prehospital care should
ensure that there is adequate oxygenation to maintain
arterial saturation between 92% and 96%,
while also ensuring adequate chest rise during
ventilation.37 Ventilation with positive end-expiratory
pressure should be initiated as soon as possible
to increase oxygenation.35
Peripheral venous access is the preferred route
for drug administration in the prehospital setting.
Intraosseous access is an alternative route. Endotracheal
administration of drugs is not recommended.28
If hypotension is not corrected by oxygenation,
a rapid crystalloid infusion should be
administered, regardless of whether salt water or
fresh water has been inhaled.17
The presenting rhythm in cases of cardiac arrest
after drowning (grade 6) is usually asystole or
pulseless electrical activity. Ventricular fibrillation
is rarely reported but may occur if there is a history
of coronary artery disease, if there has been
use of norepinephrine or epinephrine (which may
increase myocardial irritability), or in the presence
of severe hypothermia.18 During CPR, if
ventilation and chest compression do not result
in cardiac activity, a series of intravenous doses of
norepinephrine or epinephrine, at an individual
dose of 1 mg (or 0.01 mg per kilogram of body
weight) can be considered. Because of the mechanisms
of cardiac arrest due to hypoxia and the
effects of hypothermia, a higher subsequent dose,
although controversal,38 may be considered if the
initial doses are ineffective.