6 - Treatment of the immersion survivor
6.1 The treatment for hypothermia will of course depend on both the condition of the survivor and the facilities available. Generally speaking, survivors who are rational and capable of recounting their experiences, although shivering dramatically, merely require removal of all wet clothes and replacement with dry clothes or blankets. If possible, they should be taken from the water horizontally and carried this way, or else be returned to the horizontal (or, better still, to the unconscious position) as quickly as possible and kept this way. Hot sweet drinks should be given but only if the victim is fully conscious with gag and cough reflexes. Rest in a warm environment not exceeding 25°C (normal room temperature) is also recommended. Do not allow alcohol or smoking, or massaging or rubbing of the cold skin. However, always bear in mind that even conscious survivors can collapse and become unconscious shortly after rescue. They should therefore be kept resting horizontally, with their legs slightly elevated (the 'shock position'), and be watched until core rectal temperature has exceeded 35°C (see also appendix 2).
6.2 In more serious cases, where the survivor is not shivering and is semi-conscious, unconscious, or apparently dead, immediate first-aid measures will be necessary to preserve life while awaiting medical advice on more detailed management procedures. This advice should be sought as soon as possible and first-aid measures should not be delayed while advice is being sought. The recommended first-aid measures for such an immersion survivor are as follows:
- On rescue, always check the survivor's breathing and carotid pulse for one minute each side of the neck.
- If the survivor is not breathing, make sure the airway is clear (remove dentures, if any), tilt the head back, lift the chin and start artificial respiration immediately (mouth-to-mouth or mouth-to-nose). If the heart appears to have stopped beating then cardiac compressions may be applied. However, you should be certain that there is no pulse at all (remember that hypothermia slows and weakens the pulse greatly) and, once started, it must be continued properly until the patient is either fully re-warmed or delivered to a hospital.
- If the survivor is breathing but unconscious, lay him in the unconscious position. This is necessary to ensure that the person's breathing is not obstructed by his tongue or by vomit.
- Avoid all manhandling which is not necessary to determine whether there are any serious injuries; do not even remove wet clothes; do not massage.
- Prevent further heat loss through evaporation and from exposure to the wind. Carefully wrap the patient in blankets and/or a casualty bag or large plastic bag and transfer immediately to a (wind-) sheltered area or below decks to a compartment at normal room temperature, keeping him horizontal, slightly head down.
- Advice on re-warming and decisions regarding further treatment should normally be given only by a doctor. If no medical advice is immediately available, continue to apply the essential life-saving procedures given in subparagraphs .1 to .5 above. In addition, even if the rescued person is cold and appears dead, or if he deteriorates and/or the pulse and breathing are lost, resuscitation attempts should not be ended before patient has been re-warmed. In a sheltered warm room the person's clothing can be cut and removed with a minimum of disturbance. Then wrap the person in blankets to reduce further heat loss. The best method of 'active' re-warming is the use of forced warm air (maximum 40°C), which has to be blown under the blankets covering the rescued person. Alternatively use heated blankets or sheets (about 40°C, but not hotter). Never use a hot bath or hot shower!
- 'Passive' methods of warming are not very effective. Do not attempt to warm the person by vigorous actions. Apply heating pads or hot water bottles under the blanket, to the person's head, neck, chest and groin - but never place these warm objects against the bare skin as cold skin is easily burned.
6.3 If the above-mentioned methods of warming are not available then apply body warmth by direct body-to-body contact with the rescued person. In addition, wrap a blanket around both the rescued person and the person or persons supplying the warmth. In all cases try to monitor the pulse and breathing.
6.4 The above basic guidelines on first aid treatment for the unconscious person could be illustrated diagrammatically.
(Recover in a more or less horizontal position whenever possible)
IS PERSON BREATHING?
- Insulate to prevent further heat loss through evaporation and exposure to wind. Avoid unnecessary manhandling - leave wet clothes on and enclose in blankets and/or plastic bag. Move to sheltered location.
- Lay down in the unconscious position whenever possible.
- Oxygen should be given if available.
- If water was inhaled, encourage deep breathing and coughing.
- Request medical assistance.
- Watch person closely until shivering starts. In the absence of medical advice re-warm the person by either the 'active' or 'passive' method described in paragraph 6.
- Clear airway, check carotid pulse.
- Start artificial respiration immediately (mouth-to-mouth, mouth-to-nose). If a pulse cannot be detected, commence cardiac resuscitation.
- Insulate to prevent further heat loss through exposure to wind. Avoid unnecessary manhandling - leave wet clothes on and enclose in blankets and/or plastic bag. Monitor pulse, breathing and consciousness of victim and actively re-warm if the person appears dead or if the person's condition deteriorates.
- Seek medical advice. If medical advice is not available, continue resuscitation until the patient is either fully re-warmed1 or delivered to a hospital.
A person with cardiac arrest caused by severe hypothermia has a very good chance of surviving if artificial respiration and cardiac resuscitation is carried out until re-warming is finished. Mouth-to-mouth ventilation over a long period of time is very difficult and exhausting. Doing conventional cardiac resuscitation is a hard physical activity. As soon as possible use medical aids to make resuscitation more bearable for the helper and more effective for the brain and the heart of the rescued person, who is lacking oxygen: use a ventilation bag, Guedel-airway, oxygen-delivery device, Combitube-airway (which enables the helper to do rescue breathing directly into a pipe positioned in or at the entrance of the trachea), etc. The chest and the muscles of a hypothermic person are stiff. The pumping effect of chest compression can be improved by using a handheld medical device equipped with a suction cup to actively lift the anterior chest
during decompression. Instruction in advance is necessary to use these mechanical devices more effectively in basic life support.
1Note: In the context of hypothermia a person cannot be presumed dead until he is re-warmed and shows no bodily functions.