The Heimlich Controversy in Near-Drowning Resuscitation

The Heimlich Controversy in Near-Drowning Resuscitation

As a result of renewed electronic and print media exposure, the Heimlich Controversy has once more reared its head creating a confusing message for lifeguard and other rescue personnel regarding the resuscitation procedures to be used when confronted with a near-drowning resuscitation incident. The purpose of this article is to present our readers with the information needed to make a sound decision in this matter.

by Gerald M. Dworkin
February 5, 1998

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As a result of renewed electronic and print media exposure, the Heimlich Controversy has once more reared its head creating a confusing message for lifeguard and other rescue personnel regarding the resuscitation procedures to be used when confronted with a near-drowning resuscitation incident. The purpose of this article is to present our readers with the information needed to make a sound decision in this matter.

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 4 – 6 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 have 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 to ensure the airway is clear. The Maneuver should be performed until water no longer flows from the mouth, which usually occurs after 2 – 4 applications, over a period of 4 – 6 seconds.

There have been numerous reported cases which state that the Heimlich Maneuver worked when all other lifesaving measures failed. In fact a Patrick Institute study found that in a series of unconscious, non-breathing pulseless drowning victims, 87% survived when the Heimlich Maneuver was performed, whereas only 27% survived when CPR was performed without the Heimlich Maneuver. According to University of Houston Professor John Hunsucker, in a study conducted for the National Pool and Waterparks Association, that 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 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 is frequently caused by aspiration of a solid foreign body that is not effectively treated by the current ECC recommendations. The committee further finds that 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 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 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 present for resuscitating victims of cardiopulmonary arrest from all causes other than 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.

For additional information, please check out the following links:

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The following is a respiring of a 2010 Scientific Review article that appeared in the International Journal of Aquatic Research and Education.

Scientific Review

International Journal of Aquatic Research and Education, 2010, 4, 81-92

Sub-Diaphragmatic Thrusts and Drowned Persons

Advisory Council on First Aid, Aquatics, Safety, and Prevention (ACFASP)
American Red Cross
Scientific Review
(Triennial Re-Evaluation – June, 2009)
Review Authors: Francesco Pia, Ph.D., Roy Fielding, M.A.,
Peter G. Wernicki, M.D., David Markenson, M.D.

Questions to Be Addressed

After removing a person in respiratory or cardiac arrest from the water, what is the first step a first responder should carry out?

Introduction/Overview

The International Liaison Committee on Resuscitation (ILCOR) conducts a scientific evidence review and the American Red Cross (ARC) uses this review as one of the sources to provide Guidelines for Emergency Care and Education. These reviews and guidelines apply, but are not limited, to people in respiratory or cardiac arrest.

The 2005 Guidelines for Emergency Care and Education state if a person is in cardiac arrest, the rescuer should begin CPR immediately. If after repositioning the patient’s airway, ventilation efforts are not effective, the rescuer should try to clear the airway by using age-appropriate methods for relieving a solid foreign body airway obstruction. The ILCOR evidence evaluation is supported
by multiple professional and scientific organizations including the American Academy of Pediatrics, the American College of Cardiology, the American College of Emergency Physicians, and the Institute of Medicine of the National Academy of Sciences.

Despite consensus, which is part of the ILCOR scientific evidence review process, Henry J. Heimlich MD, has advocated that when treating drowned persons, subdiaphragmatic abdominal thrusts should be tried before CPR is given. Dr. Heimlich asserts aspirated water obstructs the patient’s airway and significantly hinders ventilation of the lungs. He argues subdiaphragmatic abdominal thrusts will relieve the alleged airway obstruction, remove water from the patient’s lungs, and should be continued until no water or fluid flows
from the patient’s mouth.

82 Scientific Review

Review Process and Literature Search Performed

The titles and abstracts of 128 citations were retrieved using a computerized search of the National Library of Medicine Medline database from 1966 to 2009. MeSH heading combinations of “drowning” or “near-drowning:” with “Heimlich maneuver” were used as search features. The abstracts of all citations were analyzed and those suitable for full review were obtained. Manual search of the reference lists from these articles was also conducted for added relevant citations. This process resulted in the review of 37 citations of which 18 (all class III) were found to discuss the role of the Heimlich maneuver to treat drowned people.

a. Original ACFAS Scientific Review (2000)
Heimlich states that drowned persons aspirate large amounts of water and that the water causes obstruction of the airway.1 He advocates that the safest and most effective method for removing water from the lungs of a drowned person is the subdiaphragmatic abdominal thrust (Heimlich maneuver). He states that this maneuver should be the first step in the management of these patients and should be repeated until no water or fluid flows from the patient’s mouth. In order to minimize the risk of aspiration (which he believes to be low since the patient is not breathing and will not inhale any vomitus), the head of the patient should be turned
to one side and/or on a reverse incline such as a sloping shore so the patient can be placed in a head down position. Heimlich cites several anecdotal case reports, including one involving an aspirated piece of vegetable, to support his drowned person’s protocol opinion.2,3

There is no scientific literature available supporting the concepts that drowned persons aspirate either large volumes of water, or that aspirated water obstructs the airway of these individuals. Modell in a review article reported that 15% of drowned patients have no evidence of any water aspiration.4 The remaining 85% do aspirate some water, up to 22 milliliters per kilogram of body weight, although he stresses that in many cases the amount is much less than the 22 ml/kg.5 He points out that one would expect electrolyte abnormalities in patients who have aspirated large amounts of water. In actuality, these changes are rarely found, thus suggesting that
aspiration of water does not occur. Consequently, Modell recommended immediate airway control and initiation of ventilation and correction of hypoxemia.6 Simcock also reported that many drowned patients did not have any signs of aspiration of water, including some who appeared apneic when removed from the water.7

Rosen, chairing an expert committee for the Institute of Medicine (IOM), could find no evidence that water aspiration caused airway obstruction or prevented efforts to ventilate patients.8 The IOM panel recommended that the current ECC guideline of establishing an airway and ventilation be the priority. Quan, in a study of submerged persons, reported no finding of airway fluid to impair paramedics’
ability to incubate nor any difficulty in ventilating patients once intubated.9,10

Weinstein et al point out hypoxemia is the final pathophysiologic result of near drowning.11 As noted in the IOM report, there is no evidence in any study that removing water from the lungs will alter this sequence of events or result in
the removal of significant amounts of fluids from the lungs of these patients. In conclusion, no studies have demonstrated that water must be removed immediately upon rescue of the patient, or that the Heimlich maneuver (abdominal thrust) is an effective and safe method for removing aspirated water from the airway and lungs.

b. ACFAS Reevaluation of Scientific Data (2006)
Safar, Escarraga, and Chang found an improperly opened airway was the most common cause of airway impediment.12 Rosen, Stoto, & Harley could not find evidence that water aspiration causes an airway obstruction or prevents efforts to ventilate patients.13

Numerous other authorities have also recommended that obtaining an airway, ventilating the patient, and correcting hypoxemia are the immediate treatment priorities. The work of Neal, Ornato, Modell, Olshaker, Brass, and Weinstein and Krieger supported immediate airway control, introduction of ventilation, and correction
of hypoxemia as the treatment priorities for drowned people.14-19

Since the Heimlich maneuver cannot remove water from a drowned person’s lungs, attempting this procedure prolongs the correction of hypoxemia because it delays the initiation of CPR. Given that the Heimlich protocol for drowned persons is unnecessary, multiple consecutive abdominal thrusts increase the likelihood of visceral or vascular injuries.

The recommendation by Heimlich that the drowned person’s head be turned to the side to facilitate drainage of fluid expelled while performing this maneuver has also raised concerns. With suspected spinal injury patients, turning the head to the side increases the potential exacerbation of a cervical injury.

An expert committee for the Institute of Medicine of the National Academy of Sciences recommended the ECC guideline of setting up an airway, immediately beginning ventilations, followed by chest compressions remain the first responders’ treatment sequence.

c. ACFASP Re-evaluation of Scientific Data (2009)
The current re-evaluation found no study that demonstrated the Heimlich maneuver can remove fluid from the lungs of drowned persons. Since water in the airways or lungs of drowned patients is not considered a solid object airway obstruction, subdiaphragmatic abdominal thrusts should not be given to drowned person by a first responder.

The sequence of events that occurs following water aspiration into the lungs is a patho-physiologically complex process. The aspiration of water includes larygnospam, fluid shifts across the pulmonary alveolar membrane, destruction of surfactant, atalectasis, intrapulmonary shunting, and pulmonary edema formation. Any attempt to remove the water from the airway is unnecessary, will delay CPR, hamper the correction of a drowned person’s hypoxemia, can induce vomiting, and may cause visceral or vascular injuries to the drowned person.

Several researchers have cited concerns that an abdominal thrust may cause regurgitation. This vomitus could then interfere with efforts to ventilate the patient or may result in aspiration further fostering pulmonary status deterioration. Orlowski noted concerns that the use of the Heimlich maneuver could induce regurgitation.20 Weinstein & Krieger also argued abdominal thrusts may cause vomiting, which would then interfere with efforts to ventilate the patient, and may result in aspiration
of stomach contents.21

Two studies have shown that standard chest compressions demonstrated robust efficacy in removing solid objects in a patient’s airway. Skulberg, in a single case study, cited an instance where a foreign body in the trachea was removed with a single chest compression after 3-4 Heimlich maneuvers to the epigastrum failed to remove the object.22 This author theorized that since a standard chest compression created greater thoracic pressure it might be an alternative to the Heimlich maneuver.

Langhelle et al. conducted a study of the airway pressure generated by chest compressions and abdominal thrusts in 12 recently dead cadavers with simulated complete airway obstructions.23 This study found chest compressions created a greater mean airway pressure than sub-diaphragmatic thrusts. Airway pressure from chest compressions were 40.8 <>16.4 cmH2O, while abdominal thrust yielded pressures of 26.4 <>19.8 cmH20. These values had a 95% confidence interval with a mean difference of 5.3 — 23.4cmH20.

One can derive from Skulberg’s case report and Langhelle’s study that chest compressions for a hypoxic patient generate greater force for removing solid foreign body airway obstructions than sub-diaphragmatic thrusts. Langhelle further theorized if removal of a solid foreign body can be achieved by chest compressions, this will reduce the time without circulation for a patient in cardiac arrest. These patients will be treated identically whether or not there is a foreign body airway obstruction.

Rosen et.al. cited case reports of abdominal thrust injuries but found no evidence indicating if these injuries were caused by faulty application of the Heimlich maneuver. Wolf, citing the work of Haynes & Yong and Agia & Hurst noted that correct administration of the Heimlich maneuver can lead to intra-abdominal injuries.24,25,26 A concern was noted that the incidence of complications might be greater in unconscious drowned persons than conscious choking persons.

The Heimlich maneuver/abdominal thrusts have shown efficacy in removing documented solid body airway obstructions. However, repeating the maneuver until no water or liquid flows from the person’s mouth may increase the possibility of paradoxical visceral or vascular effects.

Severe complications from the use of this technique have been cited in the medical literature. Desai et.al reported a case of traumatic dissection and rupture of the abdominal aorta after a forceful Heimlich maneuver.27 In addition to this complication, these authors cite reports of other complications occurring with the use of the Heimlich maneuver. These injuries include retinal detachment, rib fractures, ruptures of abdominal organs.28,29 Additional injuries included rupture of the diaphragm, jejunum, liver, esophagus, and stomach.30 Other reported vascular structure injuries consisting of aortic stent graft displacement,31 rupture of the aortic valve,32 acute aortic regurgitation,33 laceration of a mesenteric vessel,34 and acute aortic thrombosis in both and aneurismal and non- aneurismal aorta.35-39

Summary

There is compelling evidence to support a treatment standard. The first step after removing a drowned person from the water should be to obtain an airway, start rescue breathing and deliver cardiac compressions. The 2005 American Red Cross Guidelines for Emergency Care and Education provide one approach to patients with airway, respiratory and cardiac emergencies without variation for the techniques applied to the drowned patient. The one exception is the insertion of a step for removing the patient from the water.

Studies have shown that there is no need to clear the airway of aspirated water. Only a modest amount of water is aspirated by the majority of drowned persons and it is rapidly absorbed into the central circulation. Therefore, it does not act as an obstruction in the trachea (Institute of Medicine Report; Rosen, Stoto, &Harley, 1995). It has also been shown that some drowned persons do not aspirate fluid because they develop laryngospasm or experience breath-holding (Modell, 1993). An attempt to remove water from the breathing passages by any means other than suction (e.g., abdominal thrusts or the Heimlich maneuver) are unnecessary and
potentially dangerous (Institute of Medicine Report; Rosen Stoto, & Harley, 1995).

The routine use of abdominal thrusts for drowned persons is not recommended. The 2005 guidelines also eliminated the phrase “Heimlich maneuver” and replaced it with the more descriptive term “abdominal thrust.”

Recommendation and Strength

Standards

Manage a drowned person with airway, breathing or circulatory problems the same as any other patient with airway breathing or circulatory problem. The one variation is to remove the patient from the water as part of the care rendered.

Guidelines

Manage drowned child or infant with airway, breathing or circulatory problems the same as any other patient with airway breathing or circulatory problem. The one variation is to remove the patient from the water as part of the care rendered.

Overall Recommendation

Subdiaphragmatic abdominal thrusts are neither effective nor safe methods for attempting water removal from the airway or lungs of drowned persons. No scientific literature supports the idea that aspirated water obstructs these patients’ airways thus hindering ventilations. Since no scientific study has shown water can be removed from drowned person’s airways or lungs through subdiaphragmatic abdominal thrusts, the 2005 COSTR Guidelines remain the CPR treatment standard for drowned people.

Summary of Key Articles/Literature Found and Level of Evidence/Bibliography

The following studies (see Table 1) found that obtaining an airway, ventilating the patient, and correcting hypoxemia were immediate treatment priorities for drowned persons. These experts contended performing subdiaphragmatic abdominal thrusts prolonged establishment of an airway, delayed ventilations of a patient’s lungs, might induce regurgitation and aspiration of stomach contents, and could lead to a variety of internal injuries. The only exceptions to these treatment priorities were the articles written by Dr. Heimlich (1979, 1981, 1988).

Table 1 Summary

Author(s) Full Citation
Summary of Article (provide a
brief summary of what the article
adds to the literature and review)
Level of
Evidence
(Using table
below)
Heimlich HJ; Subdiaphragmatic pressure General description and rationale for 7
1981 to expel water from the lungs
of drowning persons. Ann
Emerg Med. 1981; 10:476performing
the maneuver
Heimlich HJ, The Heimlich Maneuver. Clin General review of the maneuver 3b
Uhley MH; Symposia. 1979; 31:3-32. primarily for the choking victim;
1979 describes a few anecdotal drowning
cases treated with Heimlich
maneuver.
Heimlich HJ, Using the Heimlich Flooding of the lungs occurs 3b
Patrick EA; maneuver to save near-routinely in drowning victims and
1988 drowning victims. Postgrad
Med. 1988; 84:62-73.
mouth-to-mouth ventilation is
ineffective until the water is removed.
The Heimlich maneuver expels
aspirated water, vomitus, debris, and
other foreign matter. The Heimlich
maneuver is a form of artificial
respiration. It elevates the diaphragm,
increasing intrathoracic pressure
and compressing the lungs, and
should be performed intermittently
until all water is expelled.Further
treatment has not been necessary in
most instances. If the victim does
not recover after water ceases to
flow from the mouth, ventilation
techniques, cardiopulmonary
resuscitation, and other measures as
indicated should be used.
Modell JH; Drowning. N Engl J Med. Responds that the Heimlich 7
1993 1993; 328:253-256. maneuver should be reserved for
those instances where a patient
cannot be ventilated and airway
obstruction is suspected.
Modell JH; Near Drowning. Circulation. The first step in resuscitation of the 7
1986 1986; 74 (suppl IV):27-28. near-drowning victim is to initiate
ventilation and circulation. The
Heimlich should only be performed
if the patient cannot be ventilated.
Simcock AD; Treatment of near drowning Many patients had no evidence of 2b
1986 – a review of 130 cases.
Anaesthesia. 1986; 41:643648.
aspiration.

(continued)

86
8686

Table 1 (continued)

Author(s) Full Citation
Summary of Article (provide a
brief summary of what the article
adds to the literature and review)
Level of
Evidence
(Using table
below)
Rosen P, Stoto
M, Harley J;
1995
The use of the Heimlich
maneuver in near drowning:
Institute of Medicine report.
J Emerg Med. 1995; 13:397405.
No evidence was found
documenting massive aspiration
causing airway obstruction or
the usefulness of the Heimlich
maneuver in near drowning. The
first step in resuscitation of the
drowned person is to initiate
ventilation and circulation.
6
Quan L; 1993 Drowning issues in resuscitation.
Ann Emerg Med. 1993;
22 (pt 2):366-369.
Recommends against using
Heimlich maneuver as the first
step in resuscitation of drowned
persons.
7
Quan L, Wentz
KR, Gore E, et
al.; 1993
Drowning issues in resuscitation.
Ann Emerg Med. 1993;
22 (pt 2):366-369.
Prehospital care providers had no
difficulty ventilating submersion
victims.
2b
Weinstein MD,
Krieger BP;
1996
Near-drowning: Epidemiology,
pathophysiology, and
initial treatment. J Emerg
Med. 1996; 14:461-467.
No evidence to support Dr.
Heimlich’s opinion of he efficacy of
the maneuver to expel fluid from the
lungs of drowned persons.
2b
Olshaker JS;
1992
Near Drowning. Emerg
Med Clinics N Amer. 1992;
10:339-350.
The first step in resuscitation of
the drowned person is to initiate
ventilation and circulation.
5
(Literature
review)
Neal JM; 1985 Near-drowning. J Emerg
Med. 1985; 3:41-52.
Notes that virtually all experts
recommend that the first step
in resuscitation of the drowned
person is to initiate ventilation
and circulation, only Heimlich
recommends the use of the
maneuver.
5
(Literature
review)
Bross MH,
Clark JL; 1995
Near-drowning. Amer Fam
Phys. 1995; 51:1545-1551.
The first step in resuscitation of
the drowned person is to initiate
ventilation and circulation. The
Heimlich maneuver should be
reserved for those cases with
documented airway obstruction.
5
(Literature
review)
Ornato JP;
1986
Special resuscitation
situations: near drowning,
traumatic injury, electric
shock, and hypothermia.
Circulation. 1986; 74 (suppl
IV):23-26.
The recommendation was to use
the Heimlich for those cases with a
documented airway obstruction.
5

(continued)

87

Table 1 (continued)

Author(s) Full Citation
Summary of Article (provide a
brief summary of what the article
adds to the literature and review)
Level of
Evidence
(Using table
below)
Safar P, Upper airway obstruction in Airways were obstructed in 80 1b
Escarraga LA, the unconscious patient. J anesthetized, spontaneously
Chang F; 1959 Appl Physiol. 14: 760-764,
1959.
breathing patients patients, both
in the supine and prone positions.
When the neck is flexed and the
mandible is not held forward
the tongue is pushed against the
posterior pharyngeal wall. The
frequency and degree of obstruction
was similar in the prone and supine
positions, with comparable positions
of the head, neck and mandible
Langhelle A, Airway pressure with In a randomized crossover design 4
Sunde K, Wik chest compressions versus standard chest compressions
L, Steen PA; Heimlich maneuver in and Heimlich maneuvers were
2000. recently dead adults with
complete airway obstruction
Resuscitation. 2000 Apr;
44(2):105-8
performed on 12 cadavers with
simulated complete airway
obstruction. The mean peak airway
pressure was significantly higher
with chest compressions compared
to abdominal thrusts
Orlowski JP; Vomiting as a complication Vomiting after the Heimlich 3b
1987 of the Heimlich maneuver.
JAMA 1987; 258:512-513.
maneuver can cause serious
complications. The first step in
resuscitation of the drowned
person is to initiate ventilation
and circulation. The Heimlich
maneuver should be reserved for
those cases with documented airway
obstruction.
American Red 2005 Guidelines for If chest does not rise after two 6
Cross; 2005 Emergency Care and
Education: Unconscious
person
rescue breaths, re-tilt head and
administer two more rescue breaths.
If chest still does not rise give
chest compressions and look inside
person’s mouth. If object is seen
remove from person’s mouth. If
no object is seen give two rescue
breaths. If chest does not rise, give
30 chest compressions
American Red 2005 Guidelines for Confirm person is choking, obtain 6
Cross; 2005 Emergency Care and
Education: Conscious
person
consent, and give 5 back blows. If
the person is still choking give 5
abdominal thrusts. If the person
is still choking administer 5 back
blows.

(continued)

88
8888

Table 1 (continued)

Author(s) Full Citation
Summary of Article (provide a
brief summary of what the article
adds to the literature and review)
Level of
Evidence
(Using table
below)
Skulberg A; Chest compression-an A single case study of a foreign 3b
1992 alternative to the Heimlich
maneuver. Resuscitation.
1992; 24:91.
body in the trachea, removed by
chest compression.
Wolf DA; Heimlich trauma: a violent The Heimlich maneuver is 3b
2001 maneuver. Am J Forensic
Med Pathology. 2001. 24 (1)
65 – 67.
a life-saving technique for
dislodging foreign material from
the respiratory tract. This report
illustrates intraabdominal injuries,
including a large mesenteric
laceration, mesenteric contusions,
and intraperitoneal hemorrhage,
that occurred in a recipient of
a vigorously applied Heimlich
maneuver. The potential for
confusing such injuries with
homicidally inflicted injuries is
emphasized.
Desai SC., Traumatic dissection and Although the Heimlich maneuver 3b
Chute DJ, rupture of the abdominal is considered the best intervention
Bharati C, aorta as a complication of for relieving acute upper airway
Desai MD, the Heimlich maneuver. J obstruction, several complications
Koloski ER; Vasc Surg. 2008; 48:1325-7 have been reported in the literature.
2008 These complications can occur as a
result of an increase in abdominal
pressure leading to a variety of
well documented visceral injuries,
including the great vessels. Acute
abdominal aortic thrombosis after
the Heimlich maneuver is a rare
but recognized event; however to
date no case of traumatic dissection
and rupture of the abdominal aorta
has been described. We report the
first known case, to our knowledge,
of a traumatic dissection and
rupture of the abdominal aorta
after a forcefully applied Heimlich
maneuver

(continued)

89

Table 1 (continued)

Level of
Evidence Definitions
Level 1a Population-based studies, randomized prospective studies or meta-analysis
of multiple studies with substantial effects
Level 1b Large non-population-based epidemiological studies or randomized prospective
studies with smaller or less significant effects
Level 2a
Level 2b
Perspective, controlled, non-randomized, cohort or case controlled studies
Historic, non-randomized, cohort or case-controlled studies
Level 3a Large observational studies
Level 3b Smaller observational studies
Level 4 Animal studies or a mechanical model studies
Level 5 Peer-reviewed, state of art articles, review articles, organizational statements
or guidelines, editorials, or consensus statements
Level 6 Non-peer reviewed published opinions, such as textbook statements, official
organizational publications, guidelines and policy statements which
are not peer-reviewed and consensus statements
Level 7 Rational conjecture (common sense); common practice is accepted before
evidence-based guidelines
Level 1-6E Extrapolations from existing data collected for other purposes, theoretical
analyses which are on point with question being asked. Modifier E
applied because extrapolating but rank base on type of study

Scienfitic Review 91

References

1. Heimlich HJ. Subdiaphragmatic pressure to expel water from the lungs of drowning
persons. Ann Emerg Med 1981;10:476-480.
2. Heimlich HJ, Uhley MH. The Heimlich Maneuver. Clin Symposia. 1979;31:3-32.
3. Heimlich HJ, Patrick EA. Using the Heimlich maneuver to save near-drowning victims.
Postgrad Med. 1988;84:62-73.
4. Modell JH. Drowning. N Engl J Med. 1993;328:253-256.
5. Modell JH. Drowning (letter response). N Engl J Med. 1993;329:65.
6. Modell JH. Near Drowning. Circulation. 1986;74 (suppl IV):27-28.
7. Simcock AD. Treatment of near drowning – a review of 130 cases. Anaesthesia.
1986;41:643-648.
8. Rosen P, Stoto M, Harley J. The use of the Heimlich maneuver in near drowning:
Institute of Medicine report. J Emerg Med. 1995;13:397-405.
9. Quan L. Drowning issues in resuscitation. Ann Emerg Med. 1993;22 (pt 2):366-369.
10. Quan L, Wentz KR, Gore E, et al. Outcome and predictors of outcome in pediatric
submersion victims receiving prehospital care in King County, WA. Pediatrics.
1990;86:586-593.
11. Weinstein MD, Krieger BP. Near-drowning: epidemiology, pathophysiology, and initial
treatment. J Emerg Med. 1996;14:461-467.
12. Safar P, Escarraga LA, Chang F. Upper airway obstruction in the unconscious patient.
J Appl Physiol. 1959;14:760-4
13. Rosen P, Stoto M, Harley J. The use of the Heimlich maneuver in near drowning:
Institute of Medicine report. J Emerg Med. 1995;13:397-405.
14. Neal JM. Near-drowning. J Emerg Med. 1985;3:41-52.
15. Ornato JP. Special resuscitation situations: near drowning, traumatic injury, electric
shock, and hypothermia. Circulation. 1986;74 (suppl IV):23-26.
16. Modell JH. Drowning. N Engl J Med. 1993;328:253-256.
17.
Olshaker JS. Near Drowning. Emerg Med Clinics N Amer. 1992;10:339-350.
18. Bross MH, Clark JL. Near-drowning. Amer Fam Phys. 1995;51:1545-1551.
19. Weinstein MD, Kruger BP. Near-drowning: epidemiology, pathophysiology, and initial
treatment. J Emerg Med. 1996;14:461-7.
20. Orlowski JP. Vomiting as a complication of the Heimlich maneuver.
JAMA.
1987;258:512-513.
21. Weinstein MD, Kruger BP. Near-drowning: epidemiology, pathophysiology, and initial
treatment. J Emerg Med. 1996;14:461-7.
22. Skulberg, A. Chest compression-an alternative to the Heimlich Manoeuver. Resuscitation.
1992;24:91.
23. Lanhelle A, Sunde K, Wik L, Steen PA. Airway pressure with chest compressions
versus Heimlich maneuver in recently dead adults with complete airway obstruction.
Resuscitation. 2000;44:105-8.
24. Wolf DA. Heimlich trauma: a violent maneuver. American J Forensic Med Pathology.
2001;22(1):65-67.
25. HaynesDE,HaynrsBE.,YongYV.EsophagealrupturecomplicatingHeimlichmaneuver.
1984. Am J Emerg Med. 2:507.
26. Agla GA, Hurst DJ. Pneumomediastinum following the Heimlich maneuver. JACEP.
1979;8:473-5.
27. Desai SC, Chute DJ, Bharati C, Desai MD, Koloski ER. Traumatic dissection and
rupture of the abdominal aorta as a complication of the Heimlich maneuver. J Vasc
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