Confirmed: Heimlich Maneuver Removes Water from
Respiratory Track of Near-Drowning Victim
by
Edward A. Patrick MD, PhD, FACEP
Introduction
There has been considerable interest in what is being called the "Lima" case, initially published
in 1981. The case proves that water is in the lungs of a fresh water near drowning child and it was
removed by the Heimlich Maneuver. The child survived for a significant amount of time after
treatment, but it is our opinion that the outcome improves when application of the Heimlich
Maneuver is not delayed.
False claims have been made which include that the case was "made-up" and was never
peer reviewed. Herein we provide a reprint of the text in that publication along with a copy of
the Emergency Department record, the later having been de-identified in accordance with
45 CFR 164.514. Peer review for the case includes that discussed in a letter written by the
Managing Editor of EMERGENCY in 1980, which illustrates the politics of the time which
set-up obstacles for publishing the case in certain other journals.
Case Report
On June 22, 1980 Dr. Edward A. Patrick MD, PhD, FACEP was the physician in charge
of the busy emergency department at Lima Memorial Hospital, Lima, Ohio. A two year old girl
was transported by rescue squad, arriving in the emergency department in cardiac arrest,
respiratory arrest and with widely dilated, fixed pupils.
One member of the rescue squad was performing cardiac compression while another
member was performing mouth-to-mouth breathing. The little girl had disappeared into
25 feet (estimated) of fresh lake water after the raft occupied by herself and parents capsized.
Her lifeless body floated to the surface after being under 20 minutes (estimated). An additional
20 minutes (estimated) elapsed for transportation to the emergency department.
While the nursing staff worked to start an IV, the author inserted an oral airway. No air
sounds were heard over the lungs (with the stethoscope) while a respiratory therapist bagged
with 100% oxygen to a face mask. The author immediately intubated the little girl while observing
a reservoir of water at and around the victim's vocal cords. An unmeasured amount of
water was suctioned from the endotracheal tube immediately after its insertion. Attaching
the bag and oxygen to the endotracheal tube, bagging produced no air flow sounds over the
lungs (with the stethoscope).
The author then performed the Heimlich Maneuver to the victim's abdomen, having identified
the area beneath the rib cage and above the umbilicus; water gushed into and out the endotracheal
tube. Prior preparation permitted collecting the water which came out of the endotracheal tube,
later measured to be 20 cc. Additional water was sucked from the endotracheal tube, estimated
to be 10cc.
The Heimlich maneuver was performed two additional times and sounds likely due to airflow
were heard coming out of the endotracheal tube, upon application of the last Heimlich Maneuver.
Suction through the endotracheal tube at this time removed an unmeasured amount of additional
water.
Attaching the bag with oxygen to the endotracheal tube, loud airflow sounds were heard over
the left lung (with the stethoscope). Faint airflow sounds then were heard over the right lung.
A subsequent x-ray showed the stomach and intestines extensively dilated with gas.
Recorded notes - Doctor, Record notes - Nurse, Recorded notes - Nurse, Recorded notes,
Recorded notes show the victim arrived in the emergency department at 2:24 pm and was intubated at
2:28 pm with a #17 tube. The notes indicate that the author expelled water through the endotracheal tube
at 2:28 pm. At 2:30 pm an IV was in place and the author ordered IV epinephrine. A ventricular rhythm
eventually resulted and at 2:34 pm the child was defibrillated for the first time with 50 watt-second.
Sodium bicarbonate was injected IV at 2:32 pm. Advanced CPR continued with blood gases drawn
at 2:44 pm and a portable chest x-ray at 2:50 pm.
First blood gases revealed a severe acidosis with normal oxygen and carbon dioxide levels.
Pupils were still dilated but slightly reactive to light at 3:15 pm, and systolic blood pressure was 80.
The victim was intermittently breathing on her own with improving color at 3:20 pm. The portable
chest x-ray revealed that the victim's stomach and intestines were extensively dilated with gas. The first
rectal temperature revealed hypothermia with temperature less than 95 F.
During the next week the child's cardiac and respiratory function remained stable. Neurological function
improved during the first five days with the child obtaining purposeful movements, reacting to pain and an
apparent recognition of her parents with purposeful eye movements. After five days, the EEG revealed
evidence of cerebral edema and the victim presented increasing signs of cerebral edema.
Discussion
We have proved that the 2 year old girl's airway was blocked with water after near-drowning.
The blockage made it impossible to deliver air to the victims lungs using mouth-to-mouth breathing. Rather,
the mouth-to-mouth breathing delivered air to the baby's stomach and intestines. The Heimlich Maneuver
applied in the emergency department relieved the blockage. It was proved scientifically that the Heimlich
Maneuver caused water blocking the airway to be expelled.
The author previously showed how the Heimlich Maneuver creates potential energy (by decreasing
volume and increasing pressure) which is converted to kinetic energy of an obstructing mass. The same model
applies in this case when the obstruction is a fluid with mass density.
A comprehensive review of the literature on drowning is beyond the scope of this article. Briefly, however
there are 7000 deaths from drowning annually in the United States and 140,000 deaths per year throughout the
world. In 1933 Karovich concluded "that the blocking effect of water has been the cause of many failures of
resuscitation." Heimlich recommended the Heimlich Maneuver to expel water blocking the airway. But Knopp
indicated that more data is needed before routine use of the Heimlich Maneuver to remove aspirated water,
although he doesn't directly address airway blockage such as in the current case. Spoor developed a protocol
for treating drowning at the scene which advocates using the Heimlich Maneuver only if airway obstruction
appears to be present.
Conclusions
Evidence is strong that treatment at the scene for an unconscious, near drowning victim should
include the Heimlich Maneuver. For the case reported here, the best first treatment was the Heimlich
Maneuver because ventilation using Mouth to Mouth breathing, an Oral Airway, or Endotracheal
Intubation did not result in pulmonary ventilation.
Determining airway obstruction in an unconscious, non-breathing drowning victim is difficult at the scene.
Detecting air sounds from the lungs with a stethescope using mouth to mouth, a face mask, or endotracheal
intubation indicates there is not complete obstruction. But this equipment usually is not available at the scene.
As shown in the case report here, even intubation with positive pressure ventilation does not insure an
unobstructed airway. Unless it is known that there is no airway obstruction, the Heimlich Maneuver should be
the first treatment of an unconscious drowning victim. Furthermore, until it is proven that a non-obstructed airway
can be detected in a time period not contributing to brain damage in an unconscious, non-breathing drowning victim,
the Heimlich Maneuver should be the first treatment.