Level 2 of 6Must-remember

Drowning: fatal and non-fatal submersion

Assess, manage and stay safe — enough on its own

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The card — assess, manage, caution

Assessment— look, ask, measure

Ask why the patient went into the water, or why they failed to get out: drowning is frequently the terminal event of another acute illness — seizure, myocardial infarction or arrhythmia (long QT and catecholaminergic polymorphic VT are swimming-triggered), hypoglycaemia, syncope, stroke, subarachnoid haemorrhage, alcohol or drugs, self-harm, or non-accidental injury in a child.
Record three numbers with the time: submersion duration (under 5 minutes is favourable), water temperature, and Glasgow Coma Scale score with pupillary reactivity.
Respiratory features dominate: cough is the commonest symptom and must never be dismissed; also breathlessness, chest tightness or pain, wheeze, haemoptysis, and crackles from a few basal rales to widespread coarse crepitations.
Pink or white froth at the mouth and nose indicates pulmonary oedema and marks severe injury.
Hypoxaemia exists even in the alert, conscious patient who appears to be breathing normally — and oximetry may be unobtainable or falsely reassuring in a cold, vasoconstricted, shivering patient.
Cardiovascular features: tachycardia, hypotension and arrhythmia — most often bradyarrhythmia and, as the patient deteriorates, pulseless electrical activity progressing to asystole; fewer than 5% are found in a shockable rhythm.
Neurological features: headache, agitation, confusion, focal deficits, seizures and coma; trismus is a described presenting sign that may obstruct airway manoeuvres and oral suction, and in a cold patient must not be mistaken for rigor mortis.
Vomiting is extremely common, and shivering — or ominously its absence — cyanosis and pallor reflect coexisting hypothermia.
Grade severity with Szpilman: rescue (no cough, no froth, no difficulty) ~0%; grade 1 cough with normal auscultation ~0%; grade 2 rales in some lung fields with a small amount of froth ~0.6%; grade 3 acute pulmonary oedema without hypotension ~5%; grade 4 acute pulmonary oedema with hypotension ~20%; grade 5 isolated respiratory arrest with pulse present ~45%; grade 6 cardiopulmonary arrest ~90–93%.
Red flags: frothy oedema fluid at the mouth or nose; SpO₂ below 90% despite high-flow oxygen; a rising respiratory rate; hypotension; any fall in the Glasgow Coma Scale score, or unequal or unreactive pupils; seizure; a core temperature below 32°C; unexplained collapse in the water; and a diving, jumping or fall mechanism.
Assume hypothermia: water is thermoneutral only at about 35°C — stage it from a core temperature measured with a probe reading down to 25°C, because a clinical thermometer bottoming out at 34°C is not a measurement.
Hypothermia stages: I 32–35°C shivering, impaired judgement or coordination, stable, conscious; II 28–32°C shivering ceases with bradycardia, dilated pupils, slowed reflexes, cold diuresis, confusion, lethargy and Osborn (J) waves; III 24–28°C unconscious with vital signs present; IV below 24°C vital signs absent, coma, areflexia, asystole or VF — may falsely appear dead.
Check capillary blood glucose immediately in everyone: hypoglycaemia may be the cause of the drowning and mimics hypoxic encephalopathy.
Cervical spine precautions only where the mechanism requires them — dive, jump, fall, surf or vehicle — since such injuries occur in only about 0.5% of cases, and precautions must never delay airway opening or ventilation.
Know the look-alikes: immersion pulmonary oedema (breathlessness, frothy sputum and haemoptysis within about 10 minutes of starting to swim, without any submersion); arterial gas embolism (neurological signs on or shortly after ascent, from depths as little as 1 m); decompression sickness (90% symptomatic within 6 hours); and shallow-water blackout (hyperventilation then breath-hold, loss of consciousness usually on ascent in less than 5 m).
The delayed course is the defining trap: a patient may be deceptively asymptomatic during the initial recovery period only to deteriorate or die from acute respiratory failure within the following 12–24 hours, and pulmonary oedema may not appear for 24 hours.

Management— do this, in order

Oxygenation is the treatment, not supportive care: the lesion is a surfactant-depleted, atelectatic lung with a right-to-left shunt.
Keep the patient horizontal on extraction after prolonged immersion, to prevent post-immersion hypotension when hydrostatic support is withdrawn; in-water CPR and rescue breaths are no longer recommended, and untrained rescuers should not enter the water — reach, throw, row, don't go.
Open and suction the airway — regurgitation is the rule — then give oxygen at the highest available concentration immediately to every drowned patient, in practice 15 L/min via a non-rebreathe mask with reservoir, targeting SpO₂ at least 90%, including in the alert patient who insists they feel well.
If saturation cannot be maintained on high-flow oxygen the patient has a shunt and needs positive airway pressure: CPAP recruits collapsed alveoli, redistributes alveolar fluid and reverses the shunt — start at about 5 cmH₂O and titrate to oxygenation and work of breathing, but only in an awake cooperative patient able to protect their own airway.Doctor / NurseNot available at your setup — Mechanical ventilator.
Intubate and ventilate for a Glasgow Coma Scale score below 9, repeated vomiting, copious unclearable froth, exhaustion or refractory hypoxaemia, using protective lung ventilation — tidal volume 6 mL/kg predicted body weight, plateau pressure below 30 cmH₂O and generous PEEP, the principal recruiting therapy here; permissive hypercapnia is acceptable, profound hypoxaemia is not.Doctor / NurseNot available at your setup — Endotracheal intubation kit, Mechanical ventilator.
Decompress the stomach in every intubated patient and in anyone with a distended abdomen, since swallowed water plus bag-mask ventilation splints the diaphragm and invites a second aspiration.
Treat wheeze with nebulised salbutamol (adult 5 mg as required; child 2.5 mg under 5 years, 5 mg from 5 years), with or without nebulised ipratropium bromide (adult 500 micrograms 4–6 hourly; child 250 micrograms under 12 years, 500 micrograms from 12).
Access: two large-bore cannulae, or intraosseous access in arrest or profound shutdown, drawing the full panel on cannulation.Doctor / Nurse
Fluid, warmed to 38–42°C so it doubles as rewarming: adult 250–500 mL of 0.9% sodium chloride or a balanced crystalloid over 15 minutes, reassessing before each further bolus; child 10–20 mL/kg reassessed after each, in 10 mL/kg increments where pulmonary oedema is likely.Doctor / Nurse
If hypotension persists after adequate warmed fluid add noradrenaline 0.05–0.5 micrograms/kg/min by titrated infusion, with inotropic support for demonstrated myocardial dysfunction — but below 30°C the myocardium may not respond to vasoactive drugs at all, and rewarming rather than escalating catecholamines is then the treatment.Doctor / NurseNot available at your setup — Infusion pump.
Drowning arrest is hypoxic arrest: give five initial rescue ventilations before chest compressions, by two-person bag-valve-mask with reservoir and 15 L/min oxygen, watching for chest rise; then high-quality compressions, 30:2 in adults and 15:2 with two rescuers in children, continuous once the airway is secured.
Dry the chest before applying defibrillation pads — wet skin causes arcing and wastes the shock; expect a non-shockable rhythm, since fewer than 5% are shockable and the usual progression is bradycardia to pulseless electrical activity to asystole.Doctor / NurseNot available at your setup — Defibrillator.
Adrenaline in arrest: adult 1 mg (10 mL of 1:10 000) IV/IO every 3–5 minutes; child 10 micrograms/kg (0.1 mL/kg of 1:10 000) IV/IO every 3–5 minutes — and correct the reversible causes that apply here: hypoxia (the primary one), hypothermia, hypoglycaemia, hypovolaemia, hyperkalaemia and trauma.Doctor / Nurse
Rewarm concurrently: remove every piece of wet clothing and dry the patient completely, warm the room, rewarm the trunk not the extremities, handle with extreme gentleness, and chart core temperature at least every 15 minutes — Stage I needs passive external rewarming, Stages II–III add warmed intravenous fluid at 38–42°C, forced-air warming, warmed humidified inspired gas and where required body-cavity lavage, and Stage IV requires CPR plus all available rewarming continued to at least 32°C.
Correct hypoglycaemia immediately: adult 10% glucose 100–200 mL IV (or 50% glucose 50 mL); child 10% glucose 2 mL/kg IV; recheck at 10 minutes, and check glucose hourly for the first six hours in the unconscious or ventilated patient.Doctor / Nurse
Treat seizures: adult midazolam 1–2 mg IV slowly, lorazepam 4 mg IV or diazepam 5–10 mg IV; child midazolam 0.05–0.1 mg/kg IV, or without access midazolam 0.3 mg/kg buccal or intranasal or diazepam 0.5 mg/kg per rectum.Doctor / Nurse
Prophylactic antibiotics only for grossly contaminated water — sewage, stagnant drains, flood water carrying faecal material, industrial effluent — taking cultures first and giving broad-spectrum cover against enteric Gram-negatives and aquatic organisms such as Aeromonas and Pseudomonas, for example piperacillin–tazobactam 4.5 g IV 8-hourly in an adult, 90 mg/kg IV 8-hourly to a maximum 4.5 g in a child.Doctor / NurseNot available at your setup — Blood culture.
Observe before discharge: asymptomatic patients with no respiratory compromise, a normal chest radiograph and a normal arterial blood gas may be discharged after 6–8 hours of observation timed from the event, and only with the cause of the immersion identified and addressed.Not available at your setup — Arterial blood gas.

Caution— what harms

Never attempt to drain water from the lungs — no abdominal thrusts, no Heimlich manoeuvre, no inverting a child by the ankles; the aspirated volume is trivially small and already absorbed, postural drainage has no proven benefit, and such attempts achieve only regurgitation, further aspiration and delay to ventilation.
Never reach for a diuretic: the pulmonary oedema of drowning is non-cardiogenic aspiration injury in a patient who is often hypovolaemic, so crackles and froth after submersion are not an indication for furosemide — immersion pulmonary oedema is the deliberate exception, treated sitting upright with nitrates and diuretics.
Never declare a cold patient dead: do not stop resuscitation while the patient remains cold — the core temperature must exceed 32°C first — since coma, fixed dilated pupils, areflexia, asystole and ventricular fibrillation may all falsely suggest death where the hypothermia is reversible.
Never let a normal chest radiograph reassure you: a normal film on arrival excludes nothing, change lags the physiology and oedema may take 24 hours to appear — repeat at 6 hours in any symptomatic patient.
Never assume supplemental oxygen alone will fix the hypoxaemia: a true shunt is refractory to increased inspired oxygen and responds instead to alveolar recruitment, which is why CPAP or PEEP is the answer when high-flow oxygen fails.
Never expect the textbook electrolyte derangements: clinically significant electrolyte disturbance is uncommon and requires more than 22 mL/kg of aspirated or swallowed fluid — resuscitation should be built around oxygen, not electrolytes — and a modest sodium abnormality more often reflects baseline or resuscitation and should be corrected slowly.
Never treat the lung and ignore the precipitant: drowning is frequently the terminal event of another acute illness, and an unexplained collapse in water is not a discharge.
Never handle the hypothermic patient roughly: rough movement can precipitate fatal arrhythmia (rescue collapse), and warming the extremities rather than the trunk causes afterdrop.
Never apply defibrillation pads to a wet chest — dry it first or the shock arcs and is wasted.Doctor / NurseNot available at your setup — Defibrillator.
Never use the obsolete terms near-drowning, wet, dry or secondary drowning: they imply a benign, self-limiting event, and that implication is what leads to premature discharge — say fatal or non-fatal drowning with a clinical grade.
Never correct acidosis with bicarbonate as a first move — correct it by ventilating and perfusing, reserving bicarbonate for extreme, refractory acidaemia.
Never start corticosteroids — they have no established role — and remember that fever with a new infiltrate in the first 24 hours is usually chemical pneumonitis, not infection, so reassess at 48–72 hours before committing to a prolonged course.
Never trust oximetry in a cold, vasoconstricted, shivering patient, and never accept a laboratory value taken from a cold patient without telling the laboratory — values are inaccurate if the sample is warmed to 37°C for analysis.
Never discharge before the observation period has elapsed from the time of the event, or without safety-net advice to return for cough, breathlessness, fever, vomiting or drowsiness; any new symptom, falling saturation, rising respiratory rate, new crackles or wheeze, or a changing radiograph converts observation into admission.

Refer / escalate

Refer or transfer urgently any patient with SpO₂ below 90% on high-flow oxygen, frothy pulmonary oedema, hypotension, a falling Glasgow Coma Scale score, seizure, core temperature below 32°C, or arrest — to a unit with ventilation and, for hypothermic arrest or instability, extracorporeal life support, which is the treatment of choice and substantially improves survival; where it is unavailable the substitute is uninterrupted CPR with every available rewarming measure, sustained far longer than in a normothermic arrest.

The card — assess, manage, caution

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