Drowning: fatal and non-fatal submersion

Manage now— 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; open and suction the airway (regurgitation is the rule); then oxygen at the highest available concentration to EVERY drowned patient — 15 L/min via non-rebreathe mask with reservoir, targeting SpO₂ at least 90%, including 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 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 GCS below 9, repeated vomiting, copious unclearable froth, exhaustion or refractory hypoxaemia: protective lung ventilation — tidal volume 6 mL/kg predicted body weight, plateau pressure below 30 cmH₂O, generous PEEP (the principal recruiting therapy); permissive hypercapnia is acceptable, profound hypoxaemia is not. Decompress the stomach in every intubated patient and in anyone with a distended abdomen.Doctor / NurseNot available at your setup — Endotracheal intubation kit, Mechanical ventilator.
• Fluid, warmed to 38–42°C so it doubles as rewarming: adult 250–500 mL 0.9% sodium chloride or 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. If hypotension persists add noradrenaline 0.05–0.5 micrograms/kg/min titrated — but below 30°C the myocardium may not respond to vasoactive drugs at all: rewarming, not escalating catecholamines, is then the treatment.Doctor / NurseNot available at your setup — Infusion pump.
• Drowning arrest is hypoxic arrest: five initial rescue ventilations before chest compressions, by two-person bag-valve-mask with reservoir and 15 L/min oxygen; then 30:2 in adults, 15:2 with two rescuers in children, continuous once the airway is secured. Dry the chest before applying defibrillation pads (wet skin arcs and wastes the shock) and expect a non-shockable rhythm. Adrenaline: 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) every 3–5 minutes. Correct hypoxia, hypothermia, hypoglycaemia, hypovolaemia, hyperkalaemia and trauma.Doctor / NurseNot available at your setup — Defibrillator.
• Rewarm concurrently and never declare a cold patient dead: remove every piece of wet clothing and dry completely, warm the room, rewarm the trunk not the extremities, handle with extreme gentleness, chart core temperature at least every 15 minutes. Continue resuscitation until the core exceeds 32°C — coma, fixed dilated pupils, areflexia and asystole may all falsely suggest death while the hypothermia is reversible.
• 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, then hourly for the first six hours in the unconscious or ventilated patient. 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/intranasal or diazepam 0.5 mg/kg per rectum.Doctor / Nurse
• 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, and such attempts achieve only regurgitation, further aspiration and delay. Never give furosemide for the crackles of drowning — this pulmonary oedema is non-cardiogenic aspiration injury in an often hypovolaemic patient. No corticosteroids; prophylactic antibiotics only for grossly contaminated water (sewage, stagnant drains, flood water), taking cultures first — e.g. piperacillin–tazobactam 4.5 g IV 8-hourly (child 90 mg/kg IV 8-hourly, maximum 4.5 g).
• 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 — only with the cause of the immersion identified and addressed, and with safety-net advice to return for cough, breathlessness, fever, vomiting or drowsiness. Any new symptom, falling saturation, rising respiratory rate, new crackles or a changing radiograph converts observation into admission.Not available at your setup — Arterial blood gas.