Drowning — chain of survival, Szpilman grade and ED management

Definition. Drowning is the process of experiencing respiratory impairment from submersion or immersion in a liquid (WHO/ILCOR). Do not use obsolete terms: near-drowning, dry/wet drowning, secondary drowning. Outcomes are death, morbidity, or no morbidity; fatal vs non-fatal.^[1]

Szpilman grade. Apnoea with bradycardia/arrest physiology = grade 6 (cardiopulmonary arrest) — worst severity tier, mandates full ALS and ICU pathway.^[1]

First 10 minutes. Primary problem is hypoxia. Continue high-quality CPR with early ventilation/oxygenation (rescue breaths matter more than in primary cardiac arrest). Secure airway (RSI/intubation), FiO2 1.0, lung-protective ventilation once ROSC (TV ~6 mL/kg, adequate PEEP). Rewarm: remove wet clothes, active external ± internal warming; hypothermia may be protective — do not declare death early in cold paediatric submersion. Glucose, blood gas, CXR, monitoring; treat reversible causes. Activate ICU/ECMO pathways if available for hypothermic refractory arrest.^[2][3]

C-spine. Immobilise only if diving, fall, MVC, or other mechanism suggests neck injury. Routine C-spine for all drowning delays resuscitation and is incorrect.^[1]

Antibiotics. No routine prophylaxis. Treat later only for confirmed/strongly suspected infection.^[1]

Prognosis. Worse with longer submersion, asystole, prolonged CPR without ROSC, low arrival GCS; better with short submersion, cold water (especially children), early bystander ventilation, ROSC in field. Submersion time and temperature dominate counselling — still resuscitate fully before prognosticating.^[1]