EM · Drowning
Drowning
Also known as Submersion injury · Non-fatal drowning · Wet drowning
Drowning — the respiratory impairment from submersion or immersion in a liquid, a primary respiratory failure produced by aspiration and laryngospasm, and a leading cause of preventable death in the young. The chain of survival (early rescue, early CPR, early advanced life support); the management (ABCDE, 100 per cent oxygen, intubation and lung-protective ventilation with a tidal volume of 6 mL/kg and PEEP for the severe case, targeted temperature management for the comatose post-arrest patient, no routine prophylactic antibiotics, cervical spine immobilisation only for a diving injury); and the prognostication (submersion time, water temperature, CPR duration, initial GCS, initial rhythm — asystole carries the worst prognosis).
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Red flags
- A drowning patient is a respiratory patient first — the primary insult is hypoxia from aspiration or laryngospasm, not a cardiac event; restore oxygenation and ventilation before anything else
- Do not routinely immobilise the cervical spine — apply it only when a diving injury, a fall, or a motor mechanism suggests a cervical injury; blanket immobilisation of every drowning victim delays resuscitation
- The apnoeic, comatose patient rescued from cold water may still recover neurologically intact after prolonged submersion — resuscitate fully before prognosticating, and use the history (submersion time, water temperature, CPR time) not a single time cutoff
- Do not give prophylactic antibiotics routinely — they do not prevent pneumonia after drowning and they breed resistance; reserve antibiotics for a confirmed or strongly suspected infection
- Asystole on the initial rhythm predicts the worst outcome, whereas a shockable rhythm or a ROSC in the field predicts a far better recovery
Meet the patient
A 7-year-old boy is brought to your ED by the retrieval team after falling through the ice on a farm dam. The submersion time is estimated at 35 minutes. He was in asystole at the scene, and CPR with rescue breaths first has been in progress for 25 minutes. On arrival he is in asystole on the monitor, cold to the touch, with a core temperature of 26 degrees by a low-reading oesophageal probe. His pupils are fixed and dilated. He is intubated and ventilated with 100 per cent oxygen.[1]
The question that decides his first hour is the one that decides every drowning: is this a respiratory arrest that oxygenation can reverse, or has the brain already died? The honest answer is that you cannot tell until he is warm — which is why the rule is "no one is dead until warm and dead", and why the resuscitation continues while the rewarming runs in parallel.[1]
References11ShowHide
- [1]Szpilman D, Bierens JJLM, Handley AJ, Orlowski JP. Drowning. N Engl J Med, 2012.PMID 22646632
- [2]Szpilman D, Webber J, Quan L, et al. Creating a drowning chain of survival. Resuscitation, 2014.PMID 24911403
- [3]Szpilman D, de Barros Oliveira R, Mocellin O, et al. Is drowning a mere matter of resuscitation? Resuscitation, 2018.PMID 29928958
- [4]Idris AH, Berg RA, Bierens J, Bossaert L, Branche CM, Gabrielli A, et al. Recommended guidelines for uniform reporting of data from drowning: the Utstein style Resuscitation, 2003.PMID 14580734
- [5]Szpilman D, Morgan PJ. Management for the Drowning Patient Chest, 2021.PMID 33065105
- [6]Weuster M, Haneya A, Panholzer B, et al. The Use of Extracorporeal Membrane Oxygenation Systems in Severe Accidental Hypothermia After Drowning: A Centre Experience ASAIO J, 2016.PMID 26579978
- [7]McCallin TE, Dezfulian C, Bierens J, et al. 2024 American Heart Association and American Academy of Pediatrics Focused Update on Special Circumstances: Resuscitation Following Drowning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics, 2024.PMID 39530213
- [8]Szpilman D. Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1,831 cases Chest, 1997.PMID 9315798
- [9]Brower RG, Matthay MA, Morris A, et al. Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome. N Engl J Med, 2000.PMID 10793162
- [10]Jones T, Rennie A. BET 1: cervical spine immobilisation in the management of drowning victims. Emerg Med J, 2019.PMID 31753855
- [11]van der Lely N, Vreede WB. [Drowning and near-drowning in children]. Ned Tijdschr Geneeskd, 1998.PMID 9864523