Drowning — respiratory failure, Szpilman and cold-water resus viva

Pathophysiology. Submersion → aspiration/laryngospasm → surfactant washout → V/Q mismatch and non-cardiogenic oedema → hypoxaemia → secondary hypoxic bradycardia/arrest. Fresh vs salt water is an examiner trap — management identical at real aspirated volumes.^[1]

Grade. Pulmonary oedema with hypotension = Szpilman grade 4 → intubate/vasopressors/ICU, not simple observation.^[4]

Respiratory support. Most drowning arrests are secondary to hypoxia — compression-only CPR is likely ineffective; give initial ventilations with supplemental oxygen and continue ventilations alongside compressions.^[3] Early intubation if hypoxaemia or work of breathing; lung-protective ventilation once intubated.

Temperature. Measure core temperature with a low-reading device; rewarm carefully; extracorporeal resuscitation may be considered for refractory arrest with severe hypothermia where available.^[3]

Antibiotics / C-spine. No routine antibiotics; C-spine only for trauma mechanism (boat trauma possible — assess).^[1]

Prognosis. Once cardiac arrest has occurred, follow standard resuscitation guidelines — severe brain hypoxia carries a poor prognosis.^[3]