ICU · environmental

Acute Drowning & Near-Drowning — Comprehensive ICU Management

Also known as Drowning · Non-fatal drowning · Fatal drowning · Submersion injury · Immersion injury · Secondary drowning (obsolete) · Near-drowning (obsolete) · Dry drowning (obsolete) · Wet drowning (obsolete) · Asphyxial cardiac arrest from submersion

Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid — a uniform definition adopted by the World Health Organization in 2005 that abolishes the obsolete terms 'near-drowning', 'dry drowning', 'wet drowning', 'secondary drowning' and 'active/passive drowning'. ALL submersion or immersion events are now called DROWNING, classified only by outcome as fatal or non-fatal drowning. The pathophysiological sequence is breath-holding and panic followed by laryngospasm, then aspiration of a SMALL volume of water (the 'dry versus wet drowning' distinction is obsolete because most victims aspirate fluid and the volume aspirated is too small to cause electrolyte or volume disturbance), leading to surfactant washout, atelectasis, ventilation-perfusion mismatch, non-cardiogenic pulmonary oedema and ARDS, with progressive HYPOXIA producing bradycardic asystolic cardiac arrest and hypoxic-ischaemic brain injury. The intensivist's priorities are (1) RESCUE with immediate resuscitation — start CPR without delay, giving rescue breaths or bag-mask ventilation first because this is an asphyxial arrest; drowning victims often have prolonged hypoxia yet achieve return of spontaneous circulation with good-quality CPR even after more than 30 minutes submerged, especially in cold water; (2) OXYGENATE and VENTILATE with high-flow oxygen and positive-pressure ventilation — most need PEEP for aspiration pneumonitis, surfactant dysfunction and pulmonary oedema, with lung-protective ventilation (tidal volume 6 mL/kg, plateau pressure under 30 cmH2O) for the ARDS-pattern lung injury; (3) TARGETED TEMPERATURE MANAGEMENT at 32 to 36 degrees C for 24 hours in comatose post-arrest patients, because drowning is a form of cardiac arrest and the same post-cardiac-arrest guidelines apply; (4) treat CO-EXISTING injuries — cervical spine immobilisation particularly after diving accidents, and concurrent hypothermia from cold-water exposure (rewarm, but follow 'not dead until warm and dead'). Prognostication is guarded by the duration of submersion, the presence of return of spontaneous circulation, the Glasgow Coma Scale, and serum potassium on presentation.