Near-drowning and drowning in the ICU

Also known as Drowning · Near-drowning · Submersion injury · Secondary drowning · Non-fatal drowning · Surfactant dysfunction drowning

Drowning is defined as 'the process of experiencing respiratory impairment from submersion/immersion in liquid.' 'Near-drowning' (old term) — now ALL submersion injuries are 'drowning' (fatal or non-fatal). Primary injury: HYPOXIA (from aspiration/laryngospasm causing hypoxaemia → brain injury + multi-organ failure). NOT salt-water vs fresh-water distinction (clinically irrelevant — both cause hypoxia). Management: ABCDE + HIGH-FLOW OXYGEN + early intubation if respiratory distress or decreased GCS. LUNG INJURY: non-cardiogenic pulmonary oedema (ARDS-like) from aspiration + surfactant washout. BRAIN INJURY: hypoxic ischaemic encephalopathy — PRIMARY cause of death and disability. Management: neuroprotection (avoid hypoxia, hyperoxia, hypotension, hyperthermia). Rescue breaths FIRST (5 breaths) — drowning is an asphyxial arrest. Lung-protective ventilation + PEEP for ARDS-pattern lung. TTM 32–36°C for comatose post-arrest patients. Surfactant may be considered for severe refractory ARDS.

medium20 referencesUpdated 3 Sept 202630 min readSource-verified · Sept 2026

Checked against its sources on 3 Sept 2026

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8 MCQs

In one line

Drowning: the process of experiencing respiratory impairment from submersion or immersion in liquid — fatal or non-fatal, with or without morbidity (WHO consensus definition).^[3] PRIMARY injury: HYPOXIA — aspirated water causes loss of surfactant, atelectasis, right-to-left shunting and non-cardiogenic pulmonary oedema; salt and fresh water aspirations cause similar pathology.^[6] The arrest is asphyxial: drowning progresses from respiratory arrest due to submersion-related hypoxia to cardiac arrest, so resuscitation must focus on restoring breathing as much as circulation — trained rescuers may begin in-water rescue breathing, then continue chest compressions in keeping with basic life support guidelines once on land.^[2] In hospital: lung-protective ventilation (tidal volume 6 mL/kg predicted body weight, plateau pressure 30 cmH₂O or less) with PEEP; do not wean prematurely because the oedema can return.^[15]^[6] For the comatose post-arrest patient, targeted temperature management at 33°C and 36°C gave equivalent outcomes in the TTM trial — the priority is preventing fever.^[14] Prognosis: submersion duration is a key factor in survival and neurologic damage; children have higher one-month survival than adults after drowning cardiac arrest, although most survivors in that registry had unfavourable neurological outcomes.^[5]^[11]

Meet the patient

An 18-year-old is pulled from a cold lake after a witnessed submersion of about 8 minutes. He is unconscious, apnoeic, with a carotid pulse. Bystanders have started chest compressions. On paramedic arrival his SpO2 is 60 percent on high-flow oxygen. The first intervention is not compressions — it is five rescue breaths, because this is an asphyxial arrest and the blood is already desaturated.^[2]

Two facts decide his outcome: the submersion time (the single strongest predictor) and the water temperature (cold water paradoxically protects the brain). Hold those two and the management slots into place — ventilate first, oxygenate with PEEP, and if the water was cold and he is hypothermic, resuscitate longer than you think reasonable.^[1]

References20Show

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