Approach

Except for CPR compression to breath ratios, defibrillation energy doses, ventilation rates, and drug doses, similar principles apply to the management of adult and pediatric patients who have drowned.

The 'Drowning Chain of Survival' refers to a series of interventions that, when put into action by laypersons or professionals, may reduce morbidity and mortality associated with drowning.[17][47]

The links of the chain are as follows:

  • Prevention - be safe in and around water

  • Recognize distress - ask someone to call for help

  • Provide flotation - to prevent submersion

  • Remove from the water - only if safe to do so

  • Provide care as needed - seek medical attention.

[Figure caption and citation for the preceding image starts]: Drowning Chain of SurvivalSzpilman et al. Creating a drowning chain of survival. Resuscitation. 2014 Sep;85(9):1149-52. Used with permission [Citation ends].com.bmj.content.model.Caption@29c29db4

Severity of injury, as determined by the drowning severity classification,​ dictates the initial treatment approach. The primary focus is the timely reversal of systemic hypoxemia to prevent secondary neurologic injury.[17]​​​[46]

Water rescue

The following links of the Drowning Chain of Survival are pertinent:[48]

  • Recognize distress and call for help to ensure early activation of professional rescue and emergency medical services.

  • Provide flotation to stop the process of drowning. A responder who is not properly trained in advanced water rescue should never enter the water to attempt a rescue. If possible, reaching/throwing an object or maneuvering a craft to the person is safest.[41]

  • If safe to do so, remove the patient from the water as quickly as possible. Once on land, place them in a horizontal position to optimize blood flow to the brain without increasing aspiration risk, and keep the airway open.[48]

  • Retrospective data suggest that, for the unconscious patient, in-water ventilation by trained individuals may increase the likelihood of neurologically intact discharge from the hospital.[37]​​[48][49]​ If there is no response to in-water ventilation, the patient should be assumed to be in cardiac arrest. Chest compressions should not be attempted while in the water.[41]​ All drowning patients without a pulse should be removed from the water as soon as possible so that effective ventilation and chest compressions can be started.[41]

Routine spinal motion restriction is not indicated for the majority of people who have drowned because the incidence of cervical spine injury is extremely low.[37][43][44] ​​​Focal neurologic deficit, altered mental status or a history of high-risk activity, suggest a higher risk for spine injury.[41]​​​ If cervical spine injury is suspected, the cervical spine may be held in midline, but attempts at further motion restriction with cervical spine collars or long spine boards should never impede resuscitative efforts.

Prehospital discharge or transfer to hospital

Symptomatic adult and pediatric patients who are conscious, alert, and coughing but with normal lung auscultation (grade 1) may be considered for release from care at the scene if, after 10 to 15 minutes of careful observation, they meet all of the following criteria:[50]​​​

  • No cough

  • Normal rate of breathing

  • Normal circulation as measured by pulse in strength and rate and/or blood pressure

  • Normal color and skin perfusion

  • No shivering

  • Fully conscious, awake, and alert.

Patients and caregivers who fulfill these criteria should be offered education regarding water safety prior to release.

Although delayed lung complications are rare, people who have been rescued from the water should be advised to seek medical advice immediately if they develop cough, breathlessness, fever, or any other worrying symptom in the ensuing 8-hour period.[51] These cases represent a progressive worsening of initially mild symptoms that may have been overlooked.

Adult and pediatric patients who have been submerged or immersed in water who require any form of resuscitation (including solely rescue breathing) should be taken to the emergency department for evaluation and monitoring, even if they appear to be alert and demonstrate effective cardiorespiratory function at the scene.[37]​​[48][51]

Airway management

Establishing an airway and providing oxygen are priorities in initial resuscitation.[41]​ All drowning patients, except those with normal oxygenation (grade 1, conscious and alert; cough with normal lung auscultation), should receive supplemental oxygen. The goal is to deliver the highest concentration of oxygen possible, with the method determined by patient condition, but positive pressure is preferred to passive ventilation.[41]

  • Patients who are protecting their airway with mildly labored breathing may be trialed with oxygen by face mask at a rate of 15 liters of oxygen per minute, with a goal of SpO₂ between 92% and 96%.[45][52]

  • Life threatening hypoxia should be treated with 100% inspired oxygen until the arterial oxygen saturation or the partial pressure of arterial oxygen can be measured reliably. Once SpO₂ can be measured reliably or arterial blood gas values are obtained, inspired oxygen should be titrated to achieve an arterial oxygen saturation of 94% to 98% or arterial partial pressure of oxygen (PaO₂) of 10-13 kPa (75-100 mmHg).[36][38]

  • If the patient’s ventilatory status, mental state, or SpO₂ decline, continue to endotracheal intubation (ETI).[36]

  • If an advanced airway is required, only rescuers who are proficient at intubating the trachea should use tracheal intubation, especially in paediatric patients.[36][48]​ The expert consensus is that a high success rate is over 95% within two attempts at intubation.[38]

  • Patients who are protecting their airway with increased breathing effort requiring support, and who are sufficiently conscious to follow commands, may be trialed on noninvasive positive pressure ventilation. Noninvasive positive pressure ventilation should only be used in patients with mild-to-moderate respiratory symptoms and who are alert; patients with altered mental status and/or active vomiting are at risk of aspiration.[41]​ If the patient does not improve or there is clinical deterioration, continue to ETI.[53][54]

  • Patients not breathing should be oxygenated via mouth-to-mouth, mouth-to-mask (pocket mask), or bag-valve mask (BVM) as a bridge to ETI.[48]​

  • If ETI is performed, mechanical ventilation should follow ventilation strategies similar to acute respiratory distress syndrome ventilation.[45]​ In adults, this includes mechanical ventilation with tidal volumes of 6-8 mL/kg-¹, with appropriate modification to maintain a plateau pressure <30 mm Hg and to achieve a PaO₂ of 55-80 mm Hg (SpO₂ 89% to 95%) through adjustment of positive end expiratory pressure (PEEP) (starting at 5 cm H₂O and adjusted in 2-3 cm H₂O increments) and FiO₂.​[41][45]​​​​​​[55]​ In pediatric patients, an inspiratory plateau pressure ≤28 cm H₂O is suggested. For mild/moderate pediatric acute respiratory distress syndrome (PARDS), SpO₂ should be maintained between 92% and 97%. For severe PARDS, after optimizing PEEP, SpO₂ less than 92% is acceptable to reduce excessive FiO₂ exposure.​[41][45]​​​​​[56]​​​ Once established, PEEP should be left unchanged for 24 hours to permit adequate surfactant regeneration and consequent alveolar recruitment before weaning is attempted. Early weaning from the ventilator may cause the return of pulmonary edema with the need for re-intubation, a prolonged hospital stay, and further morbidity.[45][56]​​​ See Acute respiratory distress syndrome.

  • If ETI equipment is not available, or airway assessment suggests that ETI is likely to be difficult, a supraglottic device may be used. If the supraglottic device does not result in sufficient ventilation (e.g., because drowning can cause reduced pulmonary compliance requiring high inflation pressures), remove the device and continue BVM ventilations or proceed to ETI should it become available.[36][45]

  • If advanced care is close by and BVM ventilations are adequate to maintain SpO₂ >95%, BVM ventilations should be continued as a bridge to ETI at the advanced care center, especially when treating children.

  • The stomach should be decompressed using a gastric tube after initial resuscitation is completed.[36]

  • Extracorporeal membrane oxygenation (ECMO) may be indicated in cases of hypoxia refractory to initial treatment measures. If local resources and protocols allow, drowning patients displaying hypoxia should be referred to an ECMO-capable center after initial resuscitation.[38]

Hypothermia

Severe hypothermia (body temperature <30°C) may be associated with marked depression of critical body functions such that the patient may appear dead during initial assessment. Resuscitation guidelines recommend that CPR should be continued unless the patient is unquestionably dead. Patients should not be considered dead until successful warming has been provided.[36][37][38]

Case reports of drowning patients surviving prolonged submersion and cardiac arrest are rare, and typically involve small children falling into icy water.[12] In the majority of cases, hypothermia carries a poor prognosis.[57]

Patients should undergo passive and active rewarming as indicated by the patient's condition and available resources:

  • Passive rewarming (including removing wet clothing, and drying and covering the patient) is the preferred treatment option for mild cases.

  • Active external rewarming is indicated for moderate to severe hypothermia. In addition to covering the patient with warm blankets, a convective temperature management system can be used to force warm air directly over the patient's body to maintain a core body temperature.

  • Active internal rewarming, used alone or in combination with active external rewarming, is the most aggressive and resource-intensive strategy. Techniques include airway rewarming with humidified oxygen at 104°F (40°C), warmed intravenous fluids, and peritoneal lavage. Extracorporeal blood warming is the most effective method and increases core body temperature by 1.8°F to 3.6°F (1°C to 2°C) every 3 to 5 minutes.[58]

See Accidental hypothermia.

In hypothermic cardiac arrest, patients should be referred to a center capable of extracorporeal life support (ECLS) after initial resuscitation, if local resources and protocols allow for this.[38] Rewarming should preferably be performed with extracorporeal membrane oxygenation (ECMO) over cardiopulmonary bypass (CPB). Non-ECLS rewarming should be initiated in a peripheral hospital if an ECLS center cannot be reached within hours (e.g., 6 hours).[38]

Targeted temperature management (TTM) is recommended for pediatric and adult patients after either out-of-hospital or in-hospital cardiac arrest (OHCA or IHCA) with any initial rhythm and who remain unresponsive after return of spontaneous circulation (ROSC). In adults, a target temperature at a constant value between 89.6°F and 96.8°F (32°C and 36°C) should be maintained for at least 24 hours. Fever (>99.9°F [>37.7°C]) should be avoided for at least 72 hours after ROSC in adults who remain in coma.[59]​ Similar principles apply when managing pediatric patients, although the evidence base exists for a target temperature of between 89.6°F and 99.5°F (32°C and 37.5°C) for 5 days.[60]​ A fever of ≥100.4°F (≥38.0°C) in a child should be aggressively reduced.[60]

Cardiopulmonary resuscitation (CPR)

Adult or pediatric patients in cardiopulmonary arrest (grade 6) should be given 5 rescue breaths before beginning chest compressions.[45] This is to address the primary issue of hypoxemia in a patient with water in the airways.[45] Cardiac arrest following drowning is most often due to a hypoxia; so rescue breathing is important to increase the likelihood of return of spontaneous circulation. This differs from sudden cardiac arrest with a cardiac etiology, in which the individual generally collapses with fully oxygenated blood and therefore compressions are usually recommended first as a bridge to defibrillation.[48]​ CPR should follow with a compression to breath ratio of 30:2 for adults and 15:2 for children.[36]

For adults, if endotracheal intubation is performed, utilize continuous compressions with a breath every 6 seconds.[36]

During the management of a pediatric cardiorespiratory arrest, once a tracheal tube is in place, continuous chest compressions should be given. In this case, ventilations should approximate to the lower limit of normal rate for age:

  • Infants: 25 breaths per minute

  • Children 1-8 years old: 20 breaths per minute

  • Children 8-12 years old: 15 breaths per minute

  • Children >12 years old: 10-12 breaths per minute.[61]​​

If an automated or manual defibrillator is available, it may safely be applied as long as this does not impede positive pressure ventilations and high-quality CPR; the majority of drowning cardiac arrest patients will be in pulseless electrical activity or asystole.​​[41][48][62]​​ CPR should not be delayed for defibrillation following drowning-related cardiac arrest.[48]

Abdominal thrusts are not recommended.[41]

The stomach should be decompressed using a gastric tube after initial resuscitation is completed.[36]

Advanced Cardiac Life Support drugs should be administered per local protocols, with the understanding that reversal of hypoxemia is the priority. Follow your current local protocols for the management of cardiac arrest, including the selection of suitable drugs and doses. See Cardiac arrest for more detailed information on the management of adults.

Patient admission or discharge following initial management

After initial management, hospital admission, level of care acuity, or discharge depends on the initial drowning severity classification​ and the patient’s response to treatment.[17]​​​[46]

  • Grade 1 adult and pediatric patients (conscious and alert; cough with normal lung auscultation) who present at the emergency department can be observed off oxygen for a few hours and released if vital signs, symptoms, lung exam, and mentation remain normal.[17][63][64]

  • Grade 2 to 6 adult and pediatric patients (where grade 2 patients have rales in some pulmonary fields) should all be transported to advanced care.

    • Grade 2 adult and pediatric patients: consider an observation period of 6 hours in the emergency department. If the patient is off supplemental oxygen for that time, with normalized vital signs and mentation, and there are no other medical/traumatic conditions requiring further treatment, consider discharge with close follow-up.[63][64] If requiring supplemental oxygen, vital signs or mentation not normalized, poor follow-up, or if the patient/family is not comfortable returning home, admit the patient to a noncritical unit.

    • Grade 3 to 6 patients (where grade 3 patients have acute pulmonary edema) should be admitted to the adult or pediatric intensive care unit.

Supportive therapies

Cardiac dysfunction with low cardiac output is common immediately after severe drowning in adult and pediatric patients, especially after the return of spontaneous circulation.[15] This may cause hypotension, which can be corrected with oxygenation, rapid crystalloid infusion, and restoration of normal body temperature. Echocardiography can help to guide the clinician in titrating inotropic agents, vasopressors, or both, if volume crystalloid replacement has failed.[45] Urine output should be monitored.

There is no evidence to support the use of any specific fluid therapy for salt- or freshwater drowning, or for the use of diuretics or water restriction in drowning pulmonary edema.[15]

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