Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

INITIAL

all patients

1st line – water rescue

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INITIAL
|
all patients
1st line – 

water rescue

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. Reaching, throwing, or dropping a buoyant object or maneuvering a craft to the person is preferred.[41]

Laypersons and rescuers without specialized training in water rescue should never enter the water to attempt a rescue.

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

The victim should be removed from the water in as near a horizontal position as possible, with the airway open.

On land, the patient should be placed supine with trunk and head at the same level.

Consider – in-water resuscitation

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INITIAL
|
all patients
Consider – 

in-water resuscitation

Treatment recommended for SOME patients in selected patient group

Retrospective data suggest that, for an 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 (up to 5 mouth-to-mouth ventilations only), 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]

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.

Consider – cervical spine considerations

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INITIAL
|
all patients
Consider – 

cervical spine considerations

Treatment recommended for SOME patients in selected patient group

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.

Those with confirmed cervical spine injury usually have obvious history, or signs of significant trauma; cervical spine imaging is not recommended for patients witnessed to have no preceding trauma prior to a drowning.

ACUTE

grade 1 (cough with normal lung auscultation)

1st line – observation

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ACUTE
|
grade 1 (cough with normal lung auscultation)
1st line – 

observation

Respiratory support and oxygen should not be required.[45] Patients can typically be released from the scene with education.

Grade 1 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]

Although delayed lung complications are rare, people who have been submerged or immersed in 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]

Plus – rewarming

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ACUTE
|
grade 1 (cough with normal lung auscultation)
|
with hypothermia
Plus – 

rewarming

Treatment recommended for ALL patients in selected patient group

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.

See Accidental hypothermia.

grade 2 (rales in some pulmonary fields)

1st line – respiratory support and oxygen

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ACUTE
|
grade 2 (rales in some pulmonary fields)
1st line – 

respiratory support and oxygen

Establishing an airway and providing oxygen are priorities in initial resuscitation.[41]

Deliver the highest concentration of oxygen available based on patient condition, with a goal of SpO₂ between 92% and 96%.[45][52]​ This can often be achieved with nasal cannula or face-mask.

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.

Plus – rewarming

Back
ACUTE
|
grade 2 (rales in some pulmonary fields)
|
with hypothermia
Plus – 

rewarming

Treatment recommended for ALL patients in selected patient group

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.

See Accidental hypothermia.

grade 3 (acute pulmonary edema with no hypotension or shock)

1st line – respiratory support and oxygen

Back
ACUTE
|
grade 3 (acute pulmonary edema with no hypotension or shock)
1st line – 

respiratory support and oxygen

Establishing an airway and providing oxygen are priorities in initial resuscitation.[41]

Based on patient condition, deliver the highest concentration of oxygen available via noninvasive or invasive ventilation, but positive pressure is preferred to passive ventilation.[41]

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 endotracheal intubation (ETI).[53][54]

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

ETI is ideal, but may be challenging to implement due to copious airway fluids. Efforts to clear the airway should be limited as they will often be futile.

Given the similar clinical course, recommendations call for following acute respiratory distress syndrome-focused ventilation strategies.[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]​ See Acute respiratory distress syndrome.

Admit to an adult or pediatric intensive care unit.

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] 

Plus – rewarming

Back
ACUTE
|
grade 3 (acute pulmonary edema with no hypotension or shock)
|
with hypothermia
Plus – 

rewarming

Treatment recommended for ALL patients in selected patient group

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.

See Accidental hypothermia.

grade 4 (acute pulmonary edema with hypotension or shock)

1st line – respiratory support and oxygen

Back
ACUTE
|
grade 4 (acute pulmonary edema with hypotension or shock)
1st line – 

respiratory support and oxygen

Establishing an airway and providing oxygen are priorities in initial resuscitation.[41]

Based on patient condition, deliver the highest concentration of oxygen available via noninvasive or invasive 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 after a short course of NIPPV, quickly convert to endotracheal intubation (ETI).[53][54]

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

ETI is ideal, but may be challenging to implement due to copious airway fluids. Efforts to clear the airway should be limited as they will often be futile.

Given the similar clinical course, recommendations call for following acute respiratory distress syndrome-focused ventilation strategies.[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-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]​ 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] ​See Acute respiratory distress syndrome.

Admit to an adult or pediatric intensive care unit.

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]

Consider – intravenous fluids ± vasopressor

Back
ACUTE
|
grade 4 (acute pulmonary edema with hypotension or shock)
Consider – 

intravenous fluids ± vasopressor

Treatment recommended for SOME patients in selected patient group

Reversal of hypoxia and/or hypothermia may resolve hypotension. Intravenous crystalloid infusion may be required.

Breathing should be monitored as respiratory arrest can still occur.[45]

Refractory hypotension may require vasopressors. If the patient is severely hypothermic, cardioactive drugs can reach toxic levels if given repeatedly. For these reasons, intravenous drugs are often withheld if the patient's core body temperature is <86°F (<30°C).[38] If the core body temperature is >86°F (>30°C), intravenous drugs may be administered but with increased intervals between doses.[37] Increase administration intervals for epinephrine (adrenaline) if the core temperature is 86°F to 93.2°F (30°C to 34°C).[38]

Primary options

epinephrine (adrenaline): children and adults: consult specialist for guidance on dose

Plus – rewarming

Back
ACUTE
|
grade 4 (acute pulmonary edema with hypotension or shock)
|
with hypothermia
Plus – 

rewarming

Treatment recommended for ALL patients in selected patient group

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.

See Accidental hypothermia.

grade 5 (no spontaneous ventilation, carotid pulse present)

1st line – respiratory support and oxygen

Back
ACUTE
|
grade 5 (no spontaneous ventilation, carotid pulse present)
1st line – 

respiratory support and oxygen

Establishing an airway and providing oxygen are priorities in initial resuscitation.[41]

Initial treatment of apneic patients with a palpable pulse is by way of mouth-to-mouth (feasible), or mouth-to-mask (pocket-mask, usually not feasible), or bag-valve mask.

Respiratory arrest is usually reversed after a few (less than 10) imposed breaths.[45]

If an advanced airway is required, only rescuers who are proficient at intubating the trachea should use tracheal intubation, especially in pediatric patients.[36][48]​

The expert consensus is that a high success rate is over 95% within two attempts at intubation.[38]

Endotracheal intubation is ideal, but may be challenging to implement due to copious airway fluids. Efforts to clear the airway should be limited as they will often be futile.

Given the similar clinical course, recommendations call for following acute respiratory distress syndrome-focused ventilation strategies.[45]​​​​​

In adults, this includes mechanical ventilation with tidal volumes of 6 to 8 mL/kg-1, with appropriate modification to maintain a plateau pressure <30 mm Hg and to achieve a PaO₂ of 55 to 80 mm Hg (SpO₂ 89 to 95%) through adjustment of positive end expiratory pressure (PEEP) (starting at 5 cm H₂O and adjusted in 2 to 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 FiO2₂ 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] See Acute respiratory distress syndrome.

Admit to an adult or pediatric intensive care unit.

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] 

Consider – intravenous fluids ± vasopressor

Back
ACUTE
|
grade 5 (no spontaneous ventilation, carotid pulse present)
Consider – 

intravenous fluids ± vasopressor

Treatment recommended for SOME patients in selected patient group

Reversal of hypoxia and/or hypothermia may resolve hypotension. Intravenous crystalloid infusion may be required.

Breathing should be monitored as respiratory arrest can still occur.[45]

Refractory hypotension may require vasopressors. If the patient is severely hypothermic, cardioactive drugs can reach toxic levels if given repeatedly. For these reasons, intravenous drugs are often withheld if the patient's core body temperature is <86°F (<30°C).[38] If the core body temperature is >86°F (>30°C), intravenous drugs may be administered but with increased intervals between doses.[37] Increase administration intervals for epinephrine (adrenaline) if the core temperature is 86°F to 93.2°F (30°C to 34°C).[38]

Primary options

epinephrine (adrenaline): children and adults: consult specialist for guidance on dose

Plus – rewarming

Back
ACUTE
|
grade 5 (no spontaneous ventilation, carotid pulse present)
|
with hypothermia
Plus – 

rewarming

Treatment recommended for ALL patients in selected patient group

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.[36][37][38]

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 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 temperature by 1.8°F to 3.6°F (1°C to 2°C) every 3 to 5 minutes.[58]

See Accidental hypothermia.

Plus – cardiopulmonary resuscitation (CPR)

Back
ACUTE
|
grade 5 (no spontaneous ventilation, carotid pulse present)
|
failure to restore spontaneous breathing
Plus – 

cardiopulmonary resuscitation (CPR)

Treatment recommended for ALL patients in selected patient group

Establishing an airway and providing oxygen are priorities in initial resuscitation.[41]

Administer 5 initial ventilations followed by 30 chest compressions to a drowning patient who does not present with obvious physical evidence of death (e.g., rigor mortis, decomposition, hemisection, decapitation).

CPR should follow with a compression to breath ratio of 30:2 for adults and 15:2 for children.[36]

If an automated or manual defibrillator is available, it may safely be applied as long as this does not impede high-quality CPR. CPR should not be delayed for defibrillation following drowning-related cardiac arrest.[48]​ Abdominal thrusts are not recommended.[41]

If an advanced airway is required, only rescuers who are proficient at intubating the trachea should use tracheal intubation, especially in pediatric patients.[36][48]

The expert consensus is that a high success rate is over 95% within two attempts at intubation.[38]

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

If endotracheal intubation is performed in pediatric patients, use continuous compressions with ventilations according to the following rates: 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]

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

grade 6 (cardiopulmonary arrest)

1st line – cardiopulmonary resuscitation (CPR) ± advanced life support drugs

Back
ACUTE
|
grade 6 (cardiopulmonary arrest)
1st line – 

cardiopulmonary resuscitation (CPR) ± advanced life support drugs

A majority of drowning cardiac arrest patients will be in pulseless electrical activity or asystole.[62]

Administer 5 initial ventilations followed by 30 chest compressions to a drowning patient who does not present with obvious physical evidence of death (e.g., rigor mortis, decomposition, hemisection, decapitation).

CPR should follow with a compression to breath ratio of 30:2 for adults and 15:2 for children.[36]

If an automated or manual defibrillator is available, it may safely be applied as long as this does not impede high-quality CPR.​​[41][48][62]​ CPR should not be delayed for defibrillation following drowning-related cardiac arrest.[48]

Abdominal thrusts are not recommended.[41]

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

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

If endotracheal intubation is performed in pediatric patients, use continuous compressions with ventilations according to the following rates: 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]

Consider Advanced Cardiac Life Support drugs as indicated, especially epinephrine. If the patient is severely hypothermic, cardioactive drugs can reach toxic levels if given repeatedly. For these reasons, intravenous drugs are often withheld if the patient's core body temperature is <86°F (<30°C).[38] If the core body temperature is >86°F (>30°C), intravenous drugs may be administered but with increased intervals between doses.[37] Increase administration intervals for epinephrine (adrenaline) if the core temperature is 86°F to 93.2°F (30°C to 34°C).[38]

Amiodarone or lidocaine may be used for refractory ventricular tachycardia/ventricular fibrillation.

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.

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

Consider – intravenous fluids ± vasopressor

Back
ACUTE
|
grade 6 (cardiopulmonary arrest)
Consider – 

intravenous fluids ± vasopressor

Treatment recommended for SOME patients in selected patient group

Reversal of hypoxia and/or hypothermia may resolve hypotension. Intravenous crystalloid infusion may be required.

Breathing should be monitored as respiratory arrest can still occur.[45]

Refractory hypotension may require vasopressors. If the patient is severely hypothermic, cardioactive drugs can reach toxic levels if given repeatedly. For these reasons, intravenous drugs are often withheld if the patient's core body temperature is <86°F (<30°C).[38] If the core body temperature is >86°F (>30°C), intravenous drugs may be administered but with increased intervals between doses.[37] Increase administration intervals for epinephrine (adrenaline) if the core temperature is 86°F to 93.2°F (30°C to 34°C).[38]

Primary options

epinephrine (adrenaline): children and adults: consult specialist for guidance on dose

Plus – rewarming

Back
ACUTE
|
grade 6 (cardiopulmonary arrest)
|
with hypothermia
Plus – 

rewarming

Treatment recommended for ALL patients in selected patient group

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]

For prolonged submersion, submersion in cold water, or if the patient is deemed to be hypothermic, passive and active rewarming measures should be administered.[36] 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]

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 techniques include airway rewarming with humidified oxygen at 104°F (40°C), heating intravenous fluids, and peritoneal lavage. Extracorporeal blood warming is the most effective method and increases core temperature by 1.8°F to 3.6°F (1°C to 2°C) every 3 to 5 minutes.[58]

Targeted temperature management (TTM) is recommended for adult and pediatric patients after either out-of-hospital or in-hospital cardiac arrest (OHCA or IHCA) with any initial rhythm who remain unresponsive after 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. 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]

See Accidental hypothermia.

Plus – respiratory support and oxygen

Back
ACUTE
|
grade 6 (cardiopulmonary arrest)
|
return of spontaneous circulation (ROSC)
Plus – 

respiratory support and oxygen

Treatment recommended for ALL patients in selected patient group

Ventilation is likely to require ongoing support following ROSC, whether through mouth-to-mouth, mouth-to-mask (pocket mask), bag-valve mask (BVM), or an advanced airway inserted during cardiopulmonary resuscitation. Some patients may remain dependent on rescue breathing until spontaneous ventilation becomes more efficient.

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

Endotracheal intubation (ETI) is ideal, but may be challenging to implement due to copious airway fluids. Efforts to clear the airway of vomit, water, or expelled pulmonary fluid should be limited as they will often be futile and delay needed interventions.

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

If ventilations cannot be given due to airway obstruction (uncommon), an attempt to quickly roll the patient and apply suction can be made with the goal of rapidly resuming ventilations.

Although there is insufficient evidence to support a specific target oxygen saturation or PaCO₂ during and after resuscitation, hypoxemia and hypercarbia should be avoided.

Given the similar clinical course, recommendations call for following acute respiratory distress syndrome-focused ventilation strategies.[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.[41] See Acute respiratory distress syndrome.

Admit to an adult or pediatric intensive care unit.

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] 

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer