Drowning ✅
Related Subjects:
Acute Kidney Injury
|Acute Rhabdomyolysis
|Drowning
|Hyperkalaemia
|Electrical injury
|Hypothermia
🌊 Most morbidity after drowning is caused by hypoxaemia from aspiration-related acute lung injury, with surfactant dysfunction, ventilation–perfusion mismatch, pulmonary oedema, and potentially ARDS.
⚠️ Do not attempt to “squeeze out water” or use abdominal thrusts/Heimlich unless there is clear evidence of foreign-body airway obstruction. Prioritise airway opening, ventilation, and oxygenation.
❌ Avoid outdated terms such as “dry drowning”, “wet drowning”, “secondary drowning”, and “near-drowning”. Management is guided by the patient’s clinical condition, with oxygenation and ventilation first.
🚑 Drowning – ED Management
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Immediate rescue and primary survey (ABCDE):
remove the patient from the water, begin assessment promptly, and treat as trauma if the mechanism suggests injury. Early attention to airway and breathing is critical.
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Cervical spine precautions:
consider cervical spine injury where there has been diving, axial load, collision, reduced consciousness, intoxication, or other unreliable assessment. In adults, use the Canadian C-spine rule where appropriate. Maintain in-line stabilisation if concern remains.
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Airway and breathing:
give high-flow oxygen and suction only visible debris, vomit, or secretions from the airway. If hypoxaemia persists, escalate respiratory support with CPAP or PEEP where appropriate. Intubate and ventilate for reduced GCS, exhaustion, apnoea, or refractory hypoxaemia.
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Circulation:
establish IV access, assess for shock, and treat haemodynamic instability. Use fluids judiciously and vasopressors if needed.
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Cardiac arrest:
follow ALS protocols. In drowning, effective oxygenation and ventilation are especially important because the arrest is usually hypoxic in origin.
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Hypothermia:
check the core temperature, handle gently, remove wet clothing, and begin rewarming. Use warmed oxygen and warmed IV fluids where available, with active rewarming for significant hypothermia.
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Mechanical ventilation:
if intubated, use a lung-protective strategy as for ARDS, with tidal volume around 6 mL/kg predicted body weight, appropriate PEEP, and FiO2 titrated to oxygenation targets.
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Adjunctive treatments:
use bronchodilators if there is bronchospasm or wheeze, and antiemetics if needed. Do not use routine antibiotics or corticosteroids. Antibiotics should be reserved for gross contamination, sepsis, or evolving infection.
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Observation:
monitor for delayed respiratory deterioration, which often becomes apparent within 4–6 hours. Even patients who initially appear well may require a period of observation depending on history and symptoms.
🔑 Key Clinical Points
- ❌ Do not use abdominal thrusts or attempt to “empty the lungs of water”. Suction only visible material from the airway.
- 🧪 Freshwater and saltwater aspiration rarely differ in a way that changes management; both are treated as aspiration-related lung injury.
- 📌 Always consider contributing factors such as alcohol, drugs, seizures, arrhythmia, syncope, hypoglycaemia, trauma, and non-accidental injury in children.
🧪 Investigations (tailored to severity)
- Core temperature, capillary glucose, ECG, and blood gas analysis if symptomatic or unwell.
- Chest X-ray may be useful in more significant cases, but can be normal early on and should not be used in isolation to determine disposition.
- FBC, U&Es, creatinine, lactate, CK, and other blood tests as guided by severity, submersion time, shock, rhabdomyolysis risk, or comorbidity.
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Imaging for suspected spinal injury:
in adults, CT cervical spine if indicated by the Canadian C-spine rule or clinical concern; MRI if there are neurological features suggestive of cord injury despite normal CT. In children, MRI may be needed where there is strong suspicion of cervical cord or column injury.
⚠️ Complications to Monitor
- Acute lung injury, non-cardiogenic pulmonary oedema, and ARDS
- Aspiration pneumonitis, with possible secondary bacterial pneumonia over the following 24–72 hours
- Hypoxic brain injury and arrhythmias
- Acute kidney injury and rhabdomyolysis after prolonged submersion, collapse, or CPR
🏥 Disposition
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Consider discharge after an appropriate observation period if the patient has a normal respiratory examination, no ongoing cough, dyspnoea, or wheeze, stable observations, and normal oxygen saturations on room air, with reliable supervision and clear safety-net advice.
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Admit if there is any oxygen requirement, abnormal observations, persistent respiratory symptoms, reduced consciousness, significant aspiration, hypothermia, associated trauma, important comorbidity, or safeguarding/social concerns.
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Escalate to HDU/ICU for significant hypoxaemia, need for non-invasive or invasive ventilatory support, ARDS, major hypothermia, shock, or post-arrest care.
🧾 Myths and Facts
- Freshwater vs saltwater: clinically, the distinction rarely alters treatment.
- Antibiotics: not given prophylactically; reserve for gross contamination, sepsis, or evolving infection.
- “Dry/secondary drowning”: these terms are misleading and should be avoided; assess the patient on current symptoms, respiratory findings, and oxygenation.
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