Makindo Medical Notes

🌊 Most drowning morbidity is from hypoxemia (aspiration, surfactant washout, alveolar injury). ⚠️ Routine attempts to “squeeze out water” are unnecessary and harmful. ❌ The old “dry vs wet drowning” terminology is discouraged — a minority may have laryngospasm with little aspiration, but management is the same: oxygenation and ventilation first.

🚑 Drowning – ED Management (Quick Algorithm)

Rescue & Triage: 🛟 Remove from water; assume C-spine injury only if diving, high-impact, or trauma evidence. Airway & Breathing: 🫁 High-flow O2. Suction visible debris. If hypoxemic → CPAP/PEEP. Intubate for ↑ work of breathing, ↓ GCS, or refractory hypoxemia. Circulation: ❤️ Treat shock; give judicious fluids; start vasopressors if needed. ALS: 💓 CPR if pulseless/apnoeic. Defibrillate when indicated. Monitor EtCO2. Hypothermia: 🧊 Check core temp. Gentle handling. Warmed O2/IV fluids; active rewarming if needed. “Not dead until warm and dead.” Ventilation Strategy (if intubated): Use ARDS-style lung-protective: VT ≈6 mL/kg PBW, adequate PEEP, titrate FiO2. Adjuncts: 🌬️ Bronchodilator for wheeze; antiemetic if vomiting. No routine steroids/antibiotics. Observation: 👀 Watch for delayed deterioration (4–8 h typical).

🔑 Key Points

• ❌ No abdominal thrusts/“water squeezing”. Use suction only for visible airway contents.
• 🧪 Fresh vs salt water electrolyte effects are usually minimal — treat both the same.
• 📌 Always consider co-factors: alcohol/drugs, seizures, arrhythmia, syncope, trauma.

🧪 Investigations (tailor to severity)

• ABG/VBG (oxygenation, pH), CXR (may be normal early), ECG, FBC/U&E/glucose/lactate, core temp.
• CT head/C-spine only if trauma, LOC, or focal neuro signs.

⚠️ Complications to Monitor

• ARDS / non-cardiogenic pulmonary edema
• Aspiration pneumonitis → bacterial pneumonia (24–72 h)
• Hypoxic brain injury, arrhythmias
• AKI, rhabdomyolysis (after prolonged submersion/CPR)

🏥 Disposition

• Safe discharge: after ≥6–8 h observation if normal exam, SpO₂ ≥95% RA, stable vitals, no dyspnea/wheeze, ambulant, reliable follow-up.
• Admit/ICU: if O₂ needed, abnormal vitals/mental status, aspiration, ARDS, pneumonia, hypothermia, comorbidities, or social concerns.

📊 Prognosis – Favourable Factors

• Short submersion (<5 min)
• Immediate bystander CPR
• Conscious/respirations on arrival
• Cold-water submersion with rapid rescue

🧾 Myths vs Facts

• Fresh vs Salt Water: electrolyte/hemolysis differences are negligible in practice → treat identically.
• Antibiotics: not prophylactic. Only if fever after 24–48 h, gross contamination, or clear infection.
• “Dry drowning”: avoid the term. Focus on current symptoms/signs after aspiration or laryngospasm.

📚 Optional Reference – Pathophysiology (Teaching)

For understanding only; does not change ED treatment.

Characteristic	Freshwater	Saltwater
Alveolar effect	Surfactant washout → collapse; some absorption	Osmotic draw → alveolar edema
Systemic impact	Electrolyte shifts minor	Hemoconcentration; shifts minor
Clinical takeaway	Treat both as aspiration-related lung injury → O2, CPAP/PEEP, ARDS ventilation as needed.

Cases — Drowning

• Case 1: A 14-year-old boy is pulled from a swimming pool after being submerged for ~2 minutes. He coughs on resuscitation, is conscious but agitated, with SpO₂ 89% on air. Chest auscultation reveals coarse crackles bilaterally. Management: Given high-flow oxygen via non-rebreather mask, nebulised salbutamol for bronchospasm, and monitored in a high-dependency unit. Chest X-ray confirms pulmonary oedema. IV fluids are restricted and he is observed for 24 hours. Outcome: Oxygen saturations improve steadily; he is discharged after 2 days with normal lung function and advice on water safety.
• Case 2: A 32-year-old woman is found in the sea after a suspected suicide attempt. Submersion time estimated at 10 minutes. On arrival she is unresponsive (GCS 5), core temperature 29 °C. Management: Intubated and mechanically ventilated with high FiO₂, warmed IV fluids and heated blankets applied, and invasive monitoring established. Broad-spectrum antibiotics started due to aspiration risk. Transferred to ICU for targeted temperature management and neuroprotection. Outcome: After 36 hours she is rewarmed to normothermia. She regains consciousness but has residual short-term memory impairment. Following psychiatric assessment, she is discharged to a mental health ward for ongoing care.
• Case 3: A 56-year-old man collapses while swimming in a reservoir. Estimated submersion time 6–7 minutes. Bystanders initiate CPR; on ED arrival he is in asystolic cardiac arrest, core temperature 31 °C. Management: Full ALS protocol commenced with airway secured and mechanical ventilation. High-quality chest compressions continued, IV adrenaline administered, and active rewarming with warmed fluids and forced-air warming system. After 25 minutes, return of spontaneous circulation (ROSC) achieved. Transferred to ICU for post-arrest care, including targeted temperature management and multi-organ support. Outcome: He remains comatose initially but over 72 hours shows neurological improvement. At 2 weeks he is discharged to neurorehabilitation with moderate hypoxic brain injury but able to mobilise with support.

Teaching Commentary 🧑‍⚕️

Drowning can cause acute lung injury resembling ARDS due to aspiration and surfactant loss. Case 1 demonstrates a relatively mild episode where observation is critical, as delayed pulmonary oedema can occur even after apparent recovery. Case 2 highlights the interplay of hypoxia, hypothermia, and mental health factors. Hypothermia complicates resuscitation but may also offer cerebral protection. Outcomes depend heavily on submersion time, quality of resuscitation, and patient comorbidities. Always combine resuscitation, supportive ICU care, and psychosocial follow-up in survivors.