Resuscitation with early ventilation, ICU management of drowning lung injury and prognosis.
At the bedside
Timed steps- 1
Cardiac arrest: ventilation first
0 minOpen airway and give 5 initial rescue breaths with oxygen if available, then CPR 30:2. Early intubation by a skilled operator. Do not attempt to drain water from the lungs (no Heimlich).
- 2
C-spine only if indicated
Immobilise only if diving, water-slide, trauma or alcohol with signs of injury; routine immobilisation delays ventilation.
- 3
Spontaneously breathing
High-flow oxygen; SpO2 target 94-98%; CPAP/NIV or HFNC if hypoxaemic and alert; intubate if failing, GCS ≤ 8 or exhausted.
- 4
Ventilated patient
Lung-protective ventilation (6 mL/kg PBW, PEEP 5-10+), treat as ARDS; may need high PEEP; bronchospasm and surfactant washout. Consider ECMO referral for refractory hypoxaemia.
- 5
Circulation and temperature
Hypotension from hypoxia and cold diuresis: crystalloid boluses. Treat hypothermia (see hypothermia topic). Post-arrest: avoid fever.
- 6
Avoid routine extras
No routine antibiotics (give if fever, new infiltrates beyond 48 h, or grossly contaminated water such as sewage/flood water); no routine steroids. Fresh vs salt water distinction does not change management.
- 7
Disposition
Asymptomatic with normal SpO2 and chest exam: observe for at least 6-8 h before discharge. Any symptoms, hypoxaemia, or abnormal CXR: admit.
Hypoxaemia
Oxygen
- Dose
- 15 L/min initially; titrate to SpO2 94-98%
Drowning
Step 1 of ~4
Decision: Breathing with a pulse?
Based on Szpilman D, Bierens JJLM, Handley AJ, Orlowski JP; Lott C, et al. Educational use; follow local protocol.
Pathophysiology
Aspiration of even small volumes (1-3 mL/kg) washes out and inactivates surfactant, causing atelectasis, intrapulmonary shunt and non-cardiogenic pulmonary oedema. Laryngospasm, hypoxic brain injury and arrhythmias follow prolonged hypoxia.
Evidence
- Szpilman's classification (grades 1-6) correlates with mortality and guides management [Szpilman 2012].
- ERC 2025 special circumstances emphasise early ventilation with initial rescue breaths in drowning arrest [ERC 2025].
Controversies
- Optimal duration of resuscitation and role of ECPR in cold-water drowning.
- Prophylactic antibiotics for heavily contaminated water.
🇮🇳 India notes
- Drowning kills tens of thousands in India annually, especially children in ponds, wells and during monsoon floods. Many victims present late via long transfers.
- Flood-water exposure raises risk of leptospirosis and melioidosis; consider doxycycline prophylaxis per local public health guidance.
References
Test yourself
Module quiz · score 70% to complete the module
Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.