Drowning Myths, Missteps, and Pro-tips

Drowning is respiratory impairment from submersion or immersion, and early hypoxia management matters more than outdated labels or routine testing. Cervical spine injury is uncommon, chest x-ray and labs rarely guide care, and the strongest prognostic signal is neurologic trajectory over the first 24 hours.

Drowning Resuscitation and ED Care

• Modern drowning definition: Use drowning to describe respiratory impairment after submersion or immersion, with outcomes classified as death, morbidity, or no morbidity; terms like near drowning and dry drowning should be retired.
• Airway first on scene: Drowning is primarily a hypoxic arrest, so ventilations come early and may be lifesaving even when a pulse remains; the five-initial-breath approach is one nuance we get into in the episode.
• C-spine immobilization priorities: Cervical spine injury is uncommon at roughly 0.5% to 5%, and immobilization should not delay CPR unless the history suggests high-risk trauma such as diving from height.
• Heimlich myth reversal: Abdominal thrusts and attempts to suction out aspirated water are not supported by quality data and worsen care by delaying ventilation during ongoing cerebral hypoxia.
• ED testing reality: Labs and an initial chest radiograph have little value for prognosis or guiding therapy; a normal early CXR does not predict blood gases or outcomes.
• Neurologic prognosis signal: The best predictor of long-term outcome is normal or rapidly improving mental status over the first 24 hours, while an initially abnormal head CT usually signals severe brain injury.

Transport, Disposition, and Special Situations

• Who needs ED transport: Normal mentation with absent or mild symptoms usually does not require ED evaluation, but frothy sputum, abnormal lung sounds, hypotension, depressed mentation, or a prolonged rescue do.
• Cold water physiology: Cold-water submersion can be neuroprotective through bradycardia, apnea, and peripheral vasoconstriction, especially in children, but only in select circumstances we parse out in the chapter.
• Shallow water blackout: Pre-dive hyperventilation lowers PaCO2 without increasing oxygen stores, blunting the urge to breathe until hypoxemic syncope occurs underwater during exertion.
• Termination on scene: Submersion duration and water temperature both matter when considering when resuscitation might be stopped, and the practical time cutoffs are worth hearing in the episode.
• Observation and discharge: Asymptomatic patients with normal oxygen saturation, vitals, and full recall can often go home without testing, while symptomatic patients generally need a short observation period before disposition.
• Prevention with effect size: Pool fencing and gating cut swimming-pool drowning by about 80%, and counseling matters for toddlers, boaters, and patients with CAD or seizure disorders.

References:

1. Bierens J, et al. Resuscitation and emergency care in drowning: A scoping review. Resuscitation. 2021;162:205-217. PMID: 33549689
2. Drowning. World Health Organization. Updated 27 April 2021. https://www.who.int/news-room/fact-sheets/detail/drowning
3. Schmidt AC, et al. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning. Wilderness Environ Med. 2016;27(2):236-251. PMID: 27061040
4. Sempsrott J SA, Hawkins S, Cushing T. Drowning and Submersion Injuries. Auerbach's Wilderness Medicine. 5 ed. 2017:1529-1549:chap 69.
5. Szpilman D, Morgan PJ. Management for the Drowning Patient. Chest. 2021;159(4):1473-1483. PMID: 33065105