Management of fresh-water drowning

1. Immediate rescue and basic life support

• Ensure rescuer safety and remove the person from water.
• Assess responsiveness, breathing, and pulse.
• If not breathing normally, begin rescue breaths immediately, followed by CPR if there is no definite pulse or signs of circulation.
  • Drowning is primarily a hypoxic respiratory arrest, so ventilations are particularly important.
  • Give an AED as soon as available and follow its prompts.
• Do not try to drain water from the lungs or stomach.
• Do not perform abdominal thrusts routinely, as this delays ventilation and can cause vomiting and aspiration.
• Immobilize the cervical spine only if there is a credible mechanism such as diving into shallow water, fall, or watercraft trauma.

2. Airway and breathing

• Clear visible vomitus or debris from the mouth and provide suction if needed.
• Give high-flow oxygen to all symptomatic patients.
• If apneic or inadequately breathing: bag-mask ventilation with oxygen.
• Endotracheal intubation and positive-pressure ventilation are indicated for:
  • Persistent apnea or respiratory failure
  • Inability to protect the airway
  • Altered consciousness
  • Refractory hypoxemia or severe pulmonary edema/ARDS
• Use lung-protective ventilation with PEEP if mechanically ventilated.
• In an awake patient with hypoxemia but preserved airway reflexes, CPAP/BiPAP may be considered with close monitoring.

3. Circulation and cardiac arrest

• Continue standard high-quality CPR and ACLS/PALS algorithms.
• Establish IV/IO access.
• Treat hypotension with isotonic crystalloid, then vasopressors if needed.
• Correct severe acidosis, hypoxia, hypothermia, and arrhythmias.
• Do not terminate resuscitation early in cold-water submersion. Rewarm first, as meaningful recovery after prolonged resuscitation can occur in selected hypothermic patients.

4. Hypothermia

• Remove wet clothes, dry the patient, insulate, and use active external rewarming as required.
• Monitor core temperature in significant cold-water exposure.
• Handle severely hypothermic patients gently because of arrhythmia risk.

5. Emergency department evaluation

• Oxygen saturation, respiratory effort, mental status, temperature, and signs of trauma.
• Chest radiograph if symptomatic, hypoxemic, or severe exposure. An initially normal radiograph does not rule out evolving lung injury.
• ABG/VBG, glucose, ECG, electrolytes, renal function, CK, and lactate in moderate or severe cases, or when clinically indicated.
• Consider causes of the event: seizure, arrhythmia, intoxication, hypoglycemia, trauma, intentional injury, or diving-related barotrauma.

6. Medications and interventions to avoid routinely

• Antibiotics: Not prophylactically. Give only if there is clinical evidence of infection, sepsis, pneumonia developing later, or grossly contaminated water exposure. Obtain cultures first in severe contaminated-water exposures where feasible.
• Corticosteroids: Not routinely recommended.
• Diuretics: Not routinely indicated for drowning-related pulmonary edema.
• Bronchoscopy: Not routine, but consider if aspirated foreign material causes unexplained ventilatory difficulty.
• Routine bicarbonate: Not indicated. Improve oxygenation and perfusion; treat severe acidosis according to resuscitation context.

7. Observation and disposition

• Alert, normal mental status
• No respiratory symptoms
• Normal oxygen saturation on room air
• Normal chest examination and no deterioration during observation
• No concerning comorbidity, trauma, or suspected precipitating condition

• Required rescue breathing, CPR, intubation, or noninvasive ventilation
• Persistent hypoxemia, abnormal work of breathing, rales, or pulmonary edema
• Altered mental status, seizures, dysrhythmia, hemodynamic instability
• Significant hypothermia, trauma, or metabolic derangement

Key exam point

Fresh-water drowning does not require a special fluid or electrolyte protocol. Treat it as hypoxic respiratory failure: early rescue ventilation, oxygenation, CPR when needed, rewarming, and observation for delayed pulmonary complications.