Drowning / Near-Drowning in a 16-Year-Old — Emergency Protocol

1. Scene / Pre-hospital (first minutes)

• Remove the patient from water by the fastest safe means and begin resuscitation immediately — do not wait until fully out of water if rescue-breathing can be started in shallow water/on a rescue board.
• Ventilation comes first. Unlike standard adult cardiac-arrest CPR, drowning resuscitation should start with a few rescue breaths/ventilations before chest compressions, because the primary problem is hypoxia, not a primary cardiac event (2024 AHA/AAP Focused Update, PMID 39530204/39530213).
• If no pulse or breathing → start full CPR (30:2 or continuous compressions with ventilations) and attach an AED/defibrillator as soon as available.
• Do NOT waste time trying to drain water from the lungs (abdominal thrusts/Heimlich are not indicated and can cause vomiting/aspiration) — this delays resuscitation and doesn't work reliably (Morgan & Mikhail's Clinical Anesthesiology, p. 2467-2468).
• C-spine precautions only if there is a history suggestive of trauma or diving into shallow water — otherwise routine spinal immobilization is not required and can hinder airway management.
• If cold-water submersion: do not declare death or stop resuscitation for "futility" until the patient has been rewarmed. Hypothermia can be neuroprotective, and full neurological recovery has occurred after prolonged submersion in cold water (Morgan & Mikhail's, p. 2467; Miller's Anesthesia, 10e).

2. Emergency Department Management (ABCDE)

• Suction/clear secretions, secure a definitive airway if GCS is low or airway reflexes are inadequate.
• In-line cervical stabilization during intubation if diving/trauma is suspected.

• High-flow 100% oxygen for everyone regardless of initial saturation.
• Get an ABG, pulse oximetry, chest X-ray.
• Almost all significant near-drowning patients have hypoxemia, hypercarbia, and combined metabolic/respiratory acidosis (Morgan & Mikhail's, p. 2468).
• If pulmonary edema/ARDS develops (very common after aspiration): intubate, ventilate with PEEP, treat bronchospasm with inhaled bronchodilators.
• Watch for delayed respiratory deterioration — symptoms of aspiration pneumonitis/ARDS can appear hours after the event even if the patient looks stable on arrival.

• Continuous cardiac monitoring/ECG — check for arrhythmias, especially with hypothermia (bradyarrhythmias, AF, VF below ~28-30°C).
• IV access, fluid resuscitation as needed.
• Check electrolytes: freshwater aspiration can cause hemodilution/hyponatremia/hemolysis; saltwater aspiration can cause hemoconcentration/hypernatremia, and hypermagnesemia/hypercalcemia have been reported (Morgan & Mikhail's, p. 2467).

• Assess GCS/pupils; an unconscious patient after submersion needs a full neuro exam.
• Treat seizures if they occur.
• Watch for and manage cerebral edema, which often complicates resuscitation after prolonged hypoxia (Morgan & Mikhail's, p. 2468).
• Head CT if focal deficits or persistently altered mental status to exclude other causes (bleed, trauma).

• Remove wet clothing, prevent further heat loss, actively rewarm if hypothermic — but avoid overly aggressive rewarming that could precipitate arrhythmias; core temperature monitoring guides this.

3. Additional work-up

• CBC, electrolytes, renal function, CK (rule out rhabdomyolysis if there was a fall/diving trauma), coagulation profile if severe.
• Blood cultures/consider antibiotics only if aspiration of contaminated/grossly polluted water or clinical signs of infection develop — routine prophylactic antibiotics are not standard.
• Toxicology screen if history suggests intentional injury, seizure disorder, or substance use contributing to the submersion (relevant in a 16-year-old — consider non-accidental/self-harm history).

4. Disposition

• Any patient who lost consciousness or aspirated water should be admitted for observation, even if they look well in the ED, because pulmonary and neurological deterioration can be delayed several hours.
• ICU-level admission if: required CPR, remains hypoxic, altered consciousness, hemodynamically unstable, or has significant acid-base/electrolyte derangement.
• Asymptomatic patients with a trivial, brief submersion and normal exam/vitals after several hours of observation may be safely discharged per Tintinalli's Emergency Medicine criteria, but this decision should not be made for a patient who was unconscious — that patient needs admission.

Key point for this case