Drowning and Submersion Injury — ED Care

Key Points

• Drowning is fundamentally a hypoxic respiratory emergency.
• CPR after drowning-related cardiac arrest should include rescue breaths as well as chest compressions.
• Do not delay effective ventilation and CPR in order to apply an AED first.
• Do not use abdominal thrusts or other attempts to drain water from the lungs.
• Saltwater versus freshwater exposure does not change initial resuscitation.
• Routine antibiotics or corticosteroids are not indicated after uncomplicated aspiration.
• Pulmonary injury can evolve after an initially reassuring appearance, so observation and repeat assessment matter.
• Always consider why the patient entered the water, including seizure, arrhythmia, intoxication, trauma, and self-harm.

Algorithm

1. Remove the patient from the water without endangering rescuers and assess responsiveness, breathing, and pulse.
2. If pulseless, start CPR with rescue breaths and chest compressions; provide oxygen when available.
3. If a pulse is present but breathing is absent or inadequate, provide rescue ventilation and oxygen.
4. Attach a monitor or AED without interrupting effective CPR and treat shockable rhythms conventionally.
5. Assess oxygenation, respiratory effort, temperature, mental status, trauma mechanism, glucose, and precipitating causes.
6. Use supplemental oxygen, noninvasive support, or intubation according to respiratory severity and airway protection.
7. Rewarm hypothermic patients and treat shock, hypoglycemia, dysrhythmia, or trauma as indicated.
8. Obtain targeted chest imaging, ECG, laboratory tests, and toxicology evaluation according to symptoms and event history.
9. Observe for evolving respiratory symptoms and repeat oxygenation and examination.
10. Admit symptomatic or unstable patients; discharge only when asymptomatic with stable oxygenation, normal mental status, and reliable follow-up.

Clinical Synopsis & Reasoning

Drowning is the process of respiratory impairment from submersion or immersion in liquid. The defining pathophysiology is hypoxemia. Water entering the upper airway can provoke cough and laryngospasm, followed by aspiration, surfactant dysfunction, ventilation-perfusion mismatch, pulmonary edema, and progressive hypoxic injury. The distinction between saltwater and freshwater drowning does not change initial resuscitation. Terms such as dry drowning, secondary drowning, and near-drowning are misleading and should not be used as separate diagnoses.

The first clinical question is whether the patient is breathing and has a pulse after safe removal from the water. Because drowning cardiac arrest usually follows hypoxia rather than a primary arrhythmia, ventilation is especially important. The 2025 American Heart Association guideline recommends CPR with breaths and chest compressions after drowning-related cardiac arrest. Trained rescuers should provide supplemental oxygen when available, and CPR should not be delayed for AED application. If the patient has a pulse but is not breathing normally, rescue ventilation is required.

After return of spontaneous circulation or in a patient who never arrested, assess oxygenation, work of breathing, mental status, temperature, trauma, and the event that preceded submersion. Consider seizure, syncope, intoxication, arrhythmia, stroke, hypoglycemia, and intentional self-harm. Cervical spine injury should be suspected based on mechanism, such as diving or high-energy water impact, rather than assumed in every drowning. Hypothermia can complicate resuscitation and may alter rhythm and drug handling.

Pulmonary findings may evolve over several hours. Cough, tachypnea, hypoxemia, crackles, increased work of breathing, or abnormal mental status suggest clinically important aspiration-related lung injury. Routine antibiotics are not indicated simply because water was aspirated. Infection treatment is reserved for convincing pneumonia or exposure to grossly contaminated water with compatible illness.

Treatment Strategy & Disposition

Begin with safe rescue and immediate assessment of breathing and circulation. In cardiac arrest after drowning, provide CPR with rescue breaths and chest compressions and use supplemental oxygen when available. Attach an AED or monitor as soon as practical without interrupting effective ventilation and compressions. Treat shockable rhythms according to standard resuscitation algorithms. Suction visible material when needed, but do not perform abdominal thrusts or other maneuvers intended to remove aspirated water because they delay ventilation and can cause vomiting.

For patients with spontaneous circulation, titrate oxygen to correct hypoxemia and support ventilation. Noninvasive positive-pressure ventilation may be appropriate in selected awake, cooperative patients with respiratory distress who can protect the airway. Intubate for persistent hypoxemia despite noninvasive support, severe work of breathing, inability to protect the airway, respiratory arrest, or severe neurologic impairment. Use lung-protective ventilation when acute respiratory distress syndrome develops.

Treat hypothermia according to severity, removing wet clothing and using passive or active rewarming as needed. In profound hypothermic cardiac arrest, follow hypothermia-specific resuscitation pathways and consider extracorporeal rewarming in appropriate candidates. Correct hypoglycemia, electrolyte abnormalities, and shock. Evaluate trauma according to mechanism. Routine corticosteroids, prophylactic antibiotics, and diuretics do not improve uncomplicated drowning lung injury and should not be given reflexively.

Disposition is based on symptoms and trajectory. Patients with persistent hypoxemia, abnormal lung examination, respiratory distress, altered mental status, significant hypothermia, hemodynamic instability, cardiac arrest, or major trauma require admission, often to intensive care. A completely asymptomatic patient with normal oxygen saturation, normal mental status, and a normal examination after an appropriate observation period may be discharged with clear return precautions. Children and patients with uncertain event histories require particularly careful observation and safeguarding assessment when appropriate.

Epidemiology / Risk Factors

• Drowning occurs across all age groups, with risk influenced by swimming ability, supervision, alcohol or drug use, seizure disorders, environmental exposure, and access to barriers around water.
• Children are at particular risk in pools, bathtubs, and natural bodies of water.
• Alcohol is a major risk factor in adolescent and adult drowning events.
• Cardiac arrest after drowning is commonly nonshockable because prolonged hypoxia precedes arrest.
• Neurologic outcome is strongly influenced by duration of submersion, time to effective ventilation, and time to return of spontaneous circulation.

Investigations

Do and Do Not

Pharmacology

Prognosis / Complications

• Rapid rescue and immediate effective ventilation are associated with the best neurologic outcomes.
• Short submersion time, witnessed event, early bystander CPR, and rapid return of spontaneous circulation are favorable features.
• Prolonged hypoxemia, persistent coma, severe acidosis, multiorgan failure, and prolonged cardiac arrest worsen prognosis.
• Initial neurologic examination can be confounded by hypothermia and sedative medications, so early prognostication must be cautious.
• Patients who remain asymptomatic with normal oxygenation after observation generally have an excellent outcome.

Patient Education / Counseling

• Use the term drowning for respiratory impairment after submersion and avoid misleading terms such as secondary drowning.
• Explain that new or worsening cough, breathing difficulty, chest pain, confusion, or excessive fatigue after discharge requires urgent reassessment.
• Review water-safety measures, barriers, supervision, swimming skills, life-jacket use, and avoidance of alcohol around water.
• Patients with seizures should review water precautions and seizure control with their clinician.
• If syncope or arrhythmia may have caused the event, arrange appropriate cardiovascular evaluation.
• Address intentional self-harm, substance use, or unsafe supervision when those factors contributed to the event.

Notes

Drowning management differs from primary sudden cardiac arrest because oxygen deprivation is usually the initiating event. The 2025 AHA guideline therefore explicitly emphasizes CPR with breaths and compressions and recommends beginning CPR before AED application. This does not diminish the importance of defibrillation when a shockable rhythm is present; it prevents a low-yield equipment step from delaying high-yield ventilation and circulation.

Hospital care should remain clinical rather than radiograph-driven. Respiratory symptoms, oxygen requirement, mental status, and trajectory determine disposition more reliably than the mere presence of aspirated water or a single imaging finding.

References

1. American Heart Association 2025 Guidelines: Drowning — Link