What is the management approach for a patient who has drowned?

From the Guidelines

The management of a drowning patient requires immediate removal from the water, followed by initiation of cardiopulmonary resuscitation (CPR) if the patient is unresponsive and not breathing, as recommended by the 2024 American Heart Association guidelines 1. The initial approach to a drowning patient involves removing them from the water as quickly and safely as possible, without putting oneself in danger.

• Removing the patient from the water is crucial to terminate the drowning process and allow for further assessment and medical management.
• If the patient is unresponsive and not breathing, CPR should be initiated immediately with a 30:2 compression-to-ventilation ratio, as stated in the guidelines 1.
• For patients who are breathing, but show signs of respiratory distress, supplemental oxygen should be provided, and their oxygen saturation levels closely monitored. Key considerations in the management of drowning patients include:
• Providing care as needed using basic life support (BLS) and advanced life support (ALS) techniques, with all persons requiring any level of resuscitation being transported to the emergency department 1.
• Recognizing distress and activating emergency services promptly, as early intervention is critical for a good outcome 1.
• Preventing submersion by providing flotation to the drowned person, if possible, and waiting for professional help to arrive 1.
• Core rewarming for hypothermic patients using warmed IV fluids, forced-air warming blankets, and warmed humidified oxygen, as hypothermia can exacerbate the condition.
• Monitoring for and treating complications, including electrolyte abnormalities, metabolic acidosis, and acute respiratory distress syndrome (ARDS), which can arise from drowning.
• The use of prophylactic antibiotics is not routinely recommended unless there are signs of infection or the drowning occurred in grossly contaminated water, as per the guidelines 1.
• Continuous cardiac monitoring, pulse oximetry, and neurological assessments are crucial, given the risk of hypoxic brain injury and other complications.
• Even patients who appear well initially should be observed for at least 6-8 hours due to the risk of delayed pulmonary edema, emphasizing the need for close monitoring and follow-up care.

From the Research

Drowning Management Approach

The management approach for a patient who has drowned involves several key steps, including:

• Prompt resuscitation and aggressive respiratory and cardiovascular treatment to interrupt hypoxia and prevent further damage to organs 2
• Immediate treatment of hypothermia and cardiovascular failure, as these are critical components of correct medical treatment 2
• Ventilation therapy to achieve an intrapulmonary shunt ≤ 20% or Pao2:Fio2 ≥ 250, and avoiding premature ventilatory weaning to prevent the return of pulmonary edema 3
• Consideration of the patient's drowning severity and comorbid or premorbid conditions when deciding to admit to an ICU 3

Treatment of Associated Clinical Concerns

The treatment of associated clinical concerns, such as:

• Hypothermia: continuing CPR for 30 minutes if necessary, particularly in hypothermic patients 4
• Mechanical ventilation: providing 100% oxygen and transferring to hospital for patients with clinical features suggesting aspiration 4
• Traumatic injuries: considering the potential for traumatic injuries and providing appropriate treatment 5

Use of Extracorporeal Membrane Oxygenation Systems

The use of extracorporeal membrane oxygenation (ECMO) systems may be considered in severe cases of accidental hypothermia after drowning, particularly in patients with cardiopulmonary failure 6

• ECMO can be a therapy option for a small range of patients with cardiopulmonary failure due to drowning with accidental hypothermia
• However, the interval of preclinical rescue remains extensively long, and the use of ECMO should be considered on a case-by-case basis 6