What are the management priorities for a patient who has experienced near drowning?

Management Priorities for Near Drowning

The primary management priority for near drowning victims is immediate provision of rescue breathing and ventilation to reverse hypoxia, which is the fundamental pathophysiological mechanism in drowning. 1

Initial Rescue and Assessment

• Remove victim from water as quickly as possible while ensuring rescuer safety 1
• Do NOT perform routine cervical spine immobilization unless specific circumstances suggest spinal injury (incidence of cervical spine injury is extremely low at 0.009%) 1, 2
• Immediately assess responsiveness and breathing
• For unresponsive victims not breathing normally:
  • Open airway
  • Provide 2 rescue breaths that make the chest rise
  • Check for pulse (healthcare providers only)
  • Begin CPR if pulseless or pulse not definitely felt within 10 seconds 1

Airway and Breathing Management

• Prioritize ventilation over compressions due to the hypoxic nature of drowning 1
• Use A-B-C approach rather than C-A-B sequence for drowning victims 1
• Do NOT attempt to remove water from airways by abdominal thrusts or Heimlich maneuver (Class III, LOE C) 1
• Provide high-concentration oxygen initially to all victims with respiratory symptoms 1, 2
• Titrate oxygen once arterial oxygen saturation can be measured to maintain normal range 1
• For victims requiring advanced airway management:
  • Bag-mask ventilation is preferred over advanced airways for most rescuers 1
  • Tracheal intubation should only be performed by those adept at advanced airway techniques 1

Circulation Management

• After establishing airway and breathing, follow standard CPR protocols with 30:2 compression-to-ventilation ratio 2
• Apply AED as soon as available and follow prompts 1
• Be prepared for vomiting during resuscitation (occurs in majority of victims requiring compressions) 1

Hospital Management

• All victims requiring any form of resuscitation should be transported to a hospital for evaluation and monitoring 2, 3
• For patients with minimal or no symptoms:
  • Observe for 4-6 hours before discharge 3
• For patients with moderate to severe symptoms:
  • Provide supplemental oxygen
  • Consider positive pressure ventilation (CPAP/PEEP) for respiratory distress 4, 3
  • Monitor for development of acute respiratory distress syndrome
  • Continuous pulse oximetry and cardiac monitoring

Special Considerations

• Hypothermia: Do not delay CPR to check temperature; continue resuscitation efforts until patient is evaluated by advanced care providers 1
• Antibiotics: Prophylactic antibiotics are not routinely recommended 4
• Corticosteroids: Not warranted and may be detrimental in pulmonary management following drowning 4

Prognostic Factors

• Duration and severity of hypoxia are the most important determinants of outcome 2
• Patients who are spontaneously breathing and not comatose after initial resuscitation generally have good neurological outcomes 4
• Approximately 25% of victims presenting to the Emergency Department will die and another 6% will develop neurological sequelae despite appropriate management 5

Common Pitfalls to Avoid

• Delaying ventilation to perform unnecessary cervical spine immobilization
• Attempting to clear water from airways using abdominal thrusts
• Underestimating the need for hospital observation even in seemingly mild cases
• Using advanced airways when rescuers lack proper training
• Discharging patients too early (observe for minimum 4-6 hours)