What is the initial management of a drowning child in the emergency setting?

Initial Management of a Drowning Child in the Emergency Setting

In a drowning child, immediately begin CPR with rescue breaths before AED application, as hypoxia is the primary mechanism of injury and prompt oxygenation is critical for survival. 1

Initial Assessment and Rescue

• Verify scene safety first before attempting rescue
• Remove the child from water as quickly as possible while ensuring rescuer safety
• Check for responsiveness
• If unresponsive, look for breathing or only gasping and check pulse simultaneously (for healthcare providers)
• If no normal breathing or pulse is detected within 10 seconds, begin CPR immediately

Airway Management and Ventilation

• Begin with airway assessment using head tilt-chin lift maneuver to open airway 2
• Provide 2 initial rescue breaths
• If pulse present but no breathing:
  • Continue rescue breathing (1 breath every 2-3 seconds, or about 20-30 breaths per minute) 1
  • Administer highest available oxygen concentration 1
  • Monitor pulse every 2 minutes 1

Cardiopulmonary Resuscitation

• If no pulse or uncertain:
  • For single rescuer: Begin cycles of 30 compressions and 2 breaths
  • For two or more rescuers: Begin cycles of 15 compressions and 2 breaths 1, 2
  • Ensure high-quality compressions (appropriate depth, complete recoil, minimal interruptions)
• Important: Unlike standard cardiac arrest protocols, in drowning victims:
  • CPR with rescue breaths should be started before AED application 1
  • Do NOT delay CPR to obtain or apply an AED 1

AED Use

• AED use is reasonable in cardiac arrest following drowning 1
• Apply AED as soon as available without delaying CPR
• Dry the chest before applying pads
• Follow AED prompts for rhythm analysis and shock delivery if indicated
• Resume CPR immediately after shock or if no shock advised

Advanced Life Support Interventions

• Establish vascular access (IV/IO) as soon as possible
• Consider endotracheal intubation for airway protection
• Correct hypothermia if present
• Treat dysrhythmias according to pediatric ACLS protocols 2
• Consider ECMO for severe cases with refractory cardiopulmonary failure 2, 3

Observation and Evaluation

• All drowning victims require hospital transport for observation and evaluation
• Even asymptomatic patients require at least 4-6 hours of observation 2, 4
• Patients with any respiratory symptoms, abnormal vital signs, or altered mental status require admission 2

Special Considerations

• Duration of submersion >10 minutes and lack of CPR at the scene are associated with poor outcomes 5
• However, prolonged CPR (>30 minutes) may still result in favorable neurologic outcomes, especially in patients who had a pulse at any point during evaluation 6
• Hypothermia may be present and require specific management strategies
• Alcohol use dramatically increases drowning risk and should be assessed in adolescents 7

Common Pitfalls to Avoid

• Delaying CPR to search for an AED
• Omitting rescue breaths in drowning victims (compression-only CPR is less effective)
• Failing to consider hypothermia as a complicating factor
• Premature termination of resuscitation efforts, especially in cold water drowning
• Discharging patients too early without adequate observation period

Remember that drowning is primarily a hypoxic event, making early oxygenation and ventilation the cornerstone of successful resuscitation. The sequence of CPR with rescue breaths followed by AED application is critical in drowning cases, unlike standard cardiac arrest protocols where AED application may take priority.