What is the management for a patient who has drowned?

Management for Drowning Patients

The management of drowning patients should follow the Drowning Chain of Survival, with immediate focus on safe removal from water, establishing airway patency, providing rescue breathing, and initiating CPR when necessary to reduce mortality and improve outcomes. 1

Initial Rescue and Assessment

• Recognize drowning distress and call for help immediately to ensure early activation of emergency medical services 1
• Provide flotation to the drowning person without endangering yourself - remain out of water if possible, throw flotation devices, and wait for professional rescue 1
• Remove the victim from water only if safe to do so - rescuers must avoid becoming secondary victims 1
• When removing from water, extricate preferably in a near-horizontal position with head maintained above body level and airway open if the patient is in shock 1
• For conscious patients where vomiting is a concern, a more vertical position may be preferable to facilitate spontaneous respirations 1

Immediate Resuscitation

• Begin resuscitation as quickly as possible after removing the victim from water - do not delay to check temperature or wait for rewarming 1
• For unresponsive victims with no normal breathing, immediately begin CPR 1
• Focus on rescue breathing as the primary intervention since hypoxia is the dominant pathophysiological mechanism 2, 3
• Healthcare providers should check for a pulse but start CPR if a pulse is not definitely felt within 10 seconds 1
• For lone rescuers, provide 5 cycles (about 2 minutes) of CPR before leaving to activate EMS 1

Airway Management

• Open the airway using head tilt-chin lift maneuver to establish patency 1, 3
• Do not perform maneuvers to relieve foreign-body airway obstruction as they are unnecessary, can cause injury, vomiting, aspiration, and delay CPR 1
• Water does not act as an obstructive foreign body - aspirated water is rapidly absorbed and does not preclude ventilation 4
• Early intubation is recommended for drowning victims with cardiac arrest 2, 3

Advanced Care

• Administer supplemental oxygen to hypoxemic patients (oxygen saturation <94%) or those with unknown oxygen saturation 1, 5
• Consider positive pressure ventilation for patients with more severe symptoms presenting with rales and foamy secretions 5
• For cardiac arrest, follow standard Advanced Life Support protocols 1
• Remove wet clothes from the victim to prevent further heat loss; insulate or shield from wind, heat, or cold 1
• If available, ventilate with warm, humidified oxygen 1

Hospital Transport and Disposition

• All persons requiring any level of resuscitation following drowning (including only rescue breaths) should be transported to the emergency department 1
• Patients with minimal or no symptoms require physical examination and 4-6 hours of observation prior to discharge 5
• For the hypothermic drowning patient in cardiac arrest, continue resuscitative efforts until the patient is evaluated by advanced care providers 1
• The decision to admit to an ICU should consider the patient's drowning severity and comorbid conditions 3
• Ventilation therapy should achieve an intrapulmonary shunt ≤20% or PaO2:FiO2 ≥250 3

Common Pitfalls and Caveats

• Do not delay CPR to perform the Heimlich maneuver - this is not recommended for drowning victims and may delay critical ventilation 4
• Avoid premature ventilatory weaning which may cause return of pulmonary edema, necessitating re-intubation and prolonging hospital stays 3
• Consider cervical spine immobilization only for victims with obvious clinical signs of injury, alcohol intoxication, or history of diving into shallow water 1
• Recognize that the window for medical intervention is primarily in the prehospital setting, not in the emergency department or intensive care unit 4
• Avoid rough movement during transport to prevent further complications 1