What is the treatment for near drowning?

Treatment of Near Drowning

Begin rescue breathing immediately upon removing the victim from water, followed by full CPR if no pulse is detected within 10 seconds—this airway-first approach (A-B-C) differs from standard cardiac arrest management because drowning causes hypoxic arrest, not primary cardiac events. 1, 2

Immediate Rescue and Safety

• Prioritize rescuer safety above all else—do not become a second victim by attempting dangerous water rescues without proper training and equipment 1, 3
• Throw flotation devices and wait for professional rescue if you are not trained in water rescue 1, 3
• Do NOT routinely immobilize the cervical spine unless there are specific indicators of trauma (diving into shallow water, obvious injury, alcohol intoxication)—routine spinal immobilization delays critical resuscitation and cervical spine injury occurs in only 0.009% of drowning victims 1, 2, 3

Airway and Breathing: The Critical First Step

For healthcare providers and trained rescuers (including lifeguards), use the A-B-C sequence, NOT the standard C-A-B approach used in other cardiac arrests. 1, 2

Immediate Ventilation Protocol

• Begin rescue breathing as soon as the victim is removed from water—do not delay for any reason 1, 2
• If trained and safe to do so, provide in-water rescue breathing in shallow water before extrication, as this may prevent progression from respiratory to cardiac arrest 1, 2
• Deliver 2 initial rescue breaths that visibly make the chest rise before checking for a pulse 2
• Open the airway using head tilt-chin lift maneuver 3
• Never perform abdominal thrusts or Heimlich maneuver—these are unnecessary, can cause injury and vomiting, and critically delay CPR 2, 3

Full CPR Initiation

• After delivering 2 effective breaths, check for a pulse for no more than 10 seconds 2, 3
• If no pulse is definitely felt, immediately begin chest compressions at 100-120 compressions per minute with depth of 5-6 cm 2, 4
• Continue standard CPR cycles with compressions and ventilations (30:2 for single rescuer, 15:2 for two healthcare providers with pediatric victims) 1, 2
• For lone rescuers, provide 5 cycles (approximately 2 minutes) of CPR before leaving to activate EMS 1, 3

Defibrillation

• Dry the chest before applying AED pads 1
• Attach an AED and analyze rhythm as soon as the victim is out of water 2
• Attempt defibrillation if a shockable rhythm is identified 2
• AED use should occur after initiating high-quality CPR, not before, in drowning-related arrests 4

Oxygen Administration

• Administer high-concentration (100%) oxygen as soon as available—hypoxemia is the primary pathophysiology in drowning 2, 4, 5, 6, 7
• Use warm, humidified oxygen if available 3
• After return of spontaneous circulation, target oxygen saturation of 94-98% or PaO₂ of 75-100 mmHg once arterial oxygen can be measured 4

Hypothermia Management

• Remove wet clothing immediately to prevent further heat loss 3
• Insulate or shield the victim from environmental exposure 3
• Do not delay resuscitation to check temperature or wait for rewarming—begin CPR immediately 3
• For hypothermic drowning victims in cardiac arrest, continue resuscitative efforts until evaluated by advanced care providers, as successful neurologically intact survival has been reported even after prolonged submersion in cold water 3, 5

Transport and Monitoring

ALL drowning victims who require ANY form of resuscitation—including rescue breathing alone—must be transported to the hospital for evaluation and monitoring, even if they appear completely alert and stable at the scene. 1, 2, 3

Critical Transport Considerations

• Minimum observation period is 4-6 hours for all patients requiring any resuscitation, as decompensation can occur within the first 4-6 hours after the event 1, 2, 7
• Transport in a near-horizontal position with head elevated above body level if the patient is in shock 1, 3
• For conscious patients where vomiting is a concern, a more vertical position may be preferable 3
• Avoid rough movement during transport 3

Advanced Life Support

• Follow standard ACLS protocols once advanced providers arrive 1, 3
• Establish IV access first when possible; use intraosseous access if IV attempts are unsuccessful 4
• Consider extracorporeal cardiopulmonary resuscitation (ECPR) for select patients with cardiac arrest refractory to standard ACLS when provided within an appropriately trained system 4

Common Pitfalls to Avoid

• Never delay ventilation to perform cervical spine immobilization in the absence of trauma indicators—this is the most common error that worsens outcomes 1, 2
• Never assume a patient is stable for discharge without appropriate hospital observation, even if initially appearing well—late decompensation is well-documented 1, 2, 7
• Never use abdominal thrusts routinely—they delay critical CPR and can cause aspiration 2, 3
• Never prioritize chest compressions over rescue breathing in drowning victims—the hypoxic mechanism of arrest requires immediate ventilation 1, 2

Prognostic Considerations

• No single clinical finding, laboratory value, or imaging study can accurately predict neurologic outcome at initial presentation 5, 8
• Unreactive pupils in the emergency department and Glasgow Coma Score ≤5 on ICU arrival are strong predictors of poor outcome, but even patients arriving without vital signs requiring full resuscitation have achieved complete neurologic recovery 8
• Aggressive initial resuscitation is indicated in virtually all near-drowning victims because survival with intact neurologic function has been documented even after prolonged submersion 5, 8, 9