Medications in Near Drowning
No specific medications are routinely indicated for near drowning—standard Basic Life Support (BLS) and Advanced Cardiac Life Support (ACLS) protocols are the cornerstones of treatment, with airway management and ventilation being the absolute priority because hypoxemia is the primary cause of death. 1
Core Management Principle
The fundamental pathophysiology of near drowning is hypoxemia from aspiration-induced injury, not a primary cardiac event. 2, 3 Therefore, the treatment focus is on:
- Immediate rescue breathing and CPR (not medications) as soon as the victim is removed from water 1
- Oxygen administration when available to reverse hypoxemia 4
- Standard ACLS medications only if cardiac arrest occurs (epinephrine, vasopressin per standard protocols) 1
When Medications ARE Indicated
During Cardiac Arrest (Standard ACLS)
If the near-drowning victim progresses to cardiac arrest, follow standard ACLS medication protocols: 1
- Epinephrine per ACLS dosing for cardiac arrest
- Vasopressors as indicated by standard cardiac arrest algorithms
- Antiarrhythmics if shockable rhythms develop (though initial shockable rhythms occur in only 2-12% of drowning-related arrests) 1
Electrolyte-Specific Scenarios (Rare)
Only if specific electrolyte abnormalities are identified: 1
- IV calcium for known or suspected hyperkalemia causing cardiac arrest (Class 1, LOE C-LD) 1
- IV magnesium for cardiotoxicity from severe hypomagnesemia (Class 1, LOE C-LD) 1
- Empirical IV calcium may be reasonable for suspected hypermagnesemia (Class 2b, LOE C-EO) 1
Post-Resuscitation Support
If shock persists after initial resuscitation despite adequate oxygenation: 1, 5
- Dopamine or epinephrine for fluid-refractory shock (typically after 40-60 mL/kg crystalloid) 1, 5
- Hydrocortisone if absolute adrenal insufficiency is suspected in catecholamine-resistant shock 1
Critical Pitfalls to Avoid
Do NOT delay CPR and rescue breathing to administer medications. The single most important determinant of outcome is the duration and severity of hypoxia—immediate ventilation saves lives, not drugs. 1
Do NOT routinely give:
- Prophylactic antibiotics (not indicated by guidelines) 1
- Steroids for pulmonary edema (no evidence of benefit) 2
- Diuretics (may worsen perfusion) 2
- Routine calcium administration (only for specific electrolyte abnormalities) 4
Do NOT assume fresh vs. salt water matters for medication choice—both cause similar hypoxemic injury requiring the same supportive approach. 1
Post-Resuscitation Monitoring
All near-drowning victims requiring any resuscitation (even rescue breaths alone) must be transported to a hospital for at least 4-6 hours of observation, as decompensation can occur during this window. 1 During this period:
- Correct hypoglycemia and hypocalcemia immediately if present 1, 5
- Target oxygen saturation 94-98% after return of spontaneous circulation to avoid both hypoxemia and hyperoxemia 4
- Avoid hypocapnia in post-arrest care 4
Advanced Support for Refractory Cases
For cardiac arrest refractory to standard ACLS within an appropriately equipped system: 1, 4
- Extracorporeal CPR (ECPR) is reasonable for select patients 4, 6
- ECMO may be lifesaving in severe refractory respiratory failure 1, 6
The bottom line: Near drowning is managed with aggressive airway support and oxygenation, not with specific drug therapy. Medications follow standard resuscitation protocols only if cardiac arrest develops or specific complications arise.