What is the medical management after resuscitation from drowning?

Medical Management After Drowning Resuscitation

Continue standard Advanced Life Support protocols with particular emphasis on oxygen administration and respiratory support, as drowning-induced cardiac arrest results from severe hypoxemia requiring aggressive ventilation and oxygenation strategies. 1, 2

Immediate Post-Resuscitation Priorities

Airway and Ventilation Management

• Administer supplemental oxygen to all hypoxemic patients (oxygen saturation <94%) or those with unknown oxygen saturation 2
• Target oxygen saturation of 94-98% after return of spontaneous circulation to avoid both hypoxemia and hyperoxemia 3, 4
• Use warm, humidified oxygen if available to prevent further heat loss 2
• Ventilation therapy should achieve an intrapulmonary shunt ≤20% or PaO₂:FiO₂ ≥250 5
• Avoid hypocapnia in post-arrest care, as insufficient evidence exists to recommend mild hypercapnia 4

Circulatory Support

• Follow standard Advanced Life Support protocols for cardiac arrest management 1
• Administer standard ACLS medications (epinephrine, vasopressin) only if cardiac arrest occurs, following standard protocols 3
• For fluid-refractory shock, consider dopamine or epinephrine after 40-60 mL/kg crystalloid administration 3
• Consider hydrocortisone if absolute adrenal insufficiency is suspected in catecholamine-resistant shock 3

Temperature Management

Hypothermia Considerations

• Do not delay resuscitation to check temperature or wait for rewarming 2
• Remove wet clothes to prevent further heat loss; insulate or shield from wind, heat, or cold 2
• For hypothermic drowning patients in cardiac arrest, continue resuscitative efforts until evaluated by advanced care providers 2
• For patients with spontaneous hypothermia after ROSC who don't follow commands, do not routinely rewarm faster than 0.5°C per hour 4

Post-Arrest Temperature Control

• All adults who do not follow commands after ROSC should receive treatment that includes a deliberate strategy for temperature control 4
• Maintain a constant temperature between 32°C and 37.5°C during post-arrest temperature control 4

Electrolyte and Metabolic Management

• Correct hypoglycemia and hypocalcemia immediately if present 3
• Administer IV calcium for known or suspected hyperkalemia causing cardiac arrest 3
• Consider IV magnesium for cardiotoxicity from severe hypomagnesemia 3
• Empirical IV calcium may be reasonable for suspected hypermagnesemia 3

Critical Pitfalls to Avoid

• Do NOT perform maneuvers to relieve foreign-body airway obstruction, as they are unnecessary, can cause injury, vomiting, aspiration, and delay CPR 2
• Do NOT administer prophylactic antibiotics, as they are not indicated by guidelines and should not be routinely given 3, 6
• Do NOT use prophylactic corticosteroids, as they are not warranted and may be detrimental 6
• Avoid premature ventilatory weaning, which may cause return of pulmonary edema with need for re-intubation and prolonged hospital stays 5

Hospital Transport and Monitoring

Mandatory Transport Criteria

• All persons requiring any level of resuscitation following drowning (including only rescue breaths) must be transported to the emergency department 2
• Observe all near-drowning victims requiring any resuscitation for at least 4-6 hours, as decompensation can occur during this window 3

Cervical Spine Considerations

• Consider cervical spine immobilization ONLY for victims with obvious clinical signs of injury, alcohol intoxication, or history of diving into shallow water 2
• Avoid rough movement during transport to prevent further complications 2

Advanced Interventions for Refractory Cases

Extracorporeal Support

• Extracorporeal CPR (ECPR) may be reasonable for select patients with refractory cardiac arrest when provided within an appropriately trained and equipped system of care 3, 4
• ECMO may be lifesaving in severe refractory respiratory failure 3
• However, conventional therapy should be initiated first for drowned children with OHCA, and if no ROSC occurs, consider withdrawal discussion when core temperature reaches 34°C 7

Neurologic Management

• A therapeutic trial of a nonsedating antiseizure medication may be reasonable in adult survivors with electroencephalography patterns on the ictal-interictal continuum 4
• Comatose near-drowning victims can survive with normal neurologic recovery when routine aggressive supportive intensive care is administered 6

Disposition Decisions

• The decision to admit to ICU should consider drowning severity and comorbid or premorbid conditions 5
• Organ donation should be considered as an important outcome in systems of care development 4
• Emergency coronary angiography is not recommended over delayed or selective strategy after ROSC unless patients exhibit ST-segment elevation MI, shock, electrical instability, signs of significant myocardial damage, or ongoing ischemia 4