Systemic Steroids in Near-Drowning: Not Recommended
Do not administer systemic steroids such as methylprednisolone to near-drowning patients as part of initial treatment. The evidence consistently shows no benefit and potential harm from routine corticosteroid use in this setting.
Evidence Against Steroid Use
The pathophysiology of near-drowning mirrors post-cardiac arrest hypoxic-ischemic injury, and guidelines explicitly state that steroids should not be given routinely after out-of-hospital cardiac arrest 1. This same principle applies to near-drowning victims who experience similar global hypoxic injury.
Historical Perspective and Current Consensus
- Consensus statements from the 1980s established that prophylactic corticosteroids are not warranted in near-drowning management, may be detrimental, and remain controversial 2
- The primary pathophysiology involves aspiration-induced noncardiogenic pulmonary edema, which responds to positive-pressure ventilation (PEEP/CPAP), not steroids 2, 3
- Both saltwater and freshwater aspiration cause similar lung injury patterns that are mechanically managed, not pharmacologically treated with steroids 4
Potential Harms of Steroid Administration
Steroids carry specific risks in critically ill near-drowning patients:
- Prolonged neuromuscular blockade recovery and myopathy, particularly when combined with neuromuscular blocking agents 1
- Induction of delirium in ICU patients, especially at high doses 1
- Impaired immune function in patients at high risk for aspiration pneumonia 1
- No established mechanism by which steroids would improve outcomes from cerebral hypoxia 1
Appropriate Management Instead
Focus on these evidence-based interventions:
- Establish adequate oxygenation and ventilation as the primary resuscitative goal 3
- Apply positive-pressure breathing (PEEP/CPAP) to reverse physiologic shunting and atelectasis 2
- Target mean arterial pressure >85-90 mmHg to optimize cerebral perfusion 1
- Maintain normoxia, avoiding both hypoxia and hyperoxia 1
- Achieve ventilation therapy goals of intrapulmonary shunt ≤20% or PaO2:FiO2 ≥250 4
Important Clinical Caveat
One case report described successful methylprednisolone treatment for organizing pneumonia that developed as a delayed complication after near-drowning 5. However, this represents a specific late-stage pathology (organizing pneumonia diagnosed by biopsy), not acute initial management. This exception does not justify routine steroid use in the immediate post-drowning period.