Management of Nonresponsive Patients Following Near-Drowning
Nonresponsive patients following near-drowning should receive immediate rescue breathing and, if pulseless or without definite pulse within 10 seconds, should be intubated as part of advanced life support measures to address the severe hypoxia that is the primary pathophysiologic injury. 1
Immediate Assessment and Airway Management
Initial Response Priorities
Rescue breathing is the single most critical intervention and should begin immediately upon removing the unresponsive victim from the water, as hypoxia is the dominant injury mechanism and the primary determinant of survival. 1
Check for breathing and pulse simultaneously, but limit this assessment to a maximum of 10 seconds to avoid delaying resuscitation. 1
If the patient is unresponsive with no breathing or only gasping, and no definite pulse is felt within 10 seconds, begin CPR immediately with an A-B-C sequence (Airway-Breathing-Compressions) rather than the standard C-A-B approach, because drowning is a hypoxic arrest. 1
Advanced Airway Decision Algorithm
For healthcare providers managing nonresponsive drowning victims:
Intubation is indicated when the patient requires advanced life support during cardiac arrest or has inadequate ventilation despite basic airway maneuvers. 2, 3
The choice of airway device (bag-mask ventilation, supraglottic airway, or tracheal intubation) should be based on the rescuer's skill level and available equipment, as no single method has proven superior in drowning resuscitation. 1
Tracheal intubation in drowning victims is associated with worse outcomes in observational studies, but this reflects confounding by severity of injury rather than harm from the procedure itself—the most severely injured patients require intubation. 1
Critical Management Principles
Ventilation Strategy
Provide 100% oxygen immediately when available, as cardiac arrest following drowning results from severe hypoxemia. 1, 4
Once return of spontaneous circulation (ROSC) is achieved, titrate oxygen to maintain SpO2 between 94-98% to avoid both hypoxemia and hyperoxia. 1, 4
Do not attempt the Heimlich maneuver or abdominal thrusts—aspirated water is rapidly absorbed and does not obstruct the airway; these maneuvers delay critical ventilation and can cause vomiting and aspiration. 1, 2
Resuscitation Sequence
After delivering 2 effective rescue breaths that make the chest rise, if no pulse is definitely felt, begin chest compressions at standard rate and depth. 1
Continue CPR with cycles of 30 compressions to 2 breaths until advanced care arrives or ROSC is achieved. 1
Attach an automated external defibrillator (AED) once the victim is out of the water, though shockable rhythms are uncommon in drowning-related cardiac arrest. 1
Common Pitfalls to Avoid
Cervical Spine Immobilization
Routine cervical spine stabilization is NOT recommended in the absence of circumstances suggesting spinal injury (diving into shallow water, obvious trauma, alcohol intoxication), as it impedes airway management and delays rescue breathing. 1
The incidence of cervical spine injury in drowning victims is extremely low (0.009%). 1
Assessment Errors
Do not mistake agonal gasps for normal breathing—these indicate cardiac arrest and require immediate CPR. 5
Brief generalized seizures may be the first manifestation of cardiac arrest and should not delay resuscitation efforts. 5
Post-Resuscitation Management
Mandatory Transport and Observation
All drowning victims who required any form of resuscitation, including rescue breathing alone, must be transported to the hospital for evaluation and monitoring, even if they appear alert with effective cardiorespiratory function at the scene. 1, 4
A minimum observation period of 4-6 hours is required for all patients who needed resuscitation. 4, 6
Many near-drowning victims will require at least 24 hours of observation due to risk of delayed complications. 6
Ongoing Respiratory Support
Aggressive oxygenation and ventilation remain the cornerstone of post-resuscitation management, not bronchodilator therapy, as hypoxemia rather than bronchospasm is the dominant clinical problem. 4
High-concentration oxygen targeting SpO2 94-98% should be maintained during the immediate post-resuscitation period (first 30 minutes after ROSC). 4
Prognosis Considerations
The duration and severity of hypoxia is the single most important determinant of outcome in drowning victims. 1, 2
Patients with adequate ventilation on hospital arrival have excellent prognosis, while those with inadequate ventilation or cardiac arrest depend on rapid, vigorous resuscitative measures for survival. 7
Approximately 25% of victims presenting to the emergency department will die and another 6% will develop neurological sequelae despite optimal treatment. 6