What is the management approach for a patient who has experienced near drowning?

Management of Near Drowning Patients

Begin rescue breathing immediately upon removing the victim from water, prioritize airway and ventilation over chest compressions initially, and transport ALL patients requiring any resuscitation to the hospital for at least 4-6 hours of monitoring. 1, 2

Immediate Rescue and Safety

• Rescuer safety is paramount—do not become a secondary victim during water rescue attempts 2, 3
• Remove the victim from water only if safe to do so, preferably in a near-horizontal position with the head maintained above body level if the patient is in shock 3
• Do NOT routinely immobilize the cervical spine unless there are specific circumstances suggesting spinal injury (diving into shallow water, obvious trauma, alcohol intoxication), as routine stabilization delays needed resuscitation and cervical spine injury occurs in only 0.009% of drowning victims 1, 2, 3

Airway and Breathing: The Critical Priority

Drowning causes hypoxic cardiac arrest, not primary cardiac arrest—therefore, use the A-B-C sequence (Airway-Breathing-Compressions), NOT the standard C-A-B sequence used for other cardiac arrests. 1, 2

In-Water Rescue Breathing

• If trained and safe to do so, provide in-water rescue breathing before removing the victim from water—this may prevent progression from respiratory arrest to full cardiac arrest 1, 2, 3
• This intervention increases survival rates compared to delaying ventilation until the victim is on dry land 1

Initial Ventilation

• Give 2 initial rescue breaths that make the chest rise BEFORE checking for pulse 2
• Open the airway using head tilt-chin lift maneuver 3
• Do NOT perform abdominal thrusts or Heimlich maneuver—these are unnecessary, can cause injury and vomiting, and critically delay CPR 2, 3

Chest Compressions and Full CPR

• After delivering 2 effective breaths, check for pulse for no more than 10 seconds 2, 3
• If no pulse is definitely felt within 10 seconds, immediately begin chest compressions 2
• Provide standard CPR cycles of compressions and ventilations according to BLS guidelines 1, 2
• For lone rescuers, provide 5 cycles (approximately 2 minutes) of CPR before leaving to activate EMS 3
• Trained rescuers MUST provide rescue breaths as part of CPR—compression-only CPR is inadequate for drowning victims due to the hypoxic nature of the arrest 1

Defibrillation

• Attach an AED and attempt defibrillation if a shockable rhythm is identified once the victim is out of the water 2
• Note that shockable rhythms are a minority in drowning-related cardiac arrests, as most present with asystole or PEA from severe hypoxemia 1
• Public-access defibrillation programs should be instituted in aquatic environments where they may provide important benefits 1

Oxygen Administration

• Administer high-concentration supplemental oxygen as soon as available—cardiac arrest following drowning results from severe hypoxemia, making oxygen administration critical 1, 2, 3
• Target oxygen saturation ≥94% or provide oxygen to all patients with unknown saturation 3
• If available, ventilate with warm, humidified oxygen 3

Advanced Life Support

• Follow standard ACLS protocols once basic resuscitation is established 1
• There is no preferred mode of delivering ventilation (with or without equipment) for trained rescuers in the prehospital setting 1
• The duration and severity of hypoxia is the single most important determinant of outcome 1

Rewarming Considerations

• Remove wet clothes immediately to prevent further heat loss; insulate or shield from environmental exposure 3
• Begin resuscitation immediately—do NOT delay to check temperature or wait for rewarming 3
• For severely hypothermic patients in cardiac arrest, continue resuscitative efforts until evaluated by advanced care providers 3
• Extracorporeal circulation (CPB or ECMO) provides efficient rewarming and full circulatory support for severe hypothermia cases, though long-term outcomes remain limited by pulmonary and neurological complications 4, 5

Transport and Hospital 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 alert with effective cardiorespiratory function at the scene. 1, 2, 3

Observation Requirements

• Minimum observation period is 4-6 hours for all patients requiring any resuscitation 1, 2
• Decompensation after fresh or salt-water drowning can occur in the first 4-6 hours after the event 1
• Many near-drowning victims will require at least 24 hours of observation 6
• Completely asymptomatic patients with normal vital signs, oxygenation, and chest radiographs require only 4-6 hours of observation 6

Critical Pitfalls to Avoid

• Never delay ventilation to perform cervical spine immobilization in the absence of trauma indicators 1, 2
• Never use abdominal thrusts or Heimlich maneuver as routine treatment—they delay life-saving CPR 2, 3
• Never assume a patient is stable for discharge without appropriate hospital observation, even if they appear well initially—respiratory decompensation is common in the first 4-6 hours 1, 2
• Never use compression-only CPR for drowning victims—rescue breaths are essential 1
• Avoid rough movement during transport to prevent complications 3

Prognosis

• Approximately 25% of victims presenting to the Emergency Department will die and another 6% will develop neurological sequelae 6
• Near-drowning victims who are spontaneously breathing and not comatose after initial resuscitation have uniformly benign neurologic outcomes 7
• A significant subset of comatose victims can survive with normal neurologic recovery when aggressive supportive intensive care is administered 7
• Successful resuscitations have been reported even after prolonged submersion, justifying aggressive resuscitation efforts unless there are obvious signs of death 1