What is the appropriate initial management and ongoing care for a patient who has survived a near‑drowning episode?

Approach to Near Drowning

Immediately prioritize airway and breathing over circulation using the A-B-C sequence (not the standard C-A-B), because drowning causes cardiac arrest through severe hypoxemia—making ventilation the single most critical intervention for survival. 1

Immediate Resuscitation Priorities

Scene and Initial Response

• Begin rescue breathing in the water if you are trained and it is safe to do so, as this may prevent progression from respiratory arrest to cardiac arrest 1
• Remove the victim from water as soon as safely possible, preferably in a near-horizontal position with head elevated above body level 1
• Do NOT perform cervical spine immobilization unless there are specific circumstances suggesting spinal injury (incidence is only 0.009%), as routine C-spine precautions dangerously delay airway management 1, 2

Airway and Breathing (First Priority)

• Deliver 2 rescue breaths immediately upon removal from water if the victim is unresponsive and not breathing 1
• Do NOT attempt to clear water from the airway using abdominal thrusts or the Heimlich maneuver—only a modest amount of water is aspirated and it is rapidly absorbed; these maneuvers are unnecessary and potentially dangerous 1
• Use suction only if needed to clear vomitus or debris 1
• Administer 100% oxygen as soon as available, then titrate to maintain normal arterial oxygen saturation once it can be measured 1

Circulation (Second Priority)

• Check for a pulse within 10 seconds after delivering the 2 initial breaths 1
• If no pulse is definitively felt, immediately begin chest compressions and continue CPR cycles 1, 2
• For healthcare providers: use the A-B-C sequence (airway-breathing-compressions) rather than standard C-A-B, given the hypoxic nature of drowning arrest 1
• Trained rescuers may initiate with either A-B-C or C-A-B, though the hypoxic etiology favors prioritizing ventilation 1, 2

Defibrillation

• Dry the chest and attach an AED once the victim is out of water 1
• Attempt defibrillation if a shockable rhythm is identified, though most drowning arrests present with non-shockable rhythms due to hypoxemia 1
• Public-access defibrillation programs are beneficial in aquatic environments despite the lower incidence of shockable rhythms 1

Common Pitfall: Vomiting During Resuscitation

• Expect vomiting—it occurs in two-thirds of victims receiving rescue breathing and 86% of those requiring full CPR 1
• Turn the victim to the side and remove vomitus using finger, cloth, or suction 1
• If spinal injury is suspected, logroll the victim as a unit to protect the cervical spine 1

Hospital Management

Mandatory Transport and Observation

• Transport ALL drowning victims who required any form of resuscitation to the hospital, even if they appear alert with effective cardiorespiratory function 1, 2
• Minimum observation period is 4-6 hours, as decompensation can occur within this timeframe after fresh or salt-water drowning 1, 3
• Admit patients who required resuscitation for extended monitoring 2

Advanced Life Support

• Continue standard ACLS/PALS protocols as the cornerstone of in-hospital management 1, 2
• Maintain aggressive airway management with high-concentration oxygen 2
• Consider advanced airway (intubation) based on severity, though this is an indicator of injury severity rather than a specific intervention that changes outcomes 1

Key Prognostic Factor

The duration and severity of hypoxia is the single most important determinant of outcome—not the type of water (fresh vs. salt), not the water temperature, but how long the brain and heart were deprived of oxygen 1, 4, 3, 5, 6

Critical Red Flags Requiring Immediate EMS Activation

• Altered mental status or sleepiness (indicates ongoing hypoxemia) 7
• Difficulty breathing or abnormal breathing pattern 7
• Persistent coughing after submersion 7
• Any history of loss of consciousness during the incident 7