What is the appropriate emergency management, including drug dosages and monitoring parameters, for a near‑drowning patient (adult or child)?

Management of Near-Drowning

Immediate Resuscitation Priorities

Begin CPR with rescue breathing immediately upon removing the unresponsive drowning victim from the water, prioritizing airway management and oxygenation above all else, as hypoxemia is the primary cause of death and the single most important determinant of outcome. 1

Initial Assessment and Airway Management

• Start rescue breathing as soon as the victim is removed from water – do not delay for any other interventions, as prompt initiation of rescue breathing increases survival. 1

• Use head tilt-chin lift maneuver to open the airway unless cervical spine injury is suspected (which occurs in only 0.009% of drowning cases). 1

• Do NOT routinely stabilize the cervical spine in the absence of circumstances suggesting spinal injury, as this delays needed resuscitation. 1

• Provide 100% high-flow oxygen as soon as available, using bag-mask ventilation initially. 1

CPR Protocol

For adults:

• Perform standard CPR with 30 compressions to 2 breaths if alone. 1
• Push hard and fast at 100-120 compressions per minute. 1

For children:

• Single rescuer: 30 compressions to 2 breaths. 1
• Two rescuers: 15 compressions to 2 breaths. 1
• Compress at least one-third of the anteroposterior diameter of the chest. 1

Vascular Access and Drug Administration

Establish IV or IO access without delaying CPR or defibrillation:

• Intraosseous (IO) access is equally acceptable as IV and should be used promptly if IV access is difficult. 1, 2

• Do not delay chest compressions to establish vascular access. 3, 2

Medication Dosing

Epinephrine (Adrenaline)

Adults:

• 1 mg IV/IO every 3-5 minutes throughout resuscitation. 3
• For non-shockable rhythms: administer as soon as feasible after establishing access. 3, 2
• For shockable rhythms: administer after the 2nd or 3rd shock if VF/pVT persists. 3, 2

Children:

• 0.01 mg/kg IV/IO (0.1 mL/kg of 1:10,000 concentration) every 3-5 minutes. 1, 2
• Maximum single dose: 1 mg. 1, 2
• If no IV/IO access: 0.1 mg/kg endotracheal (0.1 mL/kg of 1:1,000 concentration) – though this route is less reliable. 1

Antiarrhythmics (for shock-refractory VF/pVT only)

Amiodarone (preferred):

• Adults: 300 mg IV/IO bolus. 3
• Children: 5 mg/kg IV/IO bolus, may repeat up to 3 total doses. 1, 2

Lidocaine (alternative):

• Adults: 1-1.5 mg/kg IV/IO. 3
• Children: 1 mg/kg IV/IO. 1, 2

Important caveat: Neither amiodarone nor lidocaine improve long-term survival or neurological outcomes, despite improving return of spontaneous circulation. 3

Monitoring Parameters

Immediate Monitoring (First 4-6 Hours)

All near-drowning victims requiring 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

• Continuous pulse oximetry – target SpO₂ ≥94%. 4, 5

• Continuous cardiac monitoring for arrhythmias. 6

• Serial vital signs every 15-30 minutes initially. 4

• Chest radiograph to assess for pulmonary edema (aspiration-induced noncardiogenic edema is the primary pathophysiologic consequence). 4, 7

• Arterial blood gas to assess oxygenation and ventilation adequacy. 6, 7

Extended Monitoring (24+ Hours)

• Decompensation can occur 4-6 hours after the event, particularly in pediatric patients, so observation for at least 4-6 hours is mandatory for all victims. 1, 4

• Most victims require at least 24 hours of observation unless completely asymptomatic with normal vital signs, oxygenation, and chest radiograph. 4

• Monitor for development of acute respiratory distress syndrome (ARDS) requiring mechanical ventilation with PEEP/CPAP. 7

• Neurological assessments every 2-4 hours to detect cerebral injury from hypoxemia. 7

Advanced Airway Management

If spontaneous breathing is inadequate:

• Endotracheal intubation or supraglottic airway should be placed. 1

• Use waveform capnography to confirm and monitor ET tube placement. 1

• Provide mechanical ventilation with PEEP to reverse physiologic shunting from alveolar flooding or atelectasis. 7

• Once advanced airway is placed: provide continuous compressions with one breath every 2-3 seconds (20-30 breaths/minute). 1

Critical Pitfalls to Avoid

• Do NOT use high-dose epinephrine (>1 mg in adults, >0.01 mg/kg in children) – provides no benefit. 3, 2

• Do NOT use prophylactic antibiotics or corticosteroids – not warranted and may be detrimental. 7

• Do NOT use induced hypothermia or barbiturate coma for cerebral salvage – does not improve outcomes and may be harmful. 7

• Do NOT delay transport for prolonged field resuscitation – successful resuscitations have been reported even after prolonged submersion. 1

• Do NOT assume good initial appearance means safety – late decompensation is common, requiring hospital observation. 1, 4