What are the emergency department and intensive‑care unit management steps, including medication dosages, for adult and pediatric patients rescued from drowning?

Emergency and ICU Management of Drowning Patients

Immediate Resuscitation Priorities

In drowning resuscitation, airway management and ventilation must take absolute priority over circulation, using the A-B-C sequence (Airway-Breathing-Compressions) rather than standard C-A-B, because cardiac arrest results from severe hypoxemia, not primary cardiac pathology. 1, 2, 3

Initial Assessment and Airway Management

• Remove the victim from water immediately and place in a near-horizontal position with head elevated above the body 3
• Do NOT perform routine cervical spine immobilization unless specific trauma is suspected—this delays critical airway management and spinal injury incidence is only 0.009% 2, 3
• Deliver 2 rescue breaths immediately if the patient is unresponsive and not breathing 3
• Do NOT attempt abdominal thrusts or Heimlich maneuver to clear water—only modest amounts are aspirated and rapidly absorbed; these maneuvers are unnecessary and potentially harmful 3
• Use suction ONLY to clear vomitus or debris, not water 3

Oxygenation Protocol

• Administer 100% oxygen immediately upon availability 1, 3
• Once return of spontaneous circulation (ROSC) is achieved, titrate oxygen to maintain SpO2 94-98% 4
• High-concentration oxygen is the cornerstone of post-resuscitation management, NOT bronchodilators—hypoxemia is the dominant problem, not bronchospasm 4

Cardiopulmonary Resuscitation Protocol

CPR Sequence for Drowning

• Check for pulse within 10 seconds after initial 2 breaths 3
• If no pulse is definitively felt, immediately begin chest compressions and continue standard CPR cycles 1, 3
• Trained healthcare providers should use A-B-C sequence (prioritizing ventilation first) given the hypoxic etiology, though C-A-B is also acceptable 1, 3
• CPR with rescue breaths must be provided—compression-only CPR is inferior in drowning but acceptable only if rescuer is unable or unwilling to provide breaths 1

Defibrillation Guidelines

• Dry the chest and attach AED once victim is out of water 3
• CPR with rescue breaths should be started BEFORE AED application 1
• Do NOT delay CPR initiation to obtain or apply an AED—this causes harm 1
• AED use is reasonable but shockable rhythms constitute only 2-12% of drowning arrests 1

Advanced Life Support Measures

Airway Management in ED/ICU

• Follow standard Pediatric Advanced Life Support (PALS) or Advanced Cardiovascular Life Support (ACLS) protocols once initial resuscitation is underway 1, 2
• Early intubation is indicated for patients requiring advanced life support 5
• Ventilation therapy should target intrapulmonary shunt ≤20% or PaO2:FiO2 ≥250 6

Critical Pitfall: Premature Extubation

• Avoid premature ventilatory weaning—this may cause return of pulmonary edema requiring re-intubation and prolonged hospitalization 6

Managing Vomiting During Resuscitation

• Vomiting occurs in approximately 66% of victims receiving rescue breathing and 86% requiring full CPR 3
• Turn victim onto side and remove vomitus using finger, cloth, or suction 3
• If spinal injury is suspected, log-roll the victim as a unit 3

Medication Dosing

Note: The 2024 American Heart Association/American Academy of Pediatrics guidelines do not specify unique medication dosages for drowning—standard ACLS/PALS drug protocols apply. 1

Standard Resuscitation Medications (per ACLS/PALS)

• Epinephrine:

  • Adults: 1 mg IV/IO every 3-5 minutes during cardiac arrest
  • Pediatrics: 0.01 mg/kg (0.1 mL/kg of 1:10,000 solution) IV/IO every 3-5 minutes; maximum single dose 1 mg

• Amiodarone (if shockable rhythm):

  • Adults: 300 mg IV/IO first dose, 150 mg second dose
  • Pediatrics: 5 mg/kg IV/IO bolus; may repeat up to 15 mg/kg/day

Medications NOT Recommended

• Routine corticosteroids are NOT recommended by current guidelines (older literature 7 suggested high-dose steroids, but this is outdated)
• Prophylactic antibiotics are NOT routinely indicated
• Bronchodilators are NOT the primary therapy—focus on oxygenation and ventilation 4

Mandatory Observation and Disposition

Hospital Admission Criteria

• ALL drowning victims who required ANY form of resuscitation must be transported to the emergency department and admitted for observation, regardless of how well they appear 2, 4, 3
• Minimum observation period: 4-6 hours, as decompensation can occur within this timeframe 2, 4, 3

Red Flags Requiring Immediate Attention

• Altered mental status or excessive sleepiness (ongoing hypoxemia) 3
• Difficulty breathing or abnormal breathing patterns 3
• Persistent coughing after submersion 3
• Any history of loss of consciousness during drowning 3

Prognostic Factors

• Duration and severity of hypoxia is the single most important determinant of outcome—this outweighs water type (fresh vs. salt) or water temperature 3, 6, 8
• Accurate neurological prognosis cannot be predicted from initial clinical presentation, laboratory, radiological, or electrophysiological examinations 8
• Prompt resuscitation at the scene after shorter submersion duration is associated with better outcomes 9, 8

Pathophysiology Summary

• Drowning causes acute lung injury with fluid in lungs, loss of surfactant, increased capillary-alveolar permeability, resulting in decreased lung compliance, increased right-to-left shunting, atelectasis, and noncardiogenic pulmonary edema 6, 8
• Salt and fresh water aspirations cause similar pathology 6, 9
• Hypoxemia leads to loss of consciousness and apnea in seconds to minutes, followed by hypoxic cardiac arrest 6, 8