Acute Care of the Drowning Victim
By Jasmine Jolly, M.D.
At the beach or in the trauma bay - how are you going to care for your next drowning victim?
Pearls:
Prioritize rescue breaths. Avoid compression-only CPR.
Prioritize suction of vomitus only. Ignore foam and bag it back into the lungs.
Prepare to treat pulmonary edema with lung protective strategies.
Drowning is a hypoxic event - management is FiO2 and PEEP.
If persistent hypoxia, consider ECMO.
If there is a shockable rhythm, consider secondary drowning with another primary etiology
Definition & Epidemiology
Drowning can be defined as the process of experiencing respiratory impairment from submersion/immersion in liquid (1).
Terminology for drowning includes:
nonfatal or fatal (self-explanatory)
primary (airway submersion/immersion in water causes the illness) or secondary (another illness such as heart attack or stroke while in water causes one’s airway is submersed/immersed in water)
Terms no longer used are “near-drowning,” “delayed drowning,” or “wet/dry drowning.”
Drowning is a leading cause of hypoxic injury or death among children less than 15 years old. In the US, drowning is the second leading cause of unintentional death in children less than 19 years old. That being said, there are trimodal age peaks: toddlers, late teens, and elderly (3).
Pathophysiology
Laryngospasm
When water enters the airway, it hits the larynx causing a protective laryngospasm. This laryngospasm prevents most of the water from entering the lungs, but lasts one minute and then fatigues.
Foam
Water that progresses beyond the larynx causes bronchospasm. Water that reaches the lungs causes direct cellular injury to thin fragile alveolar walls, causing surfactant washout. Surfactants have hydrophilic heads and hydrophobic tails (like soap), thus surfactants + water washout causes suds, which we call foam. Foam can fill the entire lung and may fill the airways and come out of the mouth. Foam is often copious and becomes a distractor of adequate resuscitation when there is a focus on suctioning it. Rather, it can be bagged back into the lungs without compromising oxygenation (4).
Pulmonary Edema
Noncardiogenic pulmonary edema caused by drowning is multifactorial:
The extreme negative intrathoracic pressure from inspiration efforts against a closed glottis causes negative-pressure pulmonary edema.
Decreased lung compliance, ventilation-perfusion mismatching, and intrapulmonary shunting causes hypoxemia.
An increase in catecholamines due to hypoxemia and stress cause pulmonary vascular overload (4).
Vomitus
Drowning may cause a large amount of vomitus, which will need to be suctioned for airway control. Water in the pharynx triggers a swallowing reflex in a primitive attempt to keep water out of the airway, even while unconscious. Depending on inadvertent submersion/immersion time, this can lead to ingestion of 3-4L of water in the stomach (1,5). Prepare for vomiting during resuscitation, suction it, and do not confuse it with foam.
Cardiac Arrest
A continued hypoxic event will lead to cardiac arrest. There is a predictable series of arrhythmias during continued hypoxia from drowning:
Sinus tachycardia
Bradycardia
PEA arrest (pulseless electric activity)
Neither ventricular fibrillation NOR pulseless ventricular tachycardia are hypoxic arrhythmias. If your patient presents with a shockable rhythm, then this is likely a secondary drowning due to another cause (6,7).
Prehospital Resuscitation
Bottom Line
Resuscitation of the drowned victim should be focused on airway (6,7).
Misconceptions
Despite the profound evidence for compression-only CPR in the general management of cardiac arrest, a patient who has drowned will die from a respiratory etiology. They need rescue breaths during CPR.
Avoid the Heimlich Maneuver. It delays delivery of ventilations and prolongs hypoxemia (6,7).
Do not hold the child upside down in an attempt for water expulsion (6).
Plan
Yell for help. Confirm who will call EMS and bring an AED. Assess for scene safety.
Do not attempt CPR in the water — patients with purely respiratory arrest typically respond following 3 rescue breaths. If no response, get the patient to shore for resuscitation.
Give 5 rescue breaths (or instruct a family member to do so), suctioning vomitus if able. Ignore foam.
Proceed with BLS or ACLS CPR: Alternate 15 chest compressions with 2 rescue breaths for children (30:2 for adults).
Secure the airway as soon as possible. Give one breath every 6 seconds.
Use an oropharyngeal airway or nasopharyngeal airway and bag valve mask (BVM), if available. Utilization of a BVM without oxygen is better than not using it.
Once the patient is breathing, place them in the recovery position on their side in case of additional vomiting.
Use a cervical collar only if history warrants, such as diving or severe blunt injury to the head.
Remove wet clothing
Wrap in thick blankets (3,6).
Who gets transported?
Everyone gets transported to a hospital unless:
No hypoxia or oxygen requirement
No loss of consciousness or retrograde amnesia
Coughing throughout the event, without any episode of apnea
ED Management (3)
If GCS is greater than or equal to 13 and SAO2 is greater than 95%:
Monitor for 4-6 hours. It is acceptable to discharge the patient if (1) oxygen saturations remain above 95% on room air, (2) lungs are clear to auscultation bilaterally, and (3) GCS remains above 13. Labs and radiographic studies are unnecessary and not predictive of clinical course.
Upon discharge, tell the patient to return for any difficulty breathing, fever, or altered mental status.
If the above criteria are not met:
Reverse the hypoxia
Increase FiO2
Give PEEP
Clear the airway
Suction vomitus
Push foam back into the lungs with PEEP
Obtain point of care glucose, chest x-ray, and arterial blood gas
If secondary drowning, assess for etiology
Treatment
In short, treatment is simply oxygenation, ventilation, and ECMO if needed.
Monitor for hemodynamic instability.
Monitor for increased work of breathing and mechanically ventilate if needed.
Surfactant will not be regenerated for at least 48 hours.
Noninvasive ventilation is acceptable if the patient does not have an altered mental status and is not vomiting.
The patient may develop pulmonary edema and will need a protective lung ventilation strategy
Set mode to volume assist control.
Use tidal volume of 6 mL/kg ideal body weight.
Set initial respiratory rate to 35 breaths per minute or less to match baseline minute ventilation.
Keep plateau pressures less than 30 mmHg. If too high, decrease the tidal volume. If breath stacking, increase the tidal volume.
Keep PaO2 55-80 mmHg, and SpO2 88-95%
Titrate PEEP settings to open collapsed alveoli, based on the FiO2:
FiO2 40%, use PEEP of 5-8
FiO2 60% use PEEP of 10
FiO2 80% use PEEP of 14
FiO2 100% use PEEP of 18-24
Extracorporeal Membrane Oxygenation (ECMO), if able.
Treatments not found to have morbidity or mortality benefit and should be avoided include diuretics, steroids, and empiric antibiotics unless otherwise indicated (8).
Cold Water Considerations
Cold water submersion may be protective due to rapid central nervous system cooling before hypoxic damage occurs. Hypothermia associated with drowning can provide a protective mechanism as the rate of cerebral oxygen consumption is reduced by ~ 5% for each reduction of 1°C in temperature within the range of 37°C to 20°C. Take into account that epinephrine has less efficacy at less than 30°C. If the patient is in cardiac arrest, warm to 37°C prior to ceasing efforts.
Additional Concerns
Possible aspiration of contaminated foreign material, vomitus, chemical irritants (consider calling Poison Control at 1-800-222-1222).
Electrolyte abnormalities are transient and seldom significant, whether fresh or salt water.
DIisseminated Intravascular Coagulation may be caused by severe hypoxic insult .
End organ damage can occur from hypoxemia and metabolic acidosis
For a deeper dive into some of these topics, you may want to check out the references below.
References
World Health Organization. (n.d.). Drowning. World Health Organization. https://www.who.int/health-topics/drowning
Excerpts from airway physiology and anatomy: A deep dive chapter in airway management in emergencies the Infinity Edition (no date) Airway Interventions & Management in Emergencies. https://aimeairway.ca/announcement/62/excerpts-from-airway-physiology-and-anatomy-a-deep-dive-chapter-in-airway-management-in-emergencies-the-infinity-edition (Accessed: 10 May 2023).
Tintinalli JE, Ma OJ, Yealy DM, Meckler GD, Stapczynski JS, Cline DM, Thomas SH. Tintinalli's Emergency Medicine: A Comprehensive Study Guide. 8th ed. New York, NY: McGraw-Hill Education; 2016. p. 1395-7.
M. Bierens, J. L., Lunetta, P., Tipton, M., & Warner, D. S. (2016). Physiology Of Drowning: A Review. Physiology. https://doi.org/Y-00002-2015
Tipton M, Montgomery H. The experience of drowning. Med Leg J. 2022 Mar;90(1):17-26. doi: 10.1177/00258172211053127. Epub 2021 Nov 18. PMID: 34791956; PMCID: PMC8928428.
Prehospital Drowning Resuscitation. Justin Sempsrott, MD of Lifeguards Without Borders. Available at: https://vimeo.com/showcase/2926649 (Accessed: October 2023).
Wilderness Medical Society Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2019 Update. Schmidt, Andrew C. et al. Wilderness & Environmental Medicine, Volume 30, Issue 4, S70 - S86
Ramzy, Mark. “Therapy Options in Acute Respiratory Distress Syndrome.” REBEL EM - Emergency Medicine Blog, 3 Aug. 2020, rebelem.com/salvage-therapies-in-acute-respiratory-distress-syndrome/.
Saguil A, Fargo M. Acute respiratory distress syndrome: diagnosis and management. Am Fam Physician. 2012;85(4):355.
About the author!
Dr. Jasmine Jolly is a PGY-3 at USF Emergency Medicine. Upon completion of her residency in June 2024, she will be entering an Emergency Medicine Advanced Ultrasound Fellowship at Prisma Health in South Carolina.