Journal Pre-proof

Management for the drowning patient

Dr David Szpilman, Dr Paddy Morgan

PII: S0012-3692(20)34896-0
DOI: https://doi.org/10.1016/j.chest.2020.10.007
Reference: CHEST 3690

To appear in: CHEST

Received Date: 27 February 2020

Revised Date: 1 October 2020
Accepted Date: 5 October 2020

Please cite this article as: Szpilman D, Morgan P, Management for the drowning patient, CHEST (2020),
doi: https://doi.org/10.1016/j.chest.2020.10.007.

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Submitted for: CHEST Reviews

“Management for the drowning patient”

Dr David Szpilman – Brazil

of
Brazilian Life Saving Society (SOBRASA) – Founder, Former President, Medical Director,
Medical and Prevention Commission of International Life-saving Federation (ILS) –

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Member,
Science and Technology Department - Municipal Health Secretary – Rio de Janeiro City,
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Drowning Resuscitation Center - GMAR – CBMERJ – Retired
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<david@szpilman.com>
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Dr Paddy Morgan
Medical Advisor, Surf Lifesaving Great Britain, UK
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Medical Commission International Life Saving Federation – Member

Research Associate, Extreme Environments Laboratory, Department of Sport and Exercise
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Science, University of Portsmouth.

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<drpaddymorgan@gmail.com>

Corresponding address:
David Szpilman - Av. das Américas 3555, bloco 2, sala 302, Barra da Tijuca - Rio de
Janeiro – RJ - Brazil 22631-003. Phone: +55 021 999983951 david@szpilman.com

Authors has NO conflict of interest

ABSTRACT
Drowning is “the process of experiencing respiratory impairment from submersion or immersion
in liquid”. According to WHO, drowning claim the lives of more than 40 people every hour of
every day. Drowning involves some physiological principles and medical interventions that are
unique. It occurs in a deceptively hostile environment that involves an underestimation of the
dangers or an overestimation of water competency. It has been estimated that more than 90%
are preventable. When water is aspirated into the airways, coughing is the initial reflex
response. The acute lung injury alters the exchange of O2 in different proportions. The
combined effects of fluid in the lungs, loss of surfactant and increased capillary–alveolar
permeability result in decreased lung compliance, increased right-to-left shunting in the lungs,

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atelectasis, and alveolitis, a non-cardiogenic pulmonary edema. Salt and fresh water aspiration

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cause similar pathology. If the person is not rescued, aspiration continues and hypoxemia leads
to loss of consciousness and apnea in seconds to minutes. As a consequence, hypoxic cardiac
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arrest occurs. The decision to admit to an ICU should consider patient´s drowning severity and
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co-or-premorbid conditions. Ventilation therapy should achieve an intrapulmonary shunt of
20% or less, or PaO2:FiO2 of 250 or more. Premature ventilatory weaning may cause the return
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of pulmonary edema with the need for re-intubation, and an anticipation of prolonged hospital
stays and further morbidity. This review includes all the essentials steps from the first call to
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action until the best practice at the pre-hospital, emergency department, and hospitalization.
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CHEST Reviews series!
MANAGEMENT FOR THE DROWNING PATIENT
IMPORTANCE OF THE TOPIC
• Drowning is defined as the process of experiencing respiratory impairment from
submersion or immersion in liquid.
• Drowning is a leading cause of injury and death among young people where it has been
estimated that more than 90% are preventable.
• Mortality and morbidity are proportional to the hypoxic insult, its’ treatment is the
mainstay of therapy.
• Almost all drowning victims return home safely without sequelae, except the post-

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cardio-pulmonary arrest victims where outcome is almost solely determined by a single

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fate factor - duration of submersion and ICU care.
• Concurrent pathologies may “trigger’ a drowning event and should be considered.
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INTRODUCTION
According to the World Health Organization(WHO) drowning is a preventable public health
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threat claiming the lives of more than 40 people every hour of every day. With more than 90%
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of these deaths occuring in low- and middle-income countries, it is the world’s third leading
unintentional injury killer.1 International data severely underestimates the actual drowning
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mortality rate in high-income countries2 with survey data from some low- and middle-income
countries suggesting rates four to five times that of the WHO estimated drowning rate.3 Almost
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all non-fatal drowning victims are able to help themselves or are rescued in time by bystanders
or professional rescuers, but are rarely globally reported. Coastal drownings are estimated to
cost more than $273 million per year in the United States and more than $228 million per
year(in U.S. dollars) in Brazil.4 Key risk factors for drowning are male sex, age of less than 14
years, alcohol use, low income, poor education, rural residency, aquatic exposure, risky
behavior and lack of supervision.1,4

Drowning involves some physiological principles and medical interventions that are rarely found
in other medical situations. Drowning deaths can be prevented by using a series of
interventions.5 It occurs in a deceptively hostile environment that may not seem dangerous and
usually involves an underestimation of the dangers or an overestimation of water competency
to face them.6 The first challenge is to recognize someone at risk of drowning and appreciate

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the need for rescue. Early self-rescue or rescue by others, may stop the drowning process and
prevent the majority of initial and subsequent water aspiration, respiratory distress and other
medical complications. The drowning process happens quickly7,8 but removing the victim from
this environment has the potential for significant harm to the rescuer. Therefore, it’s essential
that all responders are aware of the complete sequence of action steps on drowning process.9
The details of the drowning event can assist the clinician in the hospital management of the
pathophysiology that is likely to occur as a result.

DEFINITION, DATA AND DROWNING TIMELINE

“Drowning is the process of experiencing respiratory impairment from submersion or immersion

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in liquid”10. If respiratory impairment is NOT present, then this is just a rescue and not a

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drowning. The drowning process is a continuum, beginning with respiratory impairment as the
victim’s airway goes below the surface of the liquid (submersion) or when it splashes over the
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airways(immersion). If the victim is rescued at any time, the process of drowning is interrupted:
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a non-fatal drowning. If the victim dies at any time this is fatal drowning. Terms such as “near-
drowning”, “dry or wet drowning” and “secondary drowning” should not be used.10 A uniform
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way to report data for drowning resuscitation is the Utstein template for drowning resuscitation
cases.11 For non-fatal drownings, the WHO proposed a framework based on morbidity and
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severity of respiratory impairment(table 1).12

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The drowning timeline describes every constituent of the process, triggers, actions and
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interventions from a temporal perspective of: Pre- event; Event and Post-event. The drowning
timeline constitutes a powerful tool to improve drowning data collection, contributing to a
better understanding of the process to effectively prevent, react and mitigate it and to facilitate
the prioritization of cost/benefit ratios related to public health, financial aspects, political scope
and social impacts.6(figure 1.)

PATHOPHYSIOLOGY
Whatever the reason a person is in the water drowning carries a higher possibility of death if
the individual is not rescued or unable to cope with the situation.6 The initial triggers for
drowning are diverse and very complex.9 It may simply be an inability to stay afloat(e.g. young
children may sink with minimal struggle13) or to exit the water(e.g. river channel). They vary
with age, circumstance, water temperature(cold water may precipitate cardiac arrythmias –

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autonomic conflict), water competency, and some events temporally associated with being in
the water e.g. Traumatic injury, or illness(myocardial infarction, seizure etc).14,15 These may all
result in a physical inability or loss of conscsiousness. Many of these variables are still not fully
understood. In the majority of drowning events the victim fails to keep their airway above the
surface, water that enters the mouth is voluntarily spat out or swallowed. When water is
aspirated into the airways, coughing occurs as an initial reflex response. Some morphological
forensic studies, indicate that penetration of liquid into the lungs occurs in almost all drowning
deaths. Dry-lungs can be found only in bodies disposed of into water after death on land.16 In
less than 2% of cases17,18 laryngospasm may be present but the onset of hypoxia will terminate
this rapidly. If the person is not rescued, aspiration of water continues and hypoxemia leads to

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loss of consciousness and apnea in seconds to minutes.8,19 As a consequence, hypoxic cardiac

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arrest generally occurs after a period of bradycardia and pulseless electrical activity and not
ventricular fibrillation or tachycardia.20,21 Following rescue, the clinical picture is determined by
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the personal reactivity of the airways and the amount of water that has been aspirated with the
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corresponding hypoxia. Water in the alveoli causes surfactant destruction and wash-out,
initiating an acute lung injury. Salt and fresh water aspiration cause similar pathology. In either
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situation, the effect of the osmotic gradient on the alveolar-capillary membrane can disrupt its
integrity, increase its permeability and exacerbate fluid, plasma, and electrolyte shifts.20 The
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clinical picture is of regional or generalized pulmonary edema that alters the exchange of O2 and
CO2 in different proportions.19,20,22 In animal research22, the aspiration of 2.2 ml of water per
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kilogram of body weight lead to a severe disturbance on exchange of oxygen, decreasing the
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arterial oxygen pressure(PaO2) to approximately 60 mm Hg within 3 minutes. In humans, it

seems that as little as 1 to 3 ml/kg of water aspiration produces profound alterations in
pulmonary gas exchange and decreases pulmonary compliance by 10% to 40%. The combined
effects of fluid in the lungs, loss of surfactant and increased capillary–alveolar permeability can
result in decreased lung compliance, increased right-to-left shunting in the lungs, atelectasis,
and alveolitis, a non-cardiogenic pulmonary edema.20

PRE-HOSPITAL CARE - DROWNING CHAIN OF SURVIVAL

The drowning chain of survival9(figure 2) refers to a series of interventions that, when put into
action by lay or professional people, reduces the mortality associated with drowning.

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1. Prevent drowning-The most effective way to reduce the number of drowning deaths is
prevention. It has been estimated that more than 90% of all drowning are preventable.5,23,24
2. Recognize distress and call for help-Recognizing a person in distress and sending for help is a
key element that ensures early activation of professional rescue and medical services.9
3. Provide flotation to the victim, stop the process of drowning by reducing the submersion
risk.9 It is critical that personnel take precautions not to become another victim by attempting
inappropriate or dangerous rescue responses.7,8 If not interrupted, the drowning process leads
to unconsciousness and apnea, rapidly followed by cardiac arrest. During this short window of
opportunity, immediate in-water ventilation may provide benefit if safe to do so. It can increase
the discharge from hospital without sequelae by more than threefold but it is only possible if

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the rescuer is highly trained. Victims with only respiratory arrest usually respond after a few

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rescue breaths. If there is no response, the victim should be assumed to be in cardiac arrest and
be rescued as quickly as possible to a location where full CPR can be initiated, as In-water chest
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compressions are futile.25 Considering the low spinal injury incidence(0.009-0.5%), an attempt
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to immobilize it should only be made if there is strong indication of injury and certainly not in
cases where the victim appears lifeless.26,27,28,29,30,31
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4. Remove from water - rescue only if safe to do so - Rescue involves three phases: approach,
contact and stabilization. Removal from water is essential to terminate the drowning process
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and allows assessment and clinical management of the victim.25 Take into consideration the
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rescuer experience, entering the water is a personal decision. Extrication of the water is
preferably in a near horizontal position, but with the head maintained above body level and
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airway open.32
5. Provide care as needed – Basic and advanced life support
Basic Life Support(BLS)-Cardiopulmonary or isolated respiratory arrest in drowning comprises
less than 0.5% of all rescues.23 Early basic life-support contributes to a good outcome and
should be initiated as soon as possible.4 Once on land the victim should be placed supine, with
trunk and head at the same level, and checked for responsiveness and normal breathing. If
unconscious but breathing, the recovery position should be used.25,32 If not breathing,
ventilation is essential.4,19,26 Hypoxia is the primary cause of cardiac arrest in drowning and
requires rapid alleviation.8,19,26,33 Thus the Airway–Breathing–Circulation(ABC)34 sequence is
used, including five initial ventilations followed by 30 chest compressions. The initial 5
ventilations aims to overcome the high lung resistance, due to fluid and foam occluding the
airways, allowing oxygen to reach the alveolars.26,35 Following this a ratio of two ventilations to

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30 compressions is used until there are: signs of life; rescuer exhaustion; or advanced life
support(ALS) becomes available.26,33 This is in preference to Circulation-Airway-Breathing(CAB)
or Compression-only cardio-pulmonary resuscitation(CC-CPR) sequences26,33, however any
attempt at resuscitation is preferential to none. It is common for swallowed water and stomach
contents to be regurgitated into the airway, with subsequent risk of aspiration.19,25,36 Active
efforts to expel water from the airway(abdominal thrusts or placing the victim head down)
should be avoided as they delay initiation of ventilations, increase the risk of vomiting by more
than five-fold and thereby lead to significant increase in mortality.25,32 If vomiting occurs, the
victims should be immediately turned onto the lateral position, vomitus removed by a finger
sweep or suction and resuscitation continued. The effectiveness of automated external

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defibrillators (AED) for cardiac arrest in drowning is low as the presenting rhythm is usually

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pulse-less electrical activity or asystole. The incidence of ventricular fibrillation or ventricular
tachycardia is low(4.5-6%). A shockable rhythm is however a positive predictor of survival8,36-38
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and more likely if there is a history of coronary artery disease, epinephrine use or in the
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presence of severe hypothermia.21
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Advanced Life Support (ALS) is given according to drowning severity classification4,19 stratified
into 6 grades(algorithm 1)4,19 recommending the best practice treatment and the likelihood of
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death.
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At grade 6(cardio-pulmonary arrest) advanced CPR should be initiated at the scene by using
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bag-valve-mask ventilation with high flow oxygen until a definitive airway can be achieved(oro-
tracheal tube-OTT). The use of supraglottic airway devices is controversial. The pulmonary
airway pressure usually exceeds safety threshold to maintain pharyngeal seals with pressures of
25–28 cm H2O35,39 allowing a high potential to leak, causing new aspirations of stomach
contents(water included). Once intubated, most victims can be oxygenated and ventilated
effectively despite the presence of pulmonary edema in the tracheal tube. Oro-Tracheal-tube
suctioning can disturb oxygenation and lung recruitment. This should be balanced against the
need to ventilate and oxygenate. Peripheral venous access is a good alternative route for drug
administration in the pre-hospital setting. Intraosseous access is the alternative route, if
available. Endotracheal administration of drugs is not recommended in drowning.33 Cumulative
doses of epinephrine 1mg IV(or 0.01 mg/Kg) can be considered if the routine dosage fails to
achieve success after the initial 5 minutes of CPR.33 Once resuscitation attempts are successful,

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an orogastric tube can be placed to reduce gastric distention and prevent further aspiration.
Recommendations for when to start and stop resuscitation are described at table 2.
4,5,8,11,19,20,21,24,25,40,41,42

Grade 5(isolated respiratory arrest) is usually reversed by initial BLS with oxygenation and
ventilation before ALS is commenced. If there is spontaneous ventilation but oxygenation is
compromised (acute pulmonary edema (grade 3 and 4) the objective is to achieve a pre-hospital
peripheral saturation above 92% by administering oxygen by face mask at a rate of 15 liters of
oxygen/min. Early oral tracheal intubation(OTI) and mechanical ventilation are indicated as soon
as possible, because of respiratory fatigue, despite adequate oxygenation by face mask. While
all grade 4 need OTI, a few grades 3 drowning cases will tolerate non-invasive ventilatory(NIV)

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support19,40,43,44 provided their conscious level allows. Patients should be anaesthetized to

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tolerate intubation and artificial mechanical ventilation Emergency department(ED) attendance
is recommended for all grade 2 to 6 patients. Most victims grade 2 require low flow oxygen and
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will normalize their clinical situation within 6–48 hours and can be discharged home.19
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HOSPITAL CARE
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The decision to admit to an ICU or hospital bed versus observation in the emergency
department or discharge home should consider patient´s drowning severity and co-or-
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premorbid conditions. A thorough medical assessment should be performed including, chest

radiography and/or lung ultrasound, arterial blood gas measurement and blood tests.45,46 The
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latter should include tests of renal function, liver function, electrolytes, hemoglobin and any
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appropriate toxicology given the association with suicide and alcohol excess. Patient grade 3 to
6 should be admitted to an Intensive Care Unit(ICU) for close observation and therapy. Patient
grade 2 can be observed in the emergency room, but grade 1 and rescue cases with no
complaints or associated illness or trauma can be released home.19,45

Respiratory system
Patient grade 3 to 6 usually will arrive from pre-hospital ALS on mechanical ventilation with
acceptable oxygenation. If not, the physician should reassure that. Oxygen start at 100%, but
should be reduced as soon as possible. Positive end-expiratory pressure(PEEP) should be added
initially at a level of 5cm H2O and then increased by 2 to 3 cm H2O increments if needed and
possible. The PEEP should be used until the desired intrapulmonary shunt(QS: QT) of 20% or
less, or PaO2:FiO2 of 250 or more is achieved.20 At grade 4 if hypotension is not corrected by

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oxygen, a rapid crystalloid infusion should be used before trying to reduce PEEP. Once the
desired oxygenation is achieved, that level of PEEP should be maintained unchanged for at least
48 hours before attempting to weaning.47 This is the minimum time required for adequate
surfactant regeneration. Premature ventilatory weaning may cause the return of pulmonary
edema with the need for re-intubation, and an anticipation of prolonged hospital stays and
further morbidity.4 A clinical picture very similar to acute respiratory distress syndrome(ARDS),
but with a prompt recovery and no lung sequelae is common after significant drowning
episodes (grade 3 to 6). A protective lung ventilation strategy(e.g.; low tidal volumes [6 mL/kg
ideal body weight]) similar to ARDS should be used. Permissive hypercapnia should be avoided
however to prevent further neurological insult in those with significant hypoxic-ischemic brain

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injury(usually grade 6).4 Continuous Positive Airway Pressure (CPAP), Pressure Support

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Ventilation mode(PSV) and/or NIV are appropriate weaning strategies if pulmonary and
psychological status allows.43,44
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Pools, rivers and beaches generally have insufficient bacteria colonization to promote
pneumonia in the immediate post drowning period48. Pneumonia is often misdiagnosed initially
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because of the early radiographic appearance of water in the lungs with few actually requiring
antibiotic therapy(12%). If the victim requires mechanical ventilation, the incidence of
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pneumonia (ventilator-associated) increases to 34-52% in the third or fourth day of

hospitalization when pulmonary edema is resolving.49 Vigilance not only for pulmonary but also
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other infectious complications is important. Prophylactic antibiotics tend to only select out
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more resistant and aggressive organisms.50 The first signs of pulmonary infection are at 48 to 72
hours and are gauged by prolonged fever, sustained leukocytosis, persistent or new pulmonary
infiltrates, and leukocyte response in the tracheal aspirates. A broad-spectrum antibiotic
therapy to cover gram-positive and gram-negative should be used immediately if the drowning
occurred in water with high pathogen load(UFC>1020). In ventilator associated pneumonia, the
predominant microorganisms of the ICU or available cultures should be considered. In resistant
infections, consideration should be given to alternate pathogens e.g. fungal, algae and protozoa.
Fiberoptic bronchoscopy may be useful for evaluation of infection by obtaining quantitative
cultures, determining the extent and severity of airway injury and for the rare occasions where
therapeutic clearing of sand, gravel or other solids is indicated. Corticosteroids should not be
used except for bronchospasm. The clinician must be aware of and constantly vigilant for
volutrauma and barotrauma during mechanical ventilation.48

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Focused bedside ultrasound can be used to diagnose and monitor the respiratory and
circulatory system in real time. Specifically, the rapid diagnosis of pneumothoraces and
distribution of lung oedema.46 Ultrasound assessment of cardiac function can guide fluid
therapy, indication for inotropes or vasopressors, monitor the response to therapy and exclude
concurrent pathologies.

Circulatory system
Cardiac dysfunction with low cardiac output is usual immediately after severe cases.20 Low
cardiac output is associated with high pulmonary capillary occlusion pressure(hypoxic

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vasoconstriction), high central venous pressure and pulmonary vascular resistance which can

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persist for days. This may add a cardiogenic component to the drowning primary non-
cardiogenic pulmonary edema. The reduced cardiac output can be corrected with oxygenation,
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crystalloid infusion and restoration of normal body temperature. Vasopressor infusion should
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be reserved for refractory hypotension. Echocardiography to assess cardiac function can guide
the clinician in titrating inotropes, vasopressors or both if volume crystalloid replacement is
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inadequate4. In patients who are hemodynamically unstable or have severe pulmonary

dysfunction, pulmonary artery catheterization may be considered to provide useful information.
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There is no evidence to support the use of any specific fluid therapy for salt and fresh water
drowning20, the use of diuretics or water restriction. Metabolic acidosis occurs in 70% of
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patients arriving at the hospital after a drowning episode.19

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Neurologic system
Most late deaths and long-term sequelae of drowning are neurologic in origin (anoxic-ischemic
cerebral insult) and are almost exclusive in grade 6, as pulmonary injury is usual reversible.4,48
Although the highest priority of CPR is restoration of spontaneous circulation, every effort in the
early stages should be directed at resuscitating the brain and preventing further neurologic
damage. These steps include providing adequate oxygenation(SatO2p>92%) and cerebral
perfusion(mean arterial pressure around 100 mm Hg). Any victim who remains comatose or
unresponsive after successful CPR or deteriorates neurologically should undergo careful and
frequent neurologic function assessment and care by using the measures at table 3.40,51

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Drowning victims with spontaneous circulation who remain comatose should have targeted
temperature management to improve outcomes after cerebral hypoxia-ischaemia.52–54
Maintaining a core temperature of 32°C to 34°C for at least 24 hours post arrest is associated
with improved neurological outcomes.52-55 Although there is insufficient evidence to support a
specific target PaCO2 or oxygen saturation, hypoxemia should be avoided. Studies have failed to
demonstrate improved outcome utilizing intracranial pressure monitoring56, therapies to
control intracranial hypertension or maintenance of artificially high cerebral perfusion
pressure(CPP).56,57

New therapeutic interventions for drowning victims such as artificial surfactant58-60 or nitric

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oxide61 are still experimental with a few successful case reports. Extracorporeal membrane

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oxygenation may be considered when the patient is profoundly hypothermic, or conventional
respiratory assistance is insufficient to maintain oxygenation. This assumes it is available and
feasible.62,63,64,65
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Unusual complications
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In the most severe cases(grade 6) the hypoxic and/or hypo-perfusion associated with drowning
can trigger the systemic inflammatory response syndrome. This can manifest as isolated cardiac,
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renal or hepatic dysfunction through to sepsis and multi-organ dysfunction syndrome. Rarely,
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drowning victims with normal chest radiography develop fulminant pulmonary edema upto 12
hours after the incident. Whether this late-onset pulmonary edema is delayed ARDS, a
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neurogenic pulmonary edema secondary to hypoxia, or just an airway hyperreactive to water

aspiration is still unclear.4,19,11,66

Cold water drowning

Submersion in cold water and sudden release of breath hold can induce cardiac arrhythmias,
particular in those with long QT syndrome, by simultaneously activating the antagonistic
responses of the autonomic nervous system – autonomic conflict. These being the sympathetic
“cold shock response” producing a tachycardia and the parasympathetic “diving response”
mediated bradycardia. This may, in vulnerable individuals, account for sudden death in cold
water.57-69 Hypothermia reduces the electrical and metabolic activity of the brain; with cerebral
oxygen consumption reducing by approximately 5% per each oC reduction in temperature within
the range of 37 to 20oC.70 Thus, prolonging the interval until cellular anoxia, ATP depletion and

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cell death signaling. If cooling occurs prior to submersion (i.e. hypoxia) it provides a form of
cerebral protection that explains cases with good neurological outcome despite prolonged
submersion for up to 90 minutes.26,41 In these cases, the water temperature was 6oC or lower.
Extracorporeal membrane oxygenation(ECMO) has been used in the resuscitation of these
victims with good neurological outcomes, despite initially poor prognosis.4,33,41,62,63 Previously
hypothermic victims re-warmed to near-normal core temperature, who remain asystolic with a
significantly elevated serum potassium, despite resuscitation, is a key indicator of futility.26,71,72

OUTCOME AND SCORING SYSTEMS

Of the drowning grades 1 to 5, 95% return home without sequelae.19 In grade 6, prognostic

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variables are important while counseling family members and in deciding which treatment

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strategies are appropriate.8 Victims who remain comatose or deteriorate neurologically should
undergo intensive assessment and care.40 Several studies have established that outcome is
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almost solely determined by a single fate factor-duration of submersion(table
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4).8,11,19,20,21,24,25,40,41,42
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Error! Reference source not found.This emphasizes the need for accurate documentation of the
pre-hospital presentation and incident details. After successful CPR, assessment of neurological
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severity will allow comparison of different therapeutic approaches.73 Data suggest that patients
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who remain decorticate, decerebrate, or flaccid in the 2 to 6 hours after the drowning incident
(when no drugs are implicated) are brain dead or will survive with moderate to severe
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neurological impairment.5 Patients who are improving but remain unresponsive have a 50%
likelihood of a good outcome(table 5).8

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Conclusion
As one of the most common causes of unintentional injury-related morbidity and mortality
worldwide, drowning remains a significant public health issue and an extremely complex
process in which there is no simple, or single solution. However, the true impact of drowning on
public health is unknown due to a lack of high-quality epidemiological data in the field. The
most effective intervention to reduce drowning deaths is prevention. When prevention fails
further reduction in morbidity and mortality is only achieved by effective rescue, and early
clinical interventions when indicated. In many areas of medicine, it is obvious that prevention is
better than cure, but how do you motivate and educate those populations that are at the
highest risk? Does it require the emotive scenario of a child death or severe neurological insult

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as a result of a drowning event for people to act? The drowning process may involve a complex

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interplay between acute injury or disease and an inability to maintain the airway clear of the
waters surface. The simple life skills of water awareness and the ability to float face up will
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prevent many of the complications of this potentially fatal process. There is a deficit of high-
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quality scientific evidence at all stages of the patient’s journey following a drowning event,
particularly in the hospital setting. These events result in a multisystem disorder to a greater or
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lesser extent depending upon the duration of the hypoxic insult. Following a successful rescue,
the key therapy is oxygen, and facilitation of its’ delivery to the tissues of the body.
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TABLES, FIGURES AND ALGORITHM
Table 1 - Categorization Framework for Non-fatal Drowning12
1. The severity of respiratory impairment immediately after the drowning process stopped.
There must be evidence of respiratory impairment to be classified as a non-fatal drowning.
2. The morbidity category at the time when non-fatal drowning information is gathered. For the
purposes of this categorization framework, morbidity is defined as a decline from the
individual’s functional capacity prior to the drowning.
a
The following descriptors serve to better characterize the meaning of “involuntary distressed coughing”: coughing
b
up liquid / moving liquid out of the airway; in water, in distress and coughing; sustained coughing. The phrase
“previous functional capacity” includes the person’s cognitive, motor, and psychological capacity (WHO task force

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– personal communication)

(attached in word file)

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Figure 1 – drowning timeline6 -p
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Figure 2 – Drowning Chain of Survival9
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ALGORITHM 1 - Drowning severity classification and flow chart strategy decision based on
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evaluation of 87,339 rescuesError! Reference source not found.,Error! Reference source not found..
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Table 2 – Drowning – When to initiate CPR and when to discontinue4,5,8,11,19,20,21,24,25,40,41,42

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Table 3 – Recommended care for victim who remains comatose or unresponsive after successful
CPR or deteriorates neurologically40,51

Table 4 - Probability of Neurologically Intact Survival to Hospital Discharge, based on duration of

submersion 8,11,19,20,21,24,25,40,41,42

Table 5 – Clinical Prognostic Score for the immediate period pos successful CPR, based on
Glasgow Coma Score.8

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 Severity of respiratory impairment after the drowning process stopped.

(1) Mild (2) Moderate (3) Severe

• Breathing • Difficulty breathing • Not breathing
• Involuntary distressed AND AND
• Disoriented but conscious • Unconscious
a
coughing
AND
• Fully alert
b
Morbidity category (based upon any decline from previous functional capacity ) at the time of measurement.
(A) No morbidity (B) Some morbidity (C) Severe morbidity
• No decline • Some decline • Severe decline
Table 1 - Categorization Framework for Non-fatal Drowning12
1. The severity of respiratory impairment immediately after the drowning process stopped.
There must be evidence of respiratory impairment to be classified as a non-fatal drowning.

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2. The morbidity category at the time when non-fatal drowning information is gathered. For

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the purposes of this categorization framework, morbidity is defined as a decline from the
individual’s functional capacity prior to the drowning. -p
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The following descriptors serve to better characterize the meaning of “involuntary distressed coughing”: coughing
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b
up liquid / moving liquid out of the airway; in water, in distress and coughing; sustained coughing. The phrase
“previous functional capacity” includes the person’s cognitive, motor, and psychological capacity (WHO task
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force – personal communication)

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Question Recommendations
• Give ventilatory support for respiratory distress/arrest to avoid cardiac arrest.
In whom to
• Start CPR in all submersions < 60 minutes who does not present obvious physical
begin?
evidence of death (rigor mortis, body decomposition or dependent lividity).
• Basic life support should continue unless signs of life re-appear, rescuers exhaustion or
When to advanced life support take over.
discontinue? • Advanced life support should be ongoing until patient has been rewarmed (if
hypothermic) and asystole persist for more than 20 minutes.
Table 2 – Drowning – When to initiate CPR and when to discontinue4,5,8,11,19,20,21,24,25,40,41,42

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Raise the head of the bed by 30 degrees (if there is no hypotension);
Maintain adequate mechanical ventilation by using drugs to low patient fighting the ventilator;
Ensure appropriate respiratory toilet (keeping positive airway pressure) without provoking
hypoxia;
Treat for seizure activity;
Avoid sudden metabolic corrections;
Prevent interventions that increase intracranial pressure (ICP) - including urinary retention,
pain, hypotension, hypercapnia, hypoxemia;
Hyperthermia should be avoided and normoglycemia maintained.
Table 3 – Recommended care for victim who remains comatose or unresponsive after
successful CPR or deteriorates neurologically40,51

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Duration of submersion Death or severe neurological impairment
0 to <5 minutes 10%
5 to <10 minutes 56%
10 to <25 minutes 88%
> 25 minutes 99,9%
Note in these data how 5 more minutes of submersion in the 5 to <10 min group
increases mortality almost 6 times compared to the 0 to <5-minute group
Table 4 - Probability of neurologically intact survival to hospital discharge, based on duration
of submersion 8,11,19,20,21,24,25,40,41,42

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 NEUROLOGIC PROGNOSTIC SCORE
Post successful CPR on Drowning
A – FIRST HOUR B – AFTER 5 to 8 h
Alert - 10 Alert - 9.5
Confused - 9 Confused - 8
Torpor - 7 Torpor - 6
Coma with normal brainstem - 5 Coma with normal brainstem - 3
Coma with abnormal brainstem - 2 Coma with abnormal brainstem - 1
A+B
RECOVERY WITHOUT SEQUALAE
Excellent (>= 13) > = 95%
Very good (10-12) 75 to 85%
Good (8) 40 to 60%

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Regular (5) 10 to 30%
Poor (3) < = 5%

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Table 5 – Drowning clinical prognostic score for the immediate period pos successful CPR, based
on Glasgow Coma Score.8
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