Nonfatal Drowning

BASICS

Nonfatal drowning: Respiratory impairment from submersion/immersion in liquid; the process is stopped before death and the victim survives.

Incidence (US, 2011–2020):
~4,012 fatal drownings/year
~8,061 ER visits/year for nonfatal drowning
Age peaks: 1–5 years (toddlers), 15–25 years (adolescents/young adults), elderly
~80% of fatal drownings are male
Highest risk in Black children (swimming pools) and American Indian/Alaska Native children (natural water)
Most common injury-related cause of death: ages 1–4 years
For every child death by drowning, 7 more are seen in ER for nonfatal submersion.

Mechanism: Hypoxemia (aspiration/laryngospasm) → cerebral hypoxia, multisystem dysfunction
Pulmonary: Loss/dilution of surfactant → ↓ gas transfer, atelectasis, ARDS
Cardiac: Hypoxic-ischemic injury, arrhythmia
Renal: Acute tubular necrosis (from hypoxia/shock)
Neuro: Hypoxic brain injury (especially hippocampus, insular cortex, basal ganglia), cerebral edema
Coagulation: Hemolysis, coagulopathy

Inadequate pool barriers, lack of supervision, alcohol/drugs, male sex, low SES
Seizure disorder, inability to swim, overestimation of swimming ability, trauma, boating accidents, cardiac arrhythmias (e.g., long QT)
Young children: even small amounts of water (bathtub, bucket, toilet) can be fatal.

Supervision and education: Mandatory pool fencing (four-sided, self-closing), alarms, buddy system, water safety instruction
Avoid alcohol/drugs near water
Early swimming lessons
CPR training for parents/pool owners
Use of personal flotation devices and boating safety
Children: Never leave unattended near water

Trauma, seizures, alcohol/drugs, hypothermia, cardiac arrhythmias, pneumonia, stroke/MI

Use Revised Utstein template: victim age/sex, date/time, precipitating event, submersion details, preexisting illness, water temp, witnesses, CPR/ventilation, EMS response, initial rhythm, time points (submersion, rescue, CPR start, return of spontaneous circulation, regaining consciousness).

Syncope, trauma, arrhythmia, seizure, MI, stroke, intoxication, nonaccidental trauma

If GCS and pulse ox are normal (and remain normal for 6–8h): usually no further workup needed.
If abnormal:
Pulse oximetry, ABG
CBC, electrolytes, BUN/Cr, glucose
ECG, cardiac monitoring, troponin, CK/urine myoglobin, coags
Toxicology, blood alcohol
CXR (for respiratory symptoms): aspiration, atelectasis, ARDS
Head/C-spine imaging for trauma

Early resuscitation & hypoxemia reversal are critical
Prehospital:
Do not approach victim alone; initiate BLS/ACLS as soon as safe
Immediate CPR (ABC), rescue breathing in water if unable to remove victim immediately
Remove wet clothing, start rewarming if hypothermic
AED can be used in wet environments
ED:
Oxygen to maintain sat ≥92–96%
CPAP/BiPAP or intubation (lung-protective strategy: low tidal volumes, higher PEEP) if needed
Monitor core temperature, rewarm as needed
IV fluids for hypotension; vasopressors if refractory

Admit symptomatic patients or those with abnormal vitals, oxygenation, CXR, or labs
Monitor vitals, neuro status, cardiac and pulse ox
Induce hypothermia (32–34°C for 24h) for patients with coma/neuro decline after resuscitation

Monitoring: ABGs, hemodynamics (PA catheter if needed), ICP monitoring (if neuro decline), serum electrolytes
Diet: NPO until mental status normalizes
Education: Emphasize prevention and supervision

75% survive; 6% with neurologic deficits
Favorable: initial GCS ≥13 and O2 sat ≥95%
Poor: comatose/CPR at presentation, fixed/dilated pupils, no spontaneous respiration

Early: Bronchospasm, aspiration, hypothermia, hypovolemia, seizures, arrhythmia, hypotension
Late: ARDS, pneumonia, abscess/empyema, anoxic encephalopathy, barotrauma, renal failure, coagulopathy, sepsis