Symptomdx.

Get Started

Drowning and Submersion InjuryAPPROACH

ENVIRONMENTAL AND EXPOSURE · 19 SECTIONS

⚲

421 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

Heat Illness Hypothermia And Cold Exposure Frostbite Concern Drowning And Submersion Injury

01History/hx43

Exposure and timeline

›Submersion event details

›Time of submersion

›Estimated submersion duration

›Witnessed versus unwitnessed

›Water type

›Pool

›Lake

›River

›Ocean

›Bathtub

›Water contamination concern

›Sewage

›Chemical exposure

›Rescue details

›Bystander CPR

›Rescue breaths provided

›AED used

›Post rescue course

›Persistent cough

›Vomiting

›Progressive work of breathing

›Precipitating factors

›Trauma mechanism

›Diving

›Seizure

›Syncope

›Intoxication

02Alarm Features/alarm22

Immediate high risk triggers

›Resuscitation triggers

›Apnea

›Cyanosis

›Gasping respirations

›Altered mental status

›Seizure

›Persistent hypoxemia despite oxygen

›Vital sign danger thresholds

›SpO2 less than 90 percent on supplemental oxygen

›Hypotension with signs of shock

›Bradycardia with poor perfusion

›Severe hypothermia with instability

›Airway and breathing red flags

›Copious frothy sputum

›Severe work of breathing

›Silent chest

›Suspected aspiration with worsening respiratory status

Escalation logic

›Escalate to resuscitation bay

›If respiratory failure

›If GCS less than 13

›If hemodynamic instability

›If core temperature less than 32 C with instability

03Medications/meds15

Home and recent medications

›Current medication profile

›Cardiac medications

›Antiseizure medications

›Diabetes medications

›QT prolonging medications

›Recent changes

›New prescriptions in last 30 days

›Missed doses and nonadherence pattern

High risk exposures

›Sedating substances

›Alcohol

›Opioids

›Benzodiazepines

›Performance and recreational agents

›Stimulants

›Cannabis

04Diet/diet10

Intake and hydration

›Recent intake pattern

›Fasting

›Poor oral intake

›Dehydration symptoms

›Alcohol exposure

›Recent use

›Binge pattern

›Caffeine and energy drinks

›High dose exposure

›Palpitations association

05Review of Systems/ros20

Respiratory and cardiac

›Cardiopulmonary symptoms

›Dyspnea

›Cough

›Wheeze

›Chest pain

›Palpitations

›Syncope

›Infection and inflammation

›Fever

›Chills

›Myalgias

Neurologic and trauma

›Neurologic symptoms

›Headache

›Confusion

›Weakness

›Seizure

›Trauma symptoms

›Neck pain

›Back pain

›Extremity pain

06Collateral History and Family History/chafh12

Collateral sources

›Source reliability

›EMS report

›Lifeguard report

›Witness report

›Video evidence

Family history

›Sudden cardiac death risk

›Sudden unexplained death under age 50

›Known long QT syndrome

›Known cardiomyopathy

›Seizure disorders

›Epilepsy in first degree relatives

›Febrile seizure history in siblings

07Risk Factors/rf19

Patient factors

›High risk comorbidities

›Seizure disorder (G40.909)

›Long QT syndrome (I45.81)

›Cardiomyopathy (I42.9)

›Congenital heart disease (Q24.9)

›Asthma (J45.909)

›Age related risk

›Toddlers and preschool age

›Older adults

Exposure and environment

›Cold water exposure

›Prolonged immersion

›Hypothermia risk

›High energy mechanism

›Diving

›Surf or river current

›Intent and safety concerns

›Unsafe supervision

›Possible self harm intent

›Intoxication during water activity

08Differential Diagnosis/ddx47

Life threatening

›Primary drowning related conditions

›Hypoxemic respiratory failure (J96.01)

›Refractory hypoxemia

›Progressive respiratory distress

›ARDS (J80)

›Bilateral opacities

›High oxygen requirement

›Cardiac arrest after hypoxia (I46.9)

›PEA

›Asystole

›Mimics and precipitants

›Arrhythmia (I49.9)

›Pre event palpitations

›Exertional syncope

›Seizure (G40.909)

›Witnessed convulsion

›Tongue bite

›Hypoglycemia (E16.2)

›Diabetes

›Low point of care glucose

›Intoxication or overdose (T50.901A)

›Altered mental status disproportionate to hypoxia

›Pinpoint pupils

›Cervical spine injury (S14.109A)

›Diving mechanism

›Focal neurologic deficits

09Past Medical History/pmh15

Relevant conditions and prior care

›Chronic illnesses

›Asthma (J45.909)

›COPD (J44.9)

›Heart failure (I50.9)

›Coronary artery disease (I25.10)

›Seizure disorder (G40.909)

›Prior critical illness

›Prior ICU admission

›Prior intubation history

Procedures and devices

›Implanted devices

›Pacemaker

›ICD

›Prior surgeries

›Cardiac surgery

›Airway surgery

10Physical Exam/exam31

Initial survey and vitals

›General appearance and perfusion

›Work of breathing

›Cyanosis

›Frothy sputum

›Capillary refill

›Signs of shock

›Vital sign interpretation

›SpO2 trend on room air and oxygen

›Temperature and hypothermia staging

›RR trajectory

System exam

›Respiratory exam

›Auscultation findings

›Crackles

›Wheeze

›Decreased air entry

›Accessory muscle use

›Ability to speak

›Neurologic exam

›GCS

›Pupils

›Focal deficits

›Seizure activity

›Cardiovascular exam

›Heart rate regularity

›Murmur

›Peripheral pulses

11Lab Studies/labs27

Core labs and indications

›Initial labs based on severity

›Glucose point of care

›VBG or ABG

›Hypercapnia assessment

›pH and lactate assessment

›Electrolytes

›Sodium

›Potassium

›Bicarbonate

›CBC

›Leukocytosis context

›Hemoglobin for occult bleeding if trauma

›Creatinine

›Baseline renal function for contrast planning

›Cardiac and muscle injury labs when indicated

›Troponin

›If arrest

›If ischemic symptoms

›CK

›If prolonged immersion

›If hypothermia with immobilization

Interpretation pitfalls

›ABG and VBG limitations

›Early ABG may lag clinical course

›Hyperventilation can mask hypercapnia

›Infection markers

›Leukocytosis may reflect stress response

12Imaging/img28

Scoring Systems

›Severity grading frameworks

›Clinical grading for drowning severity

›Use for disposition support

›Local protocol dependent pathways

MRI

›Neuroimaging indications

›Persistent coma with unclear etiology

›Concern for hypoxic ischemic injury timing dependent

›Contraindications and logistics

›Unstable airway or ventilation

›Implanted device compatibility

›CT head indications

›Persistent altered mental status not explained by hypoxia

›Seizure with concern for intracranial pathology

›CT cervical spine indications

›Diving mechanism

›Focal neurologic deficits

›Chest CT considerations

›Alternative diagnosis evaluation

›Pulmonary embolism evaluation when indicated

Ultrasound

›Lung ultrasound

›B lines suggesting interstitial edema

›Pleural effusion assessment

›Cardiac POCUS

›Cardiac activity in arrest

13Special Tests/spec13

Bedside monitoring and diagnostics

›Continuous monitoring

›Continuous pulse oximetry

›Cardiac monitor

›Frequent temperature reassessment

›Capnography

›If ventilated

›During CPR for quality and ROSC indicator

›Core temperature measurement

›Esophageal or bladder probe when intubated

›Rectal probe alternative

Neurologic and seizure evaluation

›EEG consideration

›Unexplained coma after ROSC

›Concern for nonconvulsive status

14ECG/ecg10

Rhythm and hypothermia patterns

›ECG screening

›After submersion with symptoms

›If syncope or arrest

›Hypothermia associated findings

›Bradycardia

›QT prolongation

›J waves

›Ischemia and stress patterns

›ST changes with hypoxia

›Takotsubo pattern consideration

15Assessment/ax22

Working problem list

›Drowning or submersion injury (T75.1)

›Severity based on symptoms

›Oxygen requirement

›Mental status trajectory

›Acute hypoxemic respiratory failure (J96.01)

›SpO2 trend

›Work of breathing

›ABG evidence of respiratory failure if obtained

›Hypothermia (T68) when present

›Core temperature category

›Hemodynamic stability

Complications to rule out

›Aspiration pneumonitis progression

›Cough and tachypnea progression within 8 hours

›New oxygen requirement

›Trauma and cervical spine injury

›Mechanism compatible

›Exam findings compatible

›Precipitating medical cause

›Arrhythmia

›Seizure

›Hypoglycemia

›Intoxication

16Plan/plan46

First 5 minutes workflow

›Immediate priorities

›Airway patency

›Ventilation support

›Oxygenation target SpO2 at least 94 percent

›Cardiac monitoring

›Core temperature measurement

›Oxygen and ventilation escalation

›High flow oxygen

›CPAP for persistent hypoxemia with adequate mental status

›Intubation if unable to protect airway

›GCS less than 8

›Refractory hypoxemia

›Hypercapnia with fatigue

›Cardiac arrest after drowning

›CPR with rescue breaths plus compressions

›Defibrillation per rhythm

›Hypothermia modified resuscitation duration local protocol dependent

Differential Management

›!Drowning→›!Aspiration pneumonia→›Hypothermia→

Therapeutics and supportive care

›Ventilator strategy if intubated

›Lung protective ventilation

›Tidal volume 6 to 8 mL per kg ideal body weight

›Plateau pressure less than 30 mmHg

›PEEP titration for oxygenation

17Disposition/dispo18

Level of care criteria

›ICU criteria

›Need for mechanical ventilation

›Hemodynamic instability

›Cardiac arrest or post ROSC care

›Severe hypothermia with instability

›Inpatient criteria

›Persistent oxygen requirement

›Abnormal mental status

›Significant aspiration with radiographic or clinical progression

›Observation pathway criteria

›Dyspnea or cough with normal SpO2

›Need for serial reassessment up to 8 hours

Discharge criteria

›Safe discharge requirements

›Normal mental status

›SpO2 greater than 95 percent on room air

›No respiratory symptoms after observation period

›Reliable adult supervision

›Clear follow up plan

18Discharge Instructions/di16

Copy discharge instructions

›Patient instructions

›You were evaluated after a drowning or submersion event

›Your exam and oxygen level remained normal during observation

›Return to the emergency department right away for

›Trouble breathing

›Persistent cough

›Chest pain

›Vomiting that does not stop

›Fever

›Confusion

›Fainting

›Avoid swimming or water sports until cleared by a clinician

›Follow up with your primary care clinician within 1 to 2 days

›If this event may have happened due to fainting, seizure, or heart rhythm issues

›Do not drive

›Avoid water activities until further testing is complete

19References/r7

Guidelines and key sources

›Core references

›American Heart Association and American Academy of Pediatrics focused update on resuscitation following drowning 2024

›American Heart Association guidelines for CPR and ECC special circumstances 2025

›Wilderness Medical Society clinical practice guidelines for drowning treatment and prevention 2024

›International Liaison Committee on Resuscitation CoSTR drowning topics 2025

›Heart and Stroke Foundation of Canada resuscitation following drowning guidance 2024

›Project source file

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.

Drowning and Submersion InjuryAPPROACH

ENVIRONMENTAL AND EXPOSURE · 19 SECTIONS

⚲

421 items

☷ Legend

⚲

Resuscitation and Universal Approaches9▾

Chest and Cardiovascular12▾

Respiratory11▾

Abdominal and Gastrointestinal24▾

Renal and Urinary7▾

Neurologic11▾

Back and Neck8▾

Women's Health, Pregnancy, and GU11▾

Infectious Disease and Fever Syndromes11▾

Allergy and Dermatology7▾

Musculoskeletal and Extremities14▾

Trauma and Wounds14▾

ENT, Eye, Dental10▾

Endocrine, Metabolic, and Abnormal Labs9▾

Toxicology and Behavioral14▾

Pediatrics16▾

Environmental and Exposure4▾

Heat Illness Hypothermia And Cold Exposure Frostbite Concern Drowning And Submersion Injury

01History/hx43

Exposure and timeline

›Submersion event details

›Time of submersion

›Estimated submersion duration

›Witnessed versus unwitnessed

›Water type

›Pool

›Lake

›River

›Ocean

›Bathtub

›Water contamination concern

›Sewage

›Chemical exposure

›Rescue details

›Bystander CPR

›Rescue breaths provided

›AED used

›Post rescue course

›Persistent cough

›Vomiting

›Progressive work of breathing

›Precipitating factors

›Trauma mechanism

›Diving

›Seizure

›Syncope

›Intoxication

02Alarm Features/alarm22

Immediate high risk triggers

›Resuscitation triggers

›Apnea

›Cyanosis

›Gasping respirations

›Altered mental status

›Seizure

›Persistent hypoxemia despite oxygen

›Vital sign danger thresholds

›SpO2 less than 90 percent on supplemental oxygen

›Hypotension with signs of shock

›Bradycardia with poor perfusion

›Severe hypothermia with instability

›Airway and breathing red flags

›Copious frothy sputum

›Severe work of breathing

›Silent chest

›Suspected aspiration with worsening respiratory status

Escalation logic

›Escalate to resuscitation bay

›If respiratory failure

›If GCS less than 13

›If hemodynamic instability

›If core temperature less than 32 C with instability

03Medications/meds15

Home and recent medications

›Current medication profile

›Cardiac medications

›Antiseizure medications

›Diabetes medications

›QT prolonging medications

›Recent changes

›New prescriptions in last 30 days

›Missed doses and nonadherence pattern

High risk exposures

›Sedating substances

›Alcohol

›Opioids

›Benzodiazepines

›Performance and recreational agents

›Stimulants

›Cannabis

04Diet/diet10

Intake and hydration

›Recent intake pattern

›Fasting

›Poor oral intake

›Dehydration symptoms

›Alcohol exposure

›Recent use

›Binge pattern

›Caffeine and energy drinks

›High dose exposure

›Palpitations association

05Review of Systems/ros20

Respiratory and cardiac

›Cardiopulmonary symptoms

›Dyspnea

›Cough

›Wheeze

›Chest pain

›Palpitations

›Syncope

›Infection and inflammation

›Fever

›Chills

›Myalgias

Neurologic and trauma

›Neurologic symptoms

›Headache

›Confusion

›Weakness

›Seizure

›Trauma symptoms

›Neck pain

›Back pain

›Extremity pain

06Collateral History and Family History/chafh12

Collateral sources

›Source reliability

›EMS report

›Lifeguard report

›Witness report

›Video evidence

Family history

›Sudden cardiac death risk

›Sudden unexplained death under age 50

›Known long QT syndrome

›Known cardiomyopathy

›Seizure disorders

›Epilepsy in first degree relatives

›Febrile seizure history in siblings

07Risk Factors/rf19

Patient factors

›High risk comorbidities

›Seizure disorder (G40.909)

›Long QT syndrome (I45.81)

›Cardiomyopathy (I42.9)

›Congenital heart disease (Q24.9)

›Asthma (J45.909)

›Age related risk

›Toddlers and preschool age

›Older adults

Exposure and environment

›Cold water exposure

›Prolonged immersion

›Hypothermia risk

›High energy mechanism

›Diving

›Surf or river current

›Intent and safety concerns

›Unsafe supervision

›Possible self harm intent

›Intoxication during water activity

08Differential Diagnosis/ddx47

Life threatening

›Primary drowning related conditions

›Hypoxemic respiratory failure (J96.01)

›Refractory hypoxemia

›Progressive respiratory distress

›ARDS (J80)

›Bilateral opacities

›High oxygen requirement

›Cardiac arrest after hypoxia (I46.9)

›PEA

›Asystole

›Mimics and precipitants

›Arrhythmia (I49.9)

›Pre event palpitations

›Exertional syncope

›Seizure (G40.909)

›Witnessed convulsion

›Tongue bite

›Hypoglycemia (E16.2)

›Diabetes

›Low point of care glucose

›Intoxication or overdose (T50.901A)

›Altered mental status disproportionate to hypoxia

›Pinpoint pupils

›Cervical spine injury (S14.109A)

›Diving mechanism

›Focal neurologic deficits

09Past Medical History/pmh15

Relevant conditions and prior care

›Chronic illnesses

›Asthma (J45.909)

›COPD (J44.9)

›Heart failure (I50.9)

›Coronary artery disease (I25.10)

›Seizure disorder (G40.909)

›Prior critical illness

›Prior ICU admission

›Prior intubation history

Procedures and devices

›Implanted devices

›Pacemaker

›ICD

›Prior surgeries

›Cardiac surgery

›Airway surgery

10Physical Exam/exam31

Initial survey and vitals

›General appearance and perfusion

›Work of breathing

›Cyanosis

›Frothy sputum

›Capillary refill

›Signs of shock

›Vital sign interpretation

›SpO2 trend on room air and oxygen

›Temperature and hypothermia staging

›RR trajectory

System exam

›Respiratory exam

›Auscultation findings

›Crackles

›Wheeze

›Decreased air entry

›Accessory muscle use

›Ability to speak

›Neurologic exam

›GCS

›Pupils

›Focal deficits

›Seizure activity

›Cardiovascular exam

›Heart rate regularity

›Murmur

›Peripheral pulses

11Lab Studies/labs27

Core labs and indications

›Initial labs based on severity

›Glucose point of care

›VBG or ABG

›Hypercapnia assessment

›pH and lactate assessment

›Electrolytes

›Sodium

›Potassium

›Bicarbonate

›CBC

›Leukocytosis context

›Hemoglobin for occult bleeding if trauma

›Creatinine

›Baseline renal function for contrast planning

›Cardiac and muscle injury labs when indicated

›Troponin

›If arrest

›If ischemic symptoms

›CK

›If prolonged immersion

›If hypothermia with immobilization

Interpretation pitfalls

›ABG and VBG limitations

›Early ABG may lag clinical course

›Hyperventilation can mask hypercapnia

›Infection markers

›Leukocytosis may reflect stress response

12Imaging/img28

Scoring Systems

›Severity grading frameworks

›Clinical grading for drowning severity

›Use for disposition support

›Local protocol dependent pathways

MRI

›Neuroimaging indications

›Persistent coma with unclear etiology

›Concern for hypoxic ischemic injury timing dependent

›Contraindications and logistics

›Unstable airway or ventilation

›Implanted device compatibility

›CT head indications

›Persistent altered mental status not explained by hypoxia

›Seizure with concern for intracranial pathology

›CT cervical spine indications

›Diving mechanism

›Focal neurologic deficits

›Chest CT considerations

›Alternative diagnosis evaluation

›Pulmonary embolism evaluation when indicated

Ultrasound

›Lung ultrasound

›B lines suggesting interstitial edema

›Pleural effusion assessment

›Cardiac POCUS

›Cardiac activity in arrest

13Special Tests/spec13

Bedside monitoring and diagnostics

›Continuous monitoring

›Continuous pulse oximetry

›Cardiac monitor

›Frequent temperature reassessment

›Capnography

›If ventilated

›During CPR for quality and ROSC indicator

›Core temperature measurement

›Esophageal or bladder probe when intubated

›Rectal probe alternative

Neurologic and seizure evaluation

›EEG consideration

›Unexplained coma after ROSC

›Concern for nonconvulsive status

14ECG/ecg10

Rhythm and hypothermia patterns

›ECG screening

›After submersion with symptoms

›If syncope or arrest

›Hypothermia associated findings

›Bradycardia

›QT prolongation

›J waves

›Ischemia and stress patterns

›ST changes with hypoxia

›Takotsubo pattern consideration

15Assessment/ax22

Working problem list

›Drowning or submersion injury (T75.1)

›Severity based on symptoms

›Oxygen requirement

›Mental status trajectory

›Acute hypoxemic respiratory failure (J96.01)

›SpO2 trend

›Work of breathing

›ABG evidence of respiratory failure if obtained

›Hypothermia (T68) when present

›Core temperature category

›Hemodynamic stability

Complications to rule out

›Aspiration pneumonitis progression

›Cough and tachypnea progression within 8 hours

›New oxygen requirement

›Trauma and cervical spine injury

›Mechanism compatible

›Exam findings compatible

›Precipitating medical cause

›Arrhythmia

›Seizure

›Hypoglycemia

›Intoxication

16Plan/plan46

First 5 minutes workflow

›Immediate priorities

›Airway patency

›Ventilation support

›Oxygenation target SpO2 at least 94 percent

›Cardiac monitoring

›Core temperature measurement

›Oxygen and ventilation escalation

›High flow oxygen

›CPAP for persistent hypoxemia with adequate mental status

›Intubation if unable to protect airway

›GCS less than 8

›Refractory hypoxemia

›Hypercapnia with fatigue

›Cardiac arrest after drowning

›CPR with rescue breaths plus compressions

›Defibrillation per rhythm

›Hypothermia modified resuscitation duration local protocol dependent

Differential Management

›!Drowning→›!Aspiration pneumonia→›Hypothermia→

Therapeutics and supportive care

›Ventilator strategy if intubated

›Lung protective ventilation

›Tidal volume 6 to 8 mL per kg ideal body weight

›Plateau pressure less than 30 mmHg

›PEEP titration for oxygenation

17Disposition/dispo18

Level of care criteria

›ICU criteria

›Need for mechanical ventilation

›Hemodynamic instability

›Cardiac arrest or post ROSC care

›Severe hypothermia with instability

›Inpatient criteria

›Persistent oxygen requirement

›Abnormal mental status

›Significant aspiration with radiographic or clinical progression

›Observation pathway criteria

›Dyspnea or cough with normal SpO2

›Need for serial reassessment up to 8 hours

Discharge criteria

›Safe discharge requirements

›Normal mental status

›SpO2 greater than 95 percent on room air

›No respiratory symptoms after observation period

›Reliable adult supervision

›Clear follow up plan

18Discharge Instructions/di16

Copy discharge instructions

›Patient instructions

›You were evaluated after a drowning or submersion event

›Your exam and oxygen level remained normal during observation

›Return to the emergency department right away for

›Trouble breathing

›Persistent cough

›Chest pain

›Vomiting that does not stop

›Fever

›Confusion

›Fainting

›Avoid swimming or water sports until cleared by a clinician

›Follow up with your primary care clinician within 1 to 2 days

›If this event may have happened due to fainting, seizure, or heart rhythm issues

›Do not drive

›Avoid water activities until further testing is complete

19References/r7

Guidelines and key sources

›Core references

›American Heart Association and American Academy of Pediatrics focused update on resuscitation following drowning 2024

›American Heart Association guidelines for CPR and ECC special circumstances 2025

›Wilderness Medical Society clinical practice guidelines for drowning treatment and prevention 2024

›International Liaison Committee on Resuscitation CoSTR drowning topics 2025

›Heart and Stroke Foundation of Canada resuscitation following drowning guidance 2024

›Project source file

Evidence & Review

Reviewed by SymptomDx Medical Team · Last reviewed February 24, 2026

SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.