Browse categories and answer follow-up questions to refine your symptom profile.
History
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
Arrhythmia symptoms before event
Symptoms and baseline
Associated symptoms
Dyspnea
Cough
Chest tightness
Wheeze
Fever
Headache
Confusion
Seizure
Functional baseline
Baseline neurologic status
Baseline cardiopulmonary disease burden
Prior episodes
Prior drowning or submersion event
Prior unexplained syncope near water
Alarm Features
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
Medications
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
Diet
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
Review of Systems
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
Collateral History and Family History
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
Risk Factors
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
Differential Diagnosis
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
Common
Aspiration pneumonitis
Cough after event
New oxygen requirement
Bronchospasm
Wheeze
History of asthma
Mild hypothermia (T68)
Shivering
Cold exposure history
Less common
Takotsubo cardiomyopathy
Stress trigger
ECG changes without clear ACS
Myocardial infarction (I21.9)
Typical chest pain
Rising troponin pattern
Pulmonary embolism (I26.99)
Risk factors for thrombosis
Disproportionate tachycardia
Toxic inhalation or chemical exposure
Pool chemical exposure
Industrial water exposure
Past Medical History
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
Physical Exam
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
Trauma screen
Head and face trauma
Cervical spine tenderness
Chest wall injury
Abdominal tenderness
Lab Studies
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
Fever early may be aspiration inflammation
Imaging
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
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
Gross ventricular function
IVC assessment
Volume status trend
Shock physiology support
Special Tests
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
ECG
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
Assessment
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
Plan
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
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
Gastric decompression when ventilated
Orogastric tube
Reduce aspiration risk from distension
Bronchospasm management when present
Inhaled beta agonist
Consider inhaled anticholinergic
Antibiotics
Not routine
Consider if heavily contaminated water exposure
Steroids and surfactant
No routine role
Avoid unless alternate clear indication
Reassessment loop
Scheduled reassessment
Respiratory status every 15 to 30 minutes until stable
SpO2 on room air trial when improving
Temperature trend during rewarming
Escalation triggers during observation
New cough or dyspnea
Rising oxygen requirement
New abnormal lung exam
Altered mental status
Disposition
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
Discharge Instructions
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
References
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
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.