DrowningMANAGEMENT

TRAUMA PRESENTATIONS · 12 SECTIONS

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460 items

☷ Legend

01Approach to the Critical Patient/attcp39

Immediate priorities

›Initial stabilization

›Scene safety and extrication considerations

›Cervical spine concern with diving trauma

›Rapid removal of wet clothing

›Airway and breathing priorities

›Hypoxia as primary mechanism

›Rescue breaths priority during resuscitation after drowning

›Circulation priorities

›High quality CPR with ventilations for arrest

›AED and rhythm assessment as soon as feasible

›Temperature priorities

›Wet clothing removal and drying

›Active rewarming if hypothermic

Key decision points

›Triage and escalation triggers

›Cardiac arrest or peri arrest physiology

›Immediate resuscitation bay

›Early airway control planning

›Persistent hypoxemia despite supplemental oxygen

›Noninvasive ventilation considerations

›Early intubation threshold

›Altered mental status

›Aspiration risk

›Hypoxic brain injury risk

›Hypothermia with instability

›Active internal rewarming pathway

›ECMO capable center notification when indicated

Monitoring and targets

›Early monitoring bundle

›Continuous pulse oximetry

›SpO2 target 94 to 98 percent

›Avoid hyperoxia once stabilized

›Cardiac monitoring

›Dysrhythmia risk with hypoxia

›Dysrhythmia risk with hypothermia

›Temperature

›Core temperature

›Rewarming response trend

›Blood pressure

›Shock recognition

›Vasopressor threshold planning

02History/hx38

Event details

›Submersion and rescue timeline

›Duration of submersion estimate

›Witnessed time

›Unwitnessed time last seen well

›Time to first ventilation

›Bystander rescue breaths

›Bag mask ventilation

›Time to ROSC if arrest

›CPR duration

›Defibrillation shocks count

Context and exposures

›Environment and risk context

›Water type

›Freshwater

›Saltwater

›Chlorinated pool

›Water temperature

›Cold water immersion

›Hypothermia likelihood

›Contaminants

›Sewage exposure

›Chemical exposure

›Trauma mechanism

›Diving

›Boating incident

›Surf impact

Predisposing conditions

›Medical contributors

›Seizure disorder

›Witnessed seizure

›Missed anticonvulsants

›Syncope risk

›Exertional collapse

›Cardiac symptoms prodrome

›Intoxication

›Alcohol

›Sedatives

›Pediatric risk factors

›Lack of supervision

›Access to water hazards

03Physical Exam/exam36

Primary survey findings

›Critical exam domains

›Airway patency

›Frothy secretions

›Emesis and aspiration

›Respiratory status

›Work of breathing

›Wheeze

›Crackles

›Perfusion status

›Capillary refill

›Skin temperature

›Peripheral pulses

›Neurologic status

›GCS

›Pupillary reactivity

›Seizure activity

›Core temperature

›Hypothermia staging

›Shivering presence

Focused exam and complications

›Complication screening

›Pulmonary injury features

›Hypoxemia

›Pink froth

›Cyanosis

›Aspiration features

›Vomitus around mouth

›New cough

›Fever later course

›Trauma features

›Head injury signs

›Cervical spine tenderness

›Long bone deformity

›Hypothermia features

›Bradycardia

›J wave pattern possibility

›Reduced responsiveness

04Differential Diagnosis/ddx24

Life threats and mimics

›Critical differentials

›Primary drowning and aspiration

›Noncardiogenic pulmonary edema

›ARDS

›Primary cardiac event with secondary submersion

›Ventricular dysrhythmia

›Long QT syndrome

›Myocardial infarction

›Seizure with secondary submersion

›Status epilepticus

›Postictal hypoventilation

›Hypothermia related collapse

›Hypothermic arrest

›Cold water induced arrhythmia

›Intoxication with airway compromise

›Alcohol related aspiration

›Sedative overdose

Coding and terminology

›Standardized terms

›ICD 10 T75.1 drowning and nonfatal submersion

›ICD 10 W65 to W74 accidental drowning and submersion

›ICD 10 V90 to V92 water transport related drowning and submersion

›SNOMED CT drowning terminology

›Submersion injury

›Near drowning terminology avoidance

05Laboratory Tests/lt42

Core labs

›Initial laboratory bundle

›Blood gas assessment

›pH and PaCO2

›PaO2

›Lactate

›Hypoperfusion marker

›Clearance trend

›Electrolytes

›Sodium mmol per L

›Potassium mmol per L

›Chloride mmol per L

›Glucose mmol per L

›Hypoglycemia exclusion

›Stress hyperglycemia trend

›Creatinine and urea

›Renal injury baseline

›Rhabdomyolysis context with prolonged resuscitation

›Complete blood count

›Leukocytosis interpretation caution

›Hemoconcentration dehydration context

Targeted labs

›Conditional testing

›Troponin

›Suspected primary cardiac event

›Post arrest myocardial injury interpretation

›CK

›Prolonged downtime

›Hypothermia shivering injury

›Coagulation studies

›ECMO planning

›Major trauma concern

›Toxicology screen

›Altered mental status unexplained

›Suspected intoxication

Microbiology and infection approach

›Infection evaluation framework

›Routine prophylactic antibiotics not recommended

›Antibiotics reserved for clinical pulmonary infection

›Blood cultures

›Septic shock physiology

›Persistent fever with infiltrate

›Sputum culture

›Intubated with pneumonia features

›Water type guided empiric coverage considerations

06Diagnostic Tests/dt48

Scoring Systems

›Severity stratification tools

›Szpilman drowning classification

›Grade 1 cough only

›Grade 2 rales some fields

›Grade 3 acute pulmonary edema

›Grade 4 pulmonary edema with hypotension

›Grade 5 respiratory arrest

›Grade 6 cardiopulmonary arrest

›Prognostic indicators

›Submersion time

›Time to effective ventilation

›Initial neurologic status

›Hypothermia ECMO selection

›HOPE score consideration for hypothermic arrest

›Pediatric hypothermic drowning ECMO selection uncertainty

MRI

›Neuroimaging considerations

›Brain MRI for delayed prognostication

›Not for initial stabilization decisions

›Diffusion restriction patterns for hypoxic injury

›Cervical spine MRI

›Persistent neurologic deficit with normal CT

›Ligamentous injury concern

›CT imaging indications

›CT head

›Persistent altered mental status

›Trauma mechanism

›CT cervical spine

›Diving injury concern

›Focal neurologic deficit

›CT chest

›Severe hypoxemia with unclear cause

›Alternative diagnosis concern

›CT abdomen pelvis

›High energy trauma

›Hemodynamic instability with trauma concern

Ultrasound (or US)

›Point of care ultrasound

›Lung ultrasound

›B lines for interstitial edema

›Pleural effusion assessment

›Cardiac ultrasound

›Global function

›Pericardial effusion

›Volume status ultrasound

›IVC assessment limitations

›Fluid responsiveness adjunct only

›FAST exam

›Trauma mechanism

›Hypotension with injury concern

07Disposition/dispo27

Observation versus admission

›Disposition pathways

›Discharge eligible after observation

›Mild or no symptoms after rescue

›Normal oxygenation on room air

›Normal exam and stable vitals through observation window

›ED observation 4 to 8 hours for mild or no symptoms

›Ward admission criteria

›Persistent cough

›Oxygen requirement

›Abnormal chest imaging

›ICU admission criteria

›Mechanical ventilation

›Shock or vasopressor use

›Significant neurologic impairment

›Refractory hypoxemia

Transfer and consultation

›Consultation triggers

›Critical care

›Intubation

›ARDS physiology

›Toxicology

›Suspected ingestion

›Toxidrome present

›Neurology

›Persistent coma

›Seizure recurrence

›ECMO center

›Hypothermic arrest with ongoing CPR and reversible context

08Treatment/t108

Resuscitation and oxygenation

›Oxygenation strategy

›Supplemental oxygen escalation ladder

›Nasal cannula

›Flow titration to SpO2 target

›Nonrebreather mask

›High flow oxygen

›High flow nasal cannula

›FiO2 titration to SpO2 target

›Flow titration for work of breathing

›Noninvasive ventilation

›CPAP for pulmonary edema physiology

›BiPAP for hypercapnia physiology

›Endotracheal intubation

›Refractory hypoxemia

›Inability to protect airway

›Severe work of breathing

Ventilation and airway procedures

›Airway management

›Bag mask ventilation optimization

›Two person technique

›PEEP valve use when available

›RSI medication options

›Etomidate IV 0.3 mg per kg

›Hemodynamic instability preference

›Adrenal suppression consideration

›Ketamine IV 1 to 2 mg per kg

›Bronchospasm benefit

›Hypotension monitoring

›Rocuronium IV 1.2 mg per kg

›Long paralysis duration planning

›Post intubation sedation requirement

›Succinylcholine IV 1 to 1.5 mg per kg

›Hyperkalemia risk screening

›Contraindications review

›Post intubation ventilation

›Lung protective ventilation

›Tidal volume 6 mL per kg predicted body weight

›Plateau pressure target 30 cm H2O or less

›PEEP strategy

›Moderate to high PEEP for alveolar recruitment

›Hemodynamic tolerance monitoring

›ARDS management pathway

›Prone positioning for severe hypoxemia

›Neuromuscular blockade short course if ventilator dyssynchrony

Circulation and shock

›Hemodynamic support

›Crystalloid bolus strategy

›Hypotension with clinical hypovolemia

›Pulmonary edema risk reassessment each bolus

›Vasopressors

›Norepinephrine infusion initiation for persistent hypotension

›Titration to MAP target

›Extravasation monitoring

›Post arrest care

›Targeted temperature management per institutional protocol

›Avoid fever

Bronchospasm and pulmonary care

›Pulmonary adjuncts

›Inhaled beta agonist

›Salbutamol inhaled 4 to 8 puffs via spacer

›Repeat dosing based on response

›Tachycardia monitoring

›Nebulized beta agonist

›Salbutamol 2.5 to 5 mg nebulized

›Repeat every 20 minutes for severe bronchospasm

›Continuous nebulization consideration in ICU

›Steroids

›Routine use not supported for drowning lung injury

›Asthma or COPD exacerbation indication only

Aspiration and antibiotics

›Infection management

›Prophylactic antibiotics avoidance

›No routine antibiotics without clinical infection

›Chemical pneumonitis supportive care focus

›Pneumonia treatment triggers

›Fever

›Leukocytosis with clinical deterioration

›New radiographic infiltrate with symptoms

›Empiric antibiotic selection framework

›Community aspiration pneumonia regimen per local antibiogram

›Water exposure organisms consideration

›Freshwater gram negative risk consideration

›MRSA coverage only with risk factors and severe pneumonia criteria

Hypothermia and rewarming

›Rewarming strategy

›Mild hypothermia

›Passive external rewarming

›Warmed blankets

›Moderate to severe hypothermia

›Active external rewarming

›Forced air warming

›Warmed IV fluids

›Active internal rewarming

›Warmed humidified oxygen

›Lavage options per institutional capability

›Hypothermic arrest pathway

›Prolonged resuscitation consideration

›ECMO consideration in selected hypothermic OHCA

Seizures and agitation

›Neurologic management

›Benzodiazepines for active seizures

›Lorazepam IV 0.1 mg per kg

›Maximum single dose 4 mg

›Repeat once if persistent seizure

›Midazolam IM 0.2 mg per kg

›Maximum single dose 10 mg

›IV access delay use case

›Second line anticonvulsant

›Levetiracetam IV 60 mg per kg

›Maximum 4500 mg

›Renal dosing adjustment consideration

›Sedation for ventilated patients

›Propofol infusion contraindication screening

›Analgesia first strategy with fentanyl

09Special Populations/sp33

Pregnancy

›Pregnancy considerations

›Maternal physiology priorities

›Maternal oxygenation as fetal oxygenation determinant

›Left lateral uterine displacement in late pregnancy during resuscitation

›Medication considerations

›RSI medication selection risk benefit framing

›Vasopressor choice favoring maternal perfusion

›Fetal considerations

›Viability gestational age threshold awareness

›Obstetric consultation for fetal monitoring when stabilized

Geriatric

›Older adult considerations

›Comorbidity burden

›Heart failure pulmonary edema overlap

›COPD baseline hypoxemia confounder

›Medication sensitivity

›Sedative hypotension risk

›Reduced renal clearance

›Prognosis modifiers

›Frailty

›Baseline cognitive impairment

Pediatrics

›Pediatric considerations

›High risk environments

›Unsupervised bathtub

›Pool access

›Airway and ventilation

›Early ventilation emphasis in drowning arrest

›Weight based dosing verification

›Aspiration risk management

›Recovery position for spontaneously breathing child

›Vomiting frequency awareness

›Observation and discharge caution

›Caregiver reliability

›Safety counseling emphasis

10Background/b33

Epidemiology

›Population impact

›Global burden

›Leading cause of injury death in children in many regions

›Seasonal and recreational clustering

›Risk patterns

›Male predominance

›Alcohol association in adolescents and adults

›Outcome drivers

›Submersion duration as major determinant

›Time to ventilation as major determinant

Pathophysiology

›Mechanisms

›Primary insult hypoxemia

›Laryngospasm and airway obstruction

›Aspiration of water and secretions

›Lung injury cascade

›Surfactant dysfunction

›Atelectasis

›Ventilation perfusion mismatch

›Noncardiogenic pulmonary edema

›System effects

›Metabolic acidosis from hypoxia

›Dysrhythmias from hypoxia and hypothermia

›Cerebral hypoxic ischemic injury

Therapeutic Considerations

›Evidence informed principles

›Ventilation importance in drowning arrest

›CPR with rescue breaths recommended after drowning arrest

›Ventilation as priority in AHA focused update

›Antibiotic stewardship

›No routine prophylaxis without infection

›Water type influences pathogens when pneumonia occurs

›Observation window rationale

›Delayed pulmonary edema possibility

›ED observation 4 to 8 hours for mild presentations

11Patient Discharge Instructions/pdi23

copy discharge instructions

›Discharge instructions for post drowning evaluation

›Home care

›Rest and avoid strenuous activity for 24 hours

›No swimming or bathing alone until cleared

›Return immediately for any of the following

›Trouble breathing

›Fast breathing

›Chest pain

›Blue lips or face

›Repeated vomiting

›Fever

›Worsening cough

›New confusion

›Severe sleepiness

›Seizure

›Follow up

›Primary care follow up within 24 to 48 hours

›Earlier follow up if any new symptoms

›Prevention counseling

›Close supervision around any water

›Pool fencing and alarms

›Life jacket use in open water

›Avoid alcohol with swimming or boating

12References/r9

Clinical guidelines and evidence

›Core sources

›AHA 2024 drowning focused update highlights

›AHA 2024 guideline update article

›Red Cross drowning resuscitation evidence summary

›StatPearls drowning clinical management observation guidance

›RCH pediatric drowning guideline principles

›Hypothermic drowning ECMO recommendation discussion

›Antibiotic use reserved for clinical infection summary

›Project specification source

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Reviewed by SymptomDx Medical Team · Last reviewed June 16, 2026

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