How to manage a drowning patient?

Drowning is a leading cause of accidental death worldwide. Prompt resuscitation and structured management are critical to survival and minimizing neurological injury. Below is a systematic approach based on ATLS (Advanced Trauma Life Support) principles and RCEM (Royal College of Emergency Medicine) guidelines.

1. Immediate Assessment & Rescue

A. Pre-Hospital Care

- Ensure rescuer safety before attempting rescue (avoid secondary drowning incidents).

- Remove the patient from water ASAP while maintaining cervical spine protection **if trauma is suspected** (e.g., diving injury, fall).

- Begin CPR if pulseless/apneic (do NOT delay for water drainage—this is ineffective).

- RCEM: Start with **5 rescue breaths** (drowning is a hypoxic arrest) followed by standard 30:2 CPR.

- AED: Apply as soon as available (shock if indicated, even in wet patients).

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2. Primary Survey (ABCDE Approach – ATLS)

A: Airway with C-Spine Protection

Assess airway for obstruction (water, vomit, debris).

- Suction if needed.

- Trauma suspicion? Apply in-line C-spine immobilization.

- Intubate early if GCS ≤8 or severe hypoxia (use rapid sequence induction).

B: Breathing

- High-flow oxygen (15L/min via NRB) initially.

Assess for:

- Hypoxia(SpO₂ <90%) → Consider CPAP/BiPAP if awake.

- Pulmonary edema (crackles, frothy sputum) → NIV or intubation if severe.

- Pneumothorax (unilateral absent breath sounds) → Needle decompression if tension suspected.

C: Circulation

- IV/IO access, check BP, HR.

- Wet drowning → Risk of hypovolemia (cold diuresis, fluid shifts).

- Dry drowning→ May present with laryngospasm-induced cardiac arrest.

- Fluid resuscitation if hypotensive (warm crystalloids, avoid overhydration in pulmonary edema).

D: Disability

- GCS, pupil response.

- Hypoxic brain injury is the major cause of death → Targeted Temperature Management (TTM) if comatose post-ROSC.

- Seizures? Treat with benzodiazepines (e.g., lorazepam).

E: Exposure & Environment

- Remove wet clothing, prevent hypothermia.

-Core temperature → If <35°C, follow hypothermia protocols (passive/active rewarming).

3. Secondary Survey & Investigations

A. History (AMPLE)

- A: Allergies

- M: Medications

- P: Past medical history (e.g., epilepsy, cardiac conditions)

- L:Last meal (aspiration risk)

- E: Events leading to drowning (alcohol/drugs, trauma, suicide attempt)

B. Key Investigations

- ABG (hypoxia, acidosis, lactate).

- CXR (pulmonary edema, aspiration, pneumothorax).

- ECG (arrhythmias from hypoxia/hypothermia).

- Bloods (FBC, U&E, lactate, CK if rhabdomyolysis suspected).

- CT Head if altered GCS or suspected trauma.

4. Definitive Management (RCEM Guidelines)

A. Respiratory Support

• Mild-Moderate Hypoxia: HFNC or NIV.

• Severe ARDS:** Intubation, lung-protective ventilation (low tidal volumes, PEEP).

B. Cardiac & Hemodynamic Support

• Ventricular arrhythmias→ Follow ACLS.

• Bradycardia (hypothermia-induced)→ Warm first, then atropine/pacing if persistent.

C. Neurological Protection

• TTM (32-36°C x 24h) if comatose post-ROSC.

• Avoid hyperoxia** (target SpO₂ 94-98%).

D. Antibiotics?

- **Not routinely given** unless aspiration of contaminated water (e.g., sewage).

5. Disposition

• ICU if intubated, severe ARDS, or hemodynamically unstable.

• Observation ward if mild symptoms resolve within 6h.

• Psych referral if suspected self-harm.

Key Takeaways

✔ CPR first, no water drainage.

✔ Early intubation if GCS ≤8 or severe hypoxia

✔ Watch for ARDS, hypothermia, delayed neurological deterioration.

✔ TTM improves outcomes in comatose patients.