Submersion injury

(Redirected from Drowning)


  • Definition: "The process of experiencing respiratory impairment from submersion/immersion in liquid"[1]
    • Term "near-drowning" no longer used

Consider Secondary Causes

Drowning Outcomes by Duration[2]

Duration of submersion Risk of death or poor outcome
0–5 min 10%
6–10 min 56%
11–25 min 88%
>25 min nearly 100%

^Signs of brain-stem injury predict death or severe neurological consequences


  • Submersion → voluntary breath holding → aspiration → coughing/laryngospasm → aspiration continues → hypoxia → death[3]
  • Aspiration destroys surfactant which → alveolar collapse, atelectasis, non-cardiogenic pulmonary edema, and V-Q mismatch.
  • Fresh vs salt water has no clinical relevance[4]

Clinical Features

Differential Diagnosis

Water-related injuries



  • CXR (on arrival and after 4 hours)
  • ABG - lactic acidosis
  • Serum sodium does not correlate to fresh water vs. salt water drowning
  • Other work-up generally not needed unless specifically indicated by history or exam[3], but may consider:
    • Labs, EKG
    • CT head/C-spine (if history of trauma) - C-spine injury extremely unlikely without evidence or history of trauma (<0.5% in large cohort study)[13]


  • Typically a clinical diagnosis


Grade Presentation Recommended Treatment Survival
0 Responds normally, lungs clear to auscultation, no cough Do not transport 100%
1 Responds normally, lungs clear to auscultation, has a cough Discharge 100%
2 Responds normally, rales in some lung fields, has a cough Nasal cannula, observe in ED 99.4%
3 Responds normally, rales in all lung fields, has a cough, normotension Non-rebreather, progress to positive pressure or intubation if needed, admit 94.8%
4 Responds normally, rales in all lung fields, has a cough, hypotension Non-rebreather with likely progression to positive pressure or intubation, IV fluids and pressors as needed, admit to ICU ~80%%
5 Unresponsive but has a pulse Positive pressure ventilation with likely progression to intubation, IV fluids and vasopressors if needed, admit to ICU ~60%
6 Unresponsive with no pulse after 5 rescue breaths ACLS protocol 7%



  • Immediate resuscitation if indicated [15]
  • Assess need for CPR but do not delay removal from water
  • Ventilation is a higher priority in drowning victims in cardiac arrest than in other situations requiring CPR
  • Deliver two rescue breaths immediately upon reaching shallow water or a stable surface; early breaths have been associated with improved survival [16]
  • If no response to rescue breaths with chest rise, continue to standard CPR algorithm
  • Administer high flow O2 and intubate apneic patients
  • Do not routinely immobilize c-spine without suspicion based on mechanism or clinical signs [17]

Emergency Department

  • Supportive care based on presentation is cornerstone of management[18]
  • Consider CPAP if inadequate tidal volume with high flow O2
  • OG tube for gastric distension
  • Indications for intubation:
    • Comatose or unable to protect airway
    • Hypoxemia or hypercapnia on ABG despite high flow O2 (PaO2 below 60, PaCO2 above 50)
  • Continue resuscitation efforts in hypothermic patients until core temperature rises to at least 30 C (not dead until warm and dead) [19]
  • Routine antibiotics in ED are not necessary, but broad spectrum coverage may be indicated for submersion in heavily contaminated water


  • Discharge after 4-6 hours of observation if:
    • Normal mental status, SpO2 >95% on room air, normal CXR and respiratory exam
  • Admit all others

See Also




  1. World Health Organization (WHO) "Global Report on Drowning". (Accessed 02/01/2017)
  2. Szpilman, David; Bierens, Joost J.L.M.; Handley, Anthony J.; Orlowski, James P. (4 October 2012). "Drowning". The New England Journal of Medicine. 366 (22): 2102–2110. doi:10.1056/NEJMra1013317. PMID 22646632.
  3. 3.0 3.1 Szpilman, D., Bierens, J. J., Handley, A. J., & Orlowski, J. P. (2012). Drowning. N Engl J Med, 366(22), 2102-2110. doi: 10.1056/NEJMra1013317
  4. Orlowski JP, Szpilman D. Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am. 2001;48(3):627-646. doi:10.1016/s0031-3955(05)70331-x
  5. Olshaker JS. Near drowning. Emerg Med Clin North Am. 1992;10(2):339
  6. Bierens et al. Drowning. Curr Opin Crit Care. 2002;8(6):578
  7. DeNicola et al. Submersion injuries in children and adults. Crit Care Clin 1997; 13: pp. 477
  8. Layon et al. Drowning: Update 2009. Anesthesiology 2009; 110: pp. 1390
  9. McGillicuddy. Cerebral protection: pathophysiology and treatment of increased intracranial pressure. Chest. 1985;87(1):85
  10. Rivers et al. Drowning. Its clinical sequelae and management. Br Med J. 1970;2(5702):157
  11. Yagyl et al. Near drowning in the dead sea. Electrolyte imbalances and therapeutic implications. Arch Intern Med. 1985;145(1):50
  12. Collis ML: Survival behaviour in cold water immersion. In (eds): Proceedings of the Cold Water Symposium. Toronto, Canada: Royal Life-Saving Society of Canada, 1976
  13. Watson RS, Cummings P, Quan L, et al. Cervical Spine Injuries Among Submersion victims. J Trauma 2001; 51:658.
  14. Szpilman D. Near-drowning and drowning classification:a proposal to stratify mortality based on the analysis of 1,831 cases. Chest 112(3):660-665, 1997.
  15. Schmidt AC, et al. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning. Wilderness Environ Med. 2016 Jun;27(2):236-51
  16. Szpilman D, et al. In-water resuscitation: Is it worthwhile? Resuscitation 2004; 63: pp. 25
  17. Vanden Hoek TL et al. Part 12: cardiac arrest in special situations: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(18 Suppl 3):S829
  18. Layon AJ et al. Drowning: Update 2009. Anesthesiology. 2009;110(6):1390
  19. American Heart Association; ILCOR : Submersion or near-drowning. Circulation 2000; 102: pp. I-233