No Lifeguard on Duty: Managing Drowning in the ED

–Case–

It’s a hot summer afternoon when EMS rushes in with an 8-year-old boy who was pulled from a community pool after being underwater for an unknown amount of time. Bystanders report he was initially unresponsive but had spontaneous respirations after CPR was started. Now in the ED, he’s tachypneic, mildly cyanotic, and lethargic. His lungs have scattered rales, and his oxygen saturation is 88% on room air. 

The question now – how bad is the damage, and what’s the next step?

-Evaluation-

Drowning evaluation in the ED largely focuses on the physiologic chaos that follows submersion. The initial insult stems from aspiration, leading to hypoxemia, surfactant dysfunction, and possible acute respiratory distress syndrome (ARDS). Secondary complications include cardiac arrhythmias, metabolic acidosis, and multisystem organ failure if prolonged hypoxia occurs.

Key factors to assess in patients who drowned include the duration of submersion, signs of respiratory distress, cardiac stability, evidence of aspiration injury, and neurologic status. In fact, GCS on arrival is actually the best predictor of outcomes.

Routine labs may show metabolic acidosis, electrolyte disturbances, and evidence of end-organ damage. Imaging, such as a chest X-ray, can reveal pulmonary edema or aspiration pneumonitis but is often normal early on.

-Management-

Drowning resuscitation revolves around reversing hypoxia and preventing secondary complications. First, secure the airway and provide supplemental oxygen. Many patients require non-invasive positive pressure ventilation (NIPPV) or endotracheal intubation if hypoxia persists. Mechanical ventilation may be necessary for ARDS or worsening respiratory distress.

Rewarming is essential in hypothermic patients as hypothermia can exacerbate bradycardia and prolong resuscitation efforts. In addition, cardiopulmonary stabilization with fluids and pressors may be required for patients in shock.

Unlike classic cardiac arrests, drowning patients should receive aggressive oxygenation and ventilation before considering defibrillation or epinephrine. CPR should continue until normothermia is achieved in hypothermic arrests.

-Fast Facts-

• The primary mechanism of injury in drowning is prolonged hypoxia, leading to multisystem failure
• ARDS can develop hours later on! Even patients who initially seem fine can deteriorate, requiring close monitoring
• CPR focus: prioritize oxygenation and ventilation before cardiac interventions in drowning-related arrests
• Even for mild or asymptomatic cases, observation for at least 4-8 hours is crucial as drowning can lead to delayed respiratory failure

Drowning cases can range from minor aspiration events to full-blown resuscitation efforts. In the ED, early recognition of respiratory distress, aggressive oxygenation, and close monitoring make all the difference. When it comes to drowning, survival isn’t just about getting out of the water – that’s only when the real battle starts!

Want to read more about this topic? Click ✨here✨to read our in-depth study guide!

Cheers,

Tamir Zitelny, MD