A key clinical pitfall in the management of the drowning patient is to suction the foam that comes up from the lungs into the oral cavity during resuscitation. This is often intuitive for the emergency physician as we typically suction blood, emesis, or anything else that could potentially hinder oxygen exchange. Foam in drowning is a result of lung surfactant mixed with water that bubbles up like soap and water. It is non-toxic and contains lung surfactant that patients’ lungs need. As such it should not be suctioned, as such attempts will delay definitive airway management. Rather, positive pressure ventilation should be used to push the foam back down into the lungs. Foam in the upper airway is an indication for endotracheal intubation.

The SALAD Technique

As soiling the airway with emesis is common in drowning, the resuscitation team should be prepared to perform suction assisted laryngoscopy airway decontamination (SALAD).^12,13 This technique is used to prevent airway soiling during laryngoscopy as a result of aspirated emesis. SALAD involves using a rigid suction catheter as a sort of tongue depressor to allow the laryngoscope blade to be placed in the ideal position (see more about this technique on page 18). The suction catheter is then used to decontaminate the proximal esophagus and stays pinned in the left corner of the patient’s oral cavity. Antiemetics, which may prevent soiling of the airway from emesis, are reasonable to administer during the resuscitation of the drowning patient.

Dysrhythmias typically progress from sinus tachycardia to bradycardia to PEA arrest. Thus, if bradycardia is present, the resuscitation team should anticipate and be prepared for cardiac arrest. In the event of cardiac arrest, consider tailoring the usual adult algorithms, as the arrest is most likely a respiratory one, as opposed to a primary cardiac event.4 It is therefore reasonable to administer five rescue breaths before chest compressions are started.4

Therapies that have traditionally been used but have subsequently shown to carry no benefit include steroids and empiric antibiotics.14 Studies of empiric antibiotic use in drowning victims demonstrated increased antibiotic resistance and no improvement in rates of pneumonia.15 

Next time you are faced with a drowning victim, consider and co-manage secondary causes, understand that it is primarily a hypoxic event with treatments directed at ventilation and oxygenation, anticipate PEA arrest with consideration of breaths before chest compressions in the event of an arrest, and manage oral foam with positive pressure ventilation instead of suctioning.