Drowning is any degree of respiratory impairment because of immersion or submersion in a liquid.1 It is the third leading cause of unintentional injury death worldwide, and there are an estimated 4,000 fatal unintentional drownings and 8,000 nonfatal drownings annually in the U.S. alone.2 Drowning tends to occur in those aged 1 to 25, with trauma or a toxicologic event often accompanying many of those aged 17 to 25.³ Drowning also occurs at a greater frequency in those aged 55 or more.3 In this latter group a primary cardiac event should be considered as an inciting event.

Cardiac Arrest in Drowning

The progression to cardiac arrest in drowning starts with water entering the upper airway. This may cause laryngospasm and up to 4L of swallowed liquid.⁴ Once the upper airway is overwhelmed, the liquid then enters the lower airways which causes bronchospasm, direct alveolar injury, surfactant washout, foam formation, and hypoxemia.⁵ After approximately 1 minute of submersion, patients typically lose consciousness and become apneic. It is imperative to understand that hypoxemia is the key pathophysiologic mechanism that leads to cardiac arrest, typically pulseless-electrical-activity (PEA) arrest, which occurs typically after 10 minutes of submersion. Thus, management should be directed toward correcting hypoxemia.

The mainstays of correcting hypoxemia in the unstable drowning patient include high fraction of inspired oxygen, positive end-expiratory pressure, mechanical ventilation, and extracorporeal membrane oxygenation.⁶ Patients with severe respiratory distress are at risk of respiratory failure within hours of drowning as surfactant regeneration takes about two days to occur.⁷ Some indications for a definitive airway include impending respiratory failure or apnea, failed non-invasive ventilation, inability to protect the airway, and presence of upper airway foam.³ After the airway has been secured, if hypoxemia persists, the patient should be considered for extracorporeal membrane oxygenation, especially if concomitant severe hypothermia is at play.⁸

Drowning may be secondary to trauma or a toxicologic or cardiac event, and parallel management should also be directed at these whenever present. Hypothermia is not uncommon in drowning victims. It is imperative to identify hypothermia using a rectal temperature and manage it appropriately in tandem with drowning management.

Cervical spine (C-spine) immobilization in trauma patients has been associated with increasing time to definitive care, difficult airways, and increased mortality in patients with penetrating injuries, and also with pressure ulcers.^9,10 Thus, C-spine immobilization of the drowning patient should be limited to those cases with a mechanism of injury concerning for significant C-spine injury. An analysis of 2,000 drowning victims found that only one in 200 suffered C-spine injuries, and all of these patients had both neurologic signs on physical exam and a concerning mechanism of injury.¹¹ 

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.

A special thanks to Dr. Dave Jerome for the EM Cases podcast from which this article was inspired. 

References

Peden M, McGee K, Sharma K. The Injury Chart Book: a Graphical Overview of The Global Burden Of Injuries. Geneva: World Health Organization, 2002.

Center for Disease Control and Prevention. Drowning Facts. CDC website. https://www.cdc.gov/drowning/facts/index.html. Last updated October 2022. Accessed June 11, 2023.

Salomez F, Vincent JL. Drowning: a review of epidemiology, pathophysiology, treatment and prevention. Resuscitation. 2004;63(3):261-8.

European Resuscitation Council. Part 8: advanced challenges in resuscitation. Section 3: special challenges in ECC. 3B: submersion or near-drowning. Resuscitation. 2000;46(1-3):273-7.

Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012;367(4):375-81.

The Joint Commission. Drowning: prevention and treatment. In: Clinical Care Program Standards: Hospital. 6th ed. Oak Brook, IL:Joint Commission Resources;2017;CCP.6.4.

Gregorakos L, Markou N, Psalida V, et al. Near-drowning: clinical course of lung injury in adults. Lung 2009;187:93-97

Kim KI, Lee WY, Kim HS, Jeong JH, Ko HH. Extracorporeal membrane oxygenation in near-drowning patients with cardiac or pulmonary failure. Scand J Trauma Resusc Emerg Med. 2014;22:77.

Ham, W. et al. Pressure ulcers from spinal immobilization in trauma patients: A systematic review. J Trauma Acute Care Surg. 2014;76(4):1131-41.

Haut, ER. Spine immobilization in penetrating trauma: more harm than good? J Trauma. 2010;68(1):115-20.

Jones T, Rennie A. BET 1: cervical spine immobilisation in the management of drowning victims. Emerg Med J. 2019;36(12):766-767.

Choi I, Choi Y, Han S, and Lee J. Successful endotracheal intubation using suction-assisted laryngoscopy assisted decontamination technique and a head-down tilt position during massive regurgitation. Soonchunhyang Medical Science. 2020;26(2):75-79.

Root C, et al. Suction assisted laryngoscopy and airway decontamination (SALAD): A technique for improved emergency airway management. Resuscitation Plus. 2020;1-2:100005.

Foex BA, Boyd R. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary: corticosteroids in the management of near-drowning. Emerg Med J. 2001;18:465-466

Wood C. Towards evidence based emergency medicine: best BETs from the Manchester Royal Infirmary: BET 1: prophylactic antibiotics in near-drowning. Emerg Med J. 2010;27:393-394