Definition & mechanism (Drowning = respiratory impairment from submersion/immersion in liquid — hypoxia is primary insult; cardiac arrest is usually hypoxic (AHA PALS 2020, ERC 2021, WHO 2022, AAP))
Initial assessment (ABCDE) (Consciousness, breathing, circulation; cervical spine **only** if trauma mechanism (diving, boating, fall) — routine immobilization not needed for simple pool/bath submersion (AHA, ERC, AAP))
Max 1 mg/dose · Duration: PRN · 0.01 mg/kg (10 mcg/kg) IV/IO q3–5 min during CPR — after hypoxia addressed; 1:10 000 (0.1 mg/mL) solution; max 1 mg/dose (AHA PALS 2020, ERC 2021)
• **Prehospital:** rescue only when safe; remove from water; start CPR if apneic or pulseless; **5 initial rescue breaths** before compressions in hypoxic drowning arrest (AHA PALS 2020, ERC 2021).
• **Ventilation priority:** pediatric drowning arrest is typically hypoxic — adequate breaths are critical; if pulse returns but apneic, rescue breathing 1 breath q3–5 s (AHA, ERC).
• **Do NOT:** abdominal thrusts (Heimlich), postural drainage, or attempts to 'drain' water from lungs — ineffective and may cause vomiting/aspiration (AHA, ERC, WHO, AAP).
• **Concurrent care:** high-flow O₂ when available; remove wet clothing; passive external warming; rapid transport if symptomatic or required resuscitation (ERC, WHO).
• **History to obtain:** duration of submersion, water type (fresh/salt/chlorinated — does not change initial management), resuscitation at scene, hypothermia, co-ingestions, diving/trauma mechanism (AAP, WHO).
Max 500 mg/dose · Duration: Continuous · 6–8 mL/kg IBW tidal volume — lung-protective ventilation; adjust rate for age-appropriate PaCO₂/pEtCO₂; PEEP per oxygenation (AHA, pediatric ARDS principles)
• **Intubation indications:** SpO₂ <94% despite supplemental O₂, GCS ↓, apnea, severe respiratory distress, inability to protect airway, or need for escalating positive pressure (AHA, ERC, AAP).
• **Mechanical ventilation:** tidal volume **6–8 mL/kg** ideal body weight; PEEP 5–10 cmH₂O initially — higher PEEP often required for drowning-related ARDS; lung-protective strategy (AHA PALS, ERC, pediatric critical care consensus).
• **CPAP/BiPAP:** may bridge stable patients with respiratory failure who do not yet need intubation — continuous SpO₂ and mental status monitoring (AAP, ERC).
• **Bronchodilators:** salbutamol if bronchospasm/wheeze — suction **only** for visible secretions or obstruction; routine aggressive suction not recommended (AAP, ERC).
• **Hypothermia:** check core temperature; passive + active rewarming per hypothermia protocols; **continue resuscitation** in severe hypothermia — 'not dead until warm and dead' (ERC hypothermia guidelines, AHA); see hypothermia card for rewarming tiers.
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Clinical notes
• ABCDE on arrival: drowning = respiratory impairment from liquid submersion/immersion; assess consciousness, breathing, circulation; c-spine only if trauma mechanism (AHA, ERC, AAP).
• Prehospital: 5 rescue breaths before compressions in hypoxic arrest; O₂, warming, remove wet clothing; no abdominal thrusts or water drainage; rapid transport (AHA PALS, ERC, WHO).
• Hypothermia: continue CPR during rewarming in severe hypothermia — outcomes improve with prolonged resuscitation; active rewarming when core temp available (ERC 2021, AHA).
• PICU admission: intubation/mechanical ventilation, hemodynamic instability, severe hypoxemia despite O₂, severe CNS injury, status epilepticus, severe hypothermia with complications (AAP, WHO).
• CXR: obtain if persistent respiratory symptoms, abnormal auscultation, or O₂ requirement — not routine in asymptomatic patients (AAP, WHO).
• AHA — Pediatric Advanced Life Support (drowning / hypoxic arrest) (2020)
• ERC — European Resuscitation Council Guidelines (paediatric drowning) (2021)
• AAP — Drowning and submersion injury clinical principles (2024)
+ 2 more
• WHO — Pocket Book of Hospital Care for Children (drowning management) (2022)
• ILCOR — Consensus on drowning resuscitation (2020)
