Last updated: September 22, 2023

Summarytoggle arrow icon

Drowning is respiratory impairment and/or the sensation of respiratory distress caused by submersion or immersion in a liquid. It is a leading cause of death in children. Risk factors for drowning include age below 14 years, male sex, alcohol use, risky behavior, and seizure disorder. Clinical features of drowning vary based on the duration of respiratory impairment, the core body temperature, and the effectiveness of initial resuscitation, but may include respiratory distress, neurologic compromise, cardiac instability, and/or hypothermia. Prehospital management begins with the removal of the patient from the water and the initiation of basic life support, if necessary. Further management in the emergency department may include advanced cardiac life support (ACLS), oxygen therapy, advanced airway management, mechanical ventilation, and efforts to treat hypothermia. Complications of drowning include acute lung injury, pulmonary edema, cardiac arrhythmia, and anoxic-ischemic brain injury.

Definitiontoggle arrow icon

  • Drowning: respiratory impairment and/or the sensation of respiratory distress caused by submersion or immersion in a liquid [1][2]
  • Immersion syndrome: the autonomic and respiratory responses caused by sudden immersion in cold water [3]
  • Shallow water blackout: unconsciousness occurring during submersion that is caused by hypoxia after intentional hyperventilation [4]

Epidemiologytoggle arrow icon

Epidemiological data refers to the US, unless otherwise specified.

Etiologytoggle arrow icon

Pathophysiologytoggle arrow icon

Submersion → panic → breath holding → respiratory drive overcomes breath holding → aspiration of liquid or laryngospasmhypoxemia → organ hypoxia (especially cerebral and cardiac) → possible injury or death [12]

Clinical featurestoggle arrow icon

Clinical presentation depends on the duration of respiratory impairment, the core body temperature, and the effectiveness of initial resuscitation. [9][12][13]

If the patient has been on a dive, examine them for diving-related injuries, e.g., barotrauma and air embolism.

Diagnosticstoggle arrow icon

Initial diagnostics [1][9][13]

Additional diagnostics

Further diagnostics may be obtained to determine the precipitating cause of drowning (e.g., seizures or intoxication) and to rule out complications.

Obtain an EEG in patients who remain unresponsive after drowning to assess for subclinical seizure activity. [13]

Pathologytoggle arrow icon

Postmortem features of drowning [15]

  • Pulmonary
  • Gastrointestinal: Wischnewsky spots (gastric mucosal petechial hemorrhages associated with hypothermia)
  • External
    • White or pink foam cone over the nostrils and/or mouth
    • Pallor and wrinkling of the palms, soles, fingers, and toes
    • Prone body position: back upwards, head and extremities dangling downwards
    • Travel abrasions and lacerations on the forehead, backs of the hands, knees, and dorsum of the feet

Prehospital caretoggle arrow icon

Rescuers should not put their lives at risk to save a drowning person.

Begin basic life support with an emphasis on ventilation immediately after rescue to optimize the chance of successful resuscitation. [9]

Use cervical spine precautions only if trauma is suspected to avoid unnecessary delays in airway management. [1][16]

Treatmenttoggle arrow icon

Approach [1][9][13]

Tympanic membrane temperatures may not be accurate in a patient who has drowned. [13]

Respiratory support [1][9][17]

Aspiration of fluid into the lung results in surfactant destruction and washout, which can cause acute respiratory distress syndrome (ARDS).

Hemodynamic support [9]

Initiate rewarming and do not withhold life-saving treatment from hypothermic patients who appear clinically dead (e.g., dilated pupils, areflexia, rigidity) without signs of irreversible death. [16][18]

Disposition [9][13][19]

  • ICU admission: all patients requiring ongoing respiratory or hemodynamic support
  • Hospital admission: all symptomatic patients
  • Discharge: Consider for asymptomatic individuals with normal mental status and respiratory function after observation for at least 4–6 hours. [1]

Acute management checklisttoggle arrow icon

Complicationstoggle arrow icon

We list the most important complications. The selection is not exhaustive.

Prognosistoggle arrow icon

Factors associated with a poor outcome include: [13]

Preventiontoggle arrow icon

  • Swimming education
  • Safety equipment (e.g., life jackets)
  • Water rescue training
  • Water safety signs posted at potential sites of drowning
  • Rescue equipment and personnel (e.g., lifeguards) at recreational swimming locations (e.g., pools, beaches)
  • Avoidance of alcohol and drug consumption before swimming
  • Installing barriers around potential water hazards (e.g., pools, wells, waterfronts)
  • Close supervision of children around water (e.g., during bathing as well as swimming)

Referencestoggle arrow icon

  1. Drowning. Updated: April 27, 2021. Accessed: October 20, 2021.
  2. Schmidt AC, Sempsrott JR, Hawkins SC, Arastu AS, Cushing TA, Auerbach PS. Wilderness Medical Society Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2019 Update. Wilderness Environ Med. 2019; 30 (4): p.S70-S86.doi: 10.1016/j.wem.2019.06.007 . | Open in Read by QxMD
  3. Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020; 142 (16_suppl_2).doi: 10.1161/cir.0000000000000916 . | Open in Read by QxMD
  4. Szpilman D, Morgan PJ. Management for the Drowning Patient. Chest. 2021; 159 (4): p.1473-1483.doi: 10.1016/j.chest.2020.10.007 . | Open in Read by QxMD
  5. Peden AE, Taylor DH, Franklin RC. Pre-Existing Medical Conditions: A Systematic Literature Review of a Silent Contributor to Adult Drowning. Int J Environ Res Public Health. 2022; 19 (14): p.8863.doi: 10.3390/ijerph19148863 . | Open in Read by QxMD
  6. Willcox-Pidgeon SM, Franklin RC, Leggat PA, Devine S. Identifying a gap in drowning prevention: high-risk populations. Inj Prev. 2020; 26 (3): p.279-288.doi: 10.1136/injuryprev-2019-043432 . | Open in Read by QxMD
  7. Bierens JJLM, Lunetta P, Tipton M, Warner DS. Physiology Of Drowning: A Review. Physiology. 2016; 31 (2): p.147-166.doi: 10.1152/physiol.00002.2015 . | Open in Read by QxMD
  8. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022
  9. Gregorakos L, Markou N, Psalida V, et al. Near-Drowning: Clinical Course of Lung Injury in Adults. Lung. 2009; 187 (2): p.93-97.doi: 10.1007/s00408-008-9132-4 . | Open in Read by QxMD
  10. Denny SA, Quan L, Gilchrist J, et al. Prevention of Drowning. Pediatrics. 2021; 148 (2).doi: 10.1542/peds.2021-052227 . | Open in Read by QxMD
  11. Liu L, Villavicencio F, Yeung D, et al. National, regional, and global causes of mortality in 5–19-year-olds from 2000 to 2019: a systematic analysis. Lancet Glob Health. 2022; 10 (3): p.e337-e347.doi: 10.1016/s2214-109x(21)00566-0 . | Open in Read by QxMD
  12. Işın A, Peden AE. Assessing variations in estimates of drowning mortality in Turkey from 2013 to 2019. Arch Public Health. 2022; 80 (1).doi: 10.1186/s13690-022-00944-w . | Open in Read by QxMD
  13. Howland J, Hingson R, Mangione TW, Bell N, Bak S. Why are most drowning victims men? Sex differences in aquatic skills and behaviors. Am J Public Health. 1996; 86 (1): p.93-6.doi: 10.2105/ajph.86.1.93 . | Open in Read by QxMD
  14. Szpilman D, Bierens JJLM, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012; 366 (22): p.2102-2110.doi: 10.1056/nejmra1013317 . | Open in Read by QxMD
  15. Dow J, Giesbrecht GG, Danzl DF, et al.. Wilderness Medical Society Clinical Practice Guidelines for the Out-of-Hospital Evaluation and Treatment of Accidental Hypothermia: 2019 Update. Wilderness Environ Med. 2019; 30 (4): p.S47-S69.doi: 10.1016/j.wem.2019.10.002 . | Open in Read by QxMD
  16. Michael Parenteau, Zsolt Stockinger, Stephen Hughes, Brad Hickey, James Mucciarone, Christopher Manganello, Andrew Beeghly. Drowning Management. Military Medicine. 2018; 183 (suppl_2): p.172-179.doi: 10.1093/milmed/usy136 . | Open in Read by QxMD
  17. van Beeck EF, Branche CM, Szpilman D, Modell JH, Bierens JJ. A new definition of drowning: towards documentation and prevention of a global public health problem. Bull World Health Organ. 2005; 83 (11): p.853-6.
  18. Farstad DJ, Dunn JA. Cold Water Immersion Syndrome and Whitewater Recreation Fatalities. Wilderness Environ Med. 2019; 30 (3): p.321-327.doi: 10.1016/j.wem.2019.03.005 . | Open in Read by QxMD
  19. Szpilman D, Orlowski JP. Sports related to drowning. Eur Respir Rev. 2016; 25 (141): p.348-359.doi: 10.1183/16000617.0038-2016 . | Open in Read by QxMD
  20. Armstrong EJ, Erskine KL. Investigation of Drowning Deaths: A Practical Review. Academic Forensic Pathology. 2018; 8 (1): p.8-43.doi: 10.23907/2018.002 . | Open in Read by QxMD

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