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.
- Drowning: respiratory impairment and/or the sensation of respiratory distress caused by submersion or immersion in a liquid 
- Immersion syndrome: the autonomic and respiratory responses caused by sudden immersion in cold water 
- Shallow water blackout: unconsciousness occurring during submersion that is caused by hypoxia after intentional hyperventilation 
- Incidence highest in children < 5 years of age 
- Leading cause of unintentional injury death in children aged 1–4 years 
- Second leading cause of unintentional injury death in children aged 5–14 years after motor vehicle accidents 
- Third leading cause of unintentional injury death worldwide 
- > 3500 drowning deaths in the US each year 
- ♂ > ♀ 
Epidemiological data refers to the US, unless otherwise specified.
- Patient risk factors 
- Situational risk factors 
Clinical presentation depends on the duration of respiratory impairment, the core body temperature, and the effectiveness of initial resuscitation. 
- Gastric distention and/or vomiting
If the patient has been on a dive, examine them for , e.g., and .
Initial diagnostics 
- Laboratory studies
- May show (e.g., bilateral diffuse opacities) 
- Initial CXR may underestimate the degree of pulmonary injury.
- Repeat CXRs are indicated for persistent respiratory symptoms.
Further diagnostics may be obtained to determine the precipitating cause of drowning (e.g., seizures or intoxication) and to rule out complications.
- Toxicology studies: ethanol level, urine toxicology screen
- CT head and/or CT cervical spine: to rule out suspected traumatic injury
- CT chest and/or lung ultrasound: to further evaluate pulmonary injuries
- EEG: to rule out subclinical seizures in obtunded patients 
Postmortem features of drowning 
- Gastrointestinal: Wischnewsky spots (gastric mucosal petechial hemorrhages associated with hypothermia)
- Notify emergency medical services.
- Maintain personal safety during the rescue.
Begin immediate basic life support in unresponsive patients if there is:
- No danger to the rescue team
- Submersion time < 60 minutes
- Implement only if trauma is suspected. 
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. 
- Begin in unresponsive patients. 
- Start continuous cardiac and respiratory monitoring, e.g., SpO2, EtCO2.
- Evaluate for respiratory support. and begin
- Begin with .
- Begin < 32° C. if core body temperature is
- In unresponsive patients, initiate neuroprotective measures (e.g., , normoglycemia) and obtain EEG.
Tympanic membrane temperatures may not be accurate in a patient who has drowned. 
Respiratory support 
- Supportive treatment
Hemodynamic support 
- Cardiac arrest: Manage with standard ACLS. 
- Hemodynamic instability
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. 
- 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. 
- Initiate ACLS in unresponsive patients.
- Start oxygen therapy for all patients with rales and/or respiratory distress.
- Begin advanced airway management and mechanical ventilation for pulmonary edema and/or respiratory failure.
- Begin immediate hemodynamic support.
- Place an orogastric tube in intubated patients.
- Obtain laboratory studies, CXR, and ECG.
- Trauma suspected: Obtain CT of the head and/or cervical spine.
- Persistently unresponsive patients: Initiate neuroprotective measures and obtain EEG.
- 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)