Drowning is a complicated clinical scenario for paramedics and EMRs/FRs.  It may involve mild symptoms to situations requiring prolonged resuscitation.  Complications of submersion incidents can include atelectasis, pulmonary edema, infection, hypothermia, and trauma.  In British Columbia, there are over 50 drowning fatalities every year and an additional 40 near drowning cases requiring hospitalization.  At least 20% of survivors experience permanent brain injury as a result of hypoxia, making early and appropriate out-of-hospital management important in promoting favourable outcomes.

• Caution: Ensure paramedic and EMR/FR safety at all times around water.  Wear lifejackets in accordance with High Risk Hazards policies and procedures.
• Cervical spine injury is uncommon in submersion incidents, but paramedics and EMRs/FRs should be alert to the possibility of damage based upon the mechanism of injury.
• All patients, including those with apparently minor injuries or symptoms, should be conveyed for observation due to the risk of developing secondary hypoxemia over subsequent hours.
• The early use of CPAP and/or PEEP can be beneficial for patients with hypoxemia and respiratory distress.
• Paramedics and EMRs/FRs must ensure adequate oxygenation, and prevent both heat loss and aspiration.

• Hypothermia should be managed in accordance with → I01: Hypothermia.
• Be suspicious for traumatic injuries based on the history of events leading up to submersion.  Apply spinal motion restriction as appropriate.
• Manage cardiac arrest in accordance with resuscitation CPGs, with particular focus on oxygenation and airway management.
• Consider medical causes of cardiac arrest in patients where the mechanism of submersion does not appear to match the clinical presentation or severity of symptoms.
• There is no difference in the management of patients submerged in fresh water versus salt water.
• Cardiac arrest considerations:
  • Although survival is uncommon in victims who have undergone prolonged submersion requiring protracted resuscitation, successful resuscitation (with full neurological recovery) has occasionally occurred after prolonged immersion in icy water (and in some instances warm water).  For this reason, scene resuscitation should be initiated and patients conveyed to the emergency department unless there are obvious signs of death.
  • Patients who have been submerged in water for a prolonged time should be evaluated for applicability of the rapid discontinuation criteria. 

• CliniCall should be involved for guidance in managing prolonged or special resuscitation situations (e.g., hypothermic submersion). See EMR interventions below.
• Contact CliniCall for assistance in managing patients refusing conveyance with minor symptoms and who are at risk for developing lung injury. See EMR interventions below.

• Water in the lungs results in alveolar collapse (atelectasis) which leads to a ventilation perfusion mismatch and impaired gas exchange.  Lung injury may take up to six hours to develop following a submersion incident.
• Monitor patients for non-specific symptoms such as productive cough, tachypnea, or mild crackles on auscultation.  These can be warning signs of deterioration.
• It is important to differentiate 'immersion' from 'submersion': a submersion involves the whole body, including the airway, being submerged in water.  Immersion does not necessarily imply submersion. 
• Hypothermia can be present in both situations and it can be difficult to differentiate whether cardiac arrest is due to primary immersion (e.g., hypothermia) or submersion (hypoxemia).
• Swimming Induced Pulmonary Edema (SIPE) is a phenomenon seen in individuals undertaking strenuous surface swimming in cold water (e.g., triathletes or rescue personnel).  Symptoms include dyspnea, hypoxemia and possible hemoptysis with a presentation similar to cardiogenic pulmonary edema.  Treatment consists of oxygen administration, CPAP, and advanced airway management/mechanical ventilation as needed to correct hypoxemia.

Drowning