Guideline sources The following summarized guidelines for the evaluation and management of near-drowning are prepared by our editorial team based on guidelines from the American Heart Association (AHA 2020), the Wilderness Medical Society (WMS 2019), and the British Thoracic Society (BTS 2017). 1 2 3 Guidelines 1. Diagnostic investigations Chest X-ray: Recognize that initial CXR findings do not correlate with arterial blood gas measurements or outcomes. B Consider obtaining CXRs to track changes in patient condition, but not for determining prognosis if obtained at the time of presentation. B Neuroimaging: https://web.pathway.md/diseases/recAC4zA8pH5uLUCl 1/5 6/30/23, 1:14 AM Near-drowning Pathway Recognize that a normal initial head CT does not have prognostic value in patients after near- drowning. B Do not obtain routine neuroimaging in awake and alert patients after near-drowning unless dictated by a change in clinical status. D Laboratory tests: do not obtain routine CBC or electrolyte testing in patients after near-drowning. D Show 2 more 2. Respiratory support Oxygen supplementation: aim at an oxygen saturation of 94-98% once spontaneous circulation is restored in patients after near-drowning. B Noninvasive positive pressure ventilation: consider initiating noninvasive positive pressure ventilation in alert patients after near-drowning with mild-to-moderate respiratory symptoms. Be cautious when the patient displays altered mental status and/or active emesis owing to the potential for aspiration. C Mechanical ventilation: follow the ARDS protocols for mechanical ventilation in patients after near-drowning. B 3. Medical management Rescue: attempt rescue from a safe location by reaching, throwing, or rowing to the drowning patient if not formally trained in water rescue. B Show 5 more In-water resuscitation: As per AHA 2020 guidelines, consider performing mouth-to-mouth ventilation in the water when administered by a trained rescuer if it does not compromise safety. C As per WMS 2019 guidelines, consider performing in-water resuscitation by a rescuer with adequate training, ability, and equipment to safely and effectively perform the skill in the aquatic environment. B Show 2 more Cardiopulmonary resuscitation: As per AHA 2020 guidelines, initiate CPR by rescuers, including rescue breathing, as soon as an unresponsive submersion victim is removed from the water. B Show 3 more As per WMS 2019 guidelines, establish an airway and provide oxygen in the initial resuscitation. Administer positive pressure ventilation in addition to chest compressions using the traditional Airway-Breathing-Circulation model of resuscitation for the patient in cardiac arrest. B Show 3 more https://web.pathway.md/diseases/recAC4zA8pH5uLUCl 2/5 6/30/23, 1:14 AM Near-drowning Pathway Management of hypothermia: suspect and treat hypothermia in patients after near-drowning. B Management of ventricular fibrillation: ensure that the incorporation of an automated external defibrillator in the initial minutes of drowning resuscitation does not interfere with oxygenation and ventilation because VF is rare in victims of drowning. Use an automated external defibrillator during the resuscitation of a drowning victim if available. Recognize that its use is not contraindicated in a wet environment. A Indications for evacuation: As per AHA 2020 guidelines, transport all victims of drowning requiring any form of resuscitation (including rescue breathing alone) to the hospital for evaluation and monitoring, even if they appear to be alert and demonstrate effective cardiorespiratory function at the scene. B As per WMS 2019 guidelines, evacuate all patients with abnormal lung sounds, severe cough, frothy sputum, foamy material in the airway, depressed mentation, or hypotension immediately to advanced medical care if the risks of evacuation do not outweigh the potential benefits. B Show 3 more Antibiotic therapy: Insufficient evidence to recommend empiric antibiotic therapy in the initial treatment of patients after near-drowning. I Guide treatment in patients with pneumonia after initial resuscitation by expectorated sputum or endotracheal aspirate bacterial culture, blood cultures, or urinary antigen tests. Decide on treatment based on clinical examination focusing on physical evidence of pulmonary or systemic infection (such as fever, increased sputum, abnormal lung auscultation) in the absence of these tests. A Corticosteroids: do not use routine corticosteroids specifically for the treatment of patients after near-drowning. D 4. Therapeutic procedures Cervical spine immobilization: As per AHA 2020 guidelines, do not perform routine stabilization of the cervical spine in the absence of circumstances suggesting a spinal injury. D As per WMS 2019 guidelines, view patients after near-drowning displaying evidence of spine injury (such as a focal neurologic deficit), having a history of high-risk activity, or exhibiting altered mental status (except patients with altered mental status witnessed to have no trauma as an inciting event) as at higher risk for spine injury. Follow the current published guidelines on spinal cord protection for the management of these patients. B Heimlich maneuver: do not perform the Heimlich maneuver for resuscitation of drowning patients owing to the possibility of delaying ventilations. D https://web.pathway.md/diseases/recAC4zA8pH5uLUCl 3/5 6/30/23, 1:14 AM Near-drowning Pathway Therapeutic hypothermia: insufficient evidence to recommend for or against induction or maintenance of therapeutic hypothermia in patients after near-drowning, although current literature recommends targeted temperature management in post-cardiac arrest care. I 5. Specific circumstances Cold water survival: advise to distance oneself from any immediate life threats (such as fire, sinking vehicle, whitewater, hazardous waves, rocks) upon falling into cold water. Remain calm and focused and control breathing by taking slow deep breaths. B Show 4 more 6. Preventative measures Participant education and training: counsel patients with coronary artery disease, prolonged QT syndrome or other ion channel disorder, autism, seizure disorders, or other medical and physical impairments about the increased risk of drowning and about steps to mitigate the risk, such as buddy swimming and rescue devices, should they choose to participate in water activities. B Show 4 more Personal flotation device: advise participants to wear properly fitted lifejackets meeting the local regulatory specifications when boating or engaging in any water sports for which lifejackets are recommended. B Presence of lifeguards: consider ensuring water safety, including contingencies for prevention, rescue, and treatment of drowning persons, during planning and execution of excursions in all groups operating in or near aquatic environments regardless of size. Consider including personnel with technical rescue training and appropriate rescue equipment in high-risk environments or large groups. B 7. Follow-up and surveillance Discharge from hospital: consider discharging patients after near-drowning with normal mental status if the respiratory function is normalized and no further deterioration in respiratory function has been observed after an observation period of 4-6 hours. C Clinical findings Symptoms Past medical history Cough Congenital long QT syndrome Epilepsy Past events Head trauma Traumatic injury Unattended swimming https://web.pathway.md/diseases/recAC4zA8pH5uLUCl 4/5 6/30/23, 1:14 AM Near-drowning Pathway Social history Vital signs Alcohol consumption Bradycardia Attempted suicide Hypotension Lack of swimming skills Signs of shock O2 saturation Vascular exam body temperature Absence of pulse Neurological exam Cardiac exam Altered mental status Cardiac arrest Respiratory exam ECG findings Apnea Crackles J waves VF Imaging findings Pulmonary edema Pulmonary infiltrates References 1. Andrew C Schmidt, Justin R Sempsrott, Seth C Hawkins et al. Wilderness Medical Society Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2019 Update. Wilderness Environ Med. 2019 Dec;30 4S S70 S86. Open 2. Ashish R Panchal, Jason A Bartos, Jos G Caba as et al. Part 3 Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2020 Oct 20;142 16_suppl_2 S366 S468. Open 3. O'Driscoll BR, Howard LS, Earis J et al. BTS guideline for oxygen use in adults in healthcare and emergency settings. Thorax. 2017 Jun;72 Suppl 1):ii1-ii90. Open https://web.pathway.md/diseases/recAC4zA8pH5uLUCl 5/5