Question 21

You are called to the Emergency Department to review a 56-year-old female found floating in the surf. Her initial rhythm was asystole, although return of spontaneous circulation was achieved within 5 minutes of ambulance arrival. She is currently intubated with a correctly positioned endotracheal tube, is being ventilated adequately with 100% oxygen, and has an unsupported blood pressure of 130/65 mmHg.

What are the management issues that must be considered in her further care? For each issue briefly outline any specific interventions or treatments required.

(Note to candidates: general details of resuscitation such as providing standard monitoring or obtaining vascular access are not required.)

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College answer

Not available.


Emergency management issues

  • Investigation of possible aspiration with CXR and ABG; ventilation with high FiOand high PEEP, 12-15
  • Correction of hypovolemia: drowning victims may become hypovolemic following prolonged immersion due to the hydrostatic effects of water (particularly salt water)
  • Investigate causes of drowning related to:
    • Intracranial events, eg. ICH, head injury or C-spine trauma resulting from a fall into submerged obstacles (thus, get a CT trauma pan-scan)
    • Extracranial causes, eg intoxication or overdose (urine drug screen, blood alcohol level)
    • Marine animal envenomation (examination of the patient, like a secondary survey)
  • Assessment of temperature, and rewarming (the immersed patient is invariably hypothermic, as it is rare to drown in a body of water with an ambient temperature higher than human core body temperature).

ICU management issues

  • Airway clearance: bronchoscopy and suction as indicated by copious aspirated material. 
  • Ventilation may grow more difficult due to washout of surfactant, aspiration of sea water causing pneumonitis, or aspiration during resuscitation
  • Electrolytes are likely to be deranged if substantial quantities of sea water were ingested. Specifically, sodium magnesium and potassium are likely to be elevated, as they are well absorbed from the lungs and the GI tract by largely uncontrolled paracellular mechanisms.
  • Post-cardiac arrest management including the pursuit of normothermia and normoglycaemia, as well as the management of the family's expectations (considering the unknown period of downtime and the unfavourable initial rhythm)


The ARC ALS2 manual (2011) has a section on drowning (pp. 127). This was my main source of information.

Pearn, John. "The management of near drowning." British medical journal (Clinical research ed.) 291.6507 (1985): 1447.

Giammona, Samuel T., and Jerome H. Modell. "Drowning by total immersion: effects on pulmonary surfactant of distilled water, isotonic saline, and sea water." American Journal of Diseases of Children 114.6 (1967): 612-616.

Modell, Jerome H., et al. "Physiologic effects of near drowning with chlorinated fresh water, distilled water and isotonic saline." Anesthesiology 27.1 (1966): 33-41.

Young, Richard SK, Edwin L. Zalneraitis, and Elizabeth C. Dooling. "Neurological outcome in cold water drowning." Jama 244.11 (1980): 1233-1235.

Szpilman, David, et al. "Drowning." New England journal of medicine 366.22 (2012): 2102-2110.

Modell, Jerome H., and J. H. Davis. "Electrolyte changes in human drowning victims." Anesthesiology 30.4 (1969): 414.

Modell, Jerome H., et al. "The effects of fluid volume in seawater drowning." Annals of internal medicine 67.1 (1967): 68-80.

Halmagyi, Denis FJ. "Lung changes and incidence of respiratory arrest in rats after aspiration of sea and fresh water." Journal of applied physiology 16.1 (1961): 41-44.

Fuller, Roger H. "The clinical pathology of human near-drowning." Proceedings of the Royal Society of Medicine 56.1 (1963): 33.