Near Drowning

1. History: event, duration of submersion, water temperature.
2. Resuscitation as per PALS protocols with attention to body temperature and hypothermia.
3. Obtain vascular access (see Vascular Access)
4. Consider need for cervical spine immobilization.
5. Airway: Consider intubating with a cuffed endotracheal tube for decreased airway compliance.
6. Ventilate patient with PEEP 5 cm H2O or more to maintain oxygenation. Monitor Peak Inspiratory pressure to reduce lung barotrauma.
7. Circulatory Support:
   1. Treat patient for signs and symptoms of shock with IV fluid resuscitation and inotropic support.
8. Place nasogastric tube and provide low intermittent suction.
9. Obtain lab values when possible (I-STAT 8+)
10. Maintain thermos-neutrality (36-37):
    1. Remove all wet clothing and keep patient covered.
    1. If temperature >32° C, passively external warm patient with warmed blankets
    1. If temperature <32° C, active core rewarming techniques include warmed IV fluids, warmed blankets and chemical heat packs.
11. Handle patient gently, do not rub extremities or allow patient to walk.
12. Frequent neurological checks.  Treat seizure activity as per Seizure Guidelines.
13. Give sedation for agitation (See Pain/Sedation Guidelines)
14. Maintenance fluids at full maintenance rate (See Fluid and Blood Component Therapy)
15. Assess for other injuries and treat associated problems.
16. If pH is ≤ 7.0, OR acidosis is strongly suspected, administer Sodium Bicarbonate 1 mEq/Kg

Citations/References:

1. Szpilman D, Bierens JJ, Handley AJ, et al. Drowning. N Engl J Med. 2012;366(22):2102-2110. (Review)
2. Bierens, JJLM. Handbook on Drowning. 1st ed. Germany: Springer-Verlag Berlin Heidelberg; 2004. (Textbook)