Drowning Rescue and Resuscitation Protocol

Drowning Resuscitation: Key Differences

Drowning CPR differs from standard cardiac arrest resuscitation in one critical way: oxygen deprivation, not cardiac arrest, is the primary problem. The victim's heart often continues beating for several minutes after submersion. Ventilations are the intervention that breaks the cascade — not compressions.

Start with 5 rescue breaths. Before beginning the standard 30:2 cycle, give 5 initial rescue breaths. With each breath, watch for chest rise. If the first 2 attempts don't produce chest rise, reposition the airway.

In water rescue breathing: If trained in in-water rescue, begin mouth-to-mouth rescue breathing while still in shallow water. Every 30 seconds of ventilation before reaching shore improves outcomes significantly.

Maintain airway position. A drowning victim's airway may be partially blocked by water, vomit, or spasm. Keep the neck extended and check for obstructions.

Expect vomiting. Most drowning victims vomit during resuscitation. Turn the head to the side to clear vomit, then immediately return to the airway position. Do not stop compressions longer than necessary.

Spinal Injury Consideration

Spinal injury is possible in diving accidents, surf injuries, or falls into water. It is NOT a concern in plain submersion drowning — do not let hypothetical spinal precautions delay resuscitation.

When spinal injury is a concern (witnessed dive, impact with hard surface, surf rescue):

• Maintain in-line stabilization of the head during rescue
• Logroll rather than flip
• Do not apply hard cervical collar until on stable ground — it does not help and delays resuscitation

When spinal injury is not a concern (submersion in calm water, no witnessed impact): prioritize rescue breathing. Spinal immobilization in these cases delays care without benefit.

Hypothermia and Cold Water Drowning

Cold water drowning has better outcomes than warm water drowning. The diving reflex — bradycardia and peripheral vasoconstriction triggered by cold water on the face — significantly reduces oxygen consumption and has allowed survival after extended submersion. Children, with a stronger diving reflex, have survived neurologically intact after 20+ minutes submerged in cold water.

The rule: "No one is dead until they are warm and dead."

Continue resuscitation on a drowning victim from cold water while actively rewarming them. Do not stop CPR based on time submerged alone if the water was cold.

Post-rescue: Even successfully resuscitated drowning victims from cold water are hypothermic. Rewarm following hypothermia protocol — remove wet clothing, insulate, apply heat to core zones.

Secondary Drowning: Watch for 24 Hours

A victim who was submerged, perhaps showed no symptoms at rescue, or appeared to recover, can deteriorate over the following 24 hours from pulmonary complications.

Warning signs requiring immediate evaluation:

• Persistent cough or worsening cough
• Chest pain or pressure
• Increasing difficulty breathing at rest
• Unusual fatigue beyond what's expected
• Altered mental status, unusual behavior, or excessive sleepiness in a child
• Foamy or pink-tinged mucus

Any person who was significantly submerged — meaning they inhaled water, required resuscitation, or was unconscious — should be evaluated medically even if they appear well after rescue. The stakes of missing secondary drowning are high enough that precautionary evaluation is always warranted.

Post-Resuscitation Priorities

After successful resuscitation from drowning:

1. Airway and breathing assessment — respiratory rate, work of breathing, breath sounds (crackling indicates aspirated water)
2. Hypothermia management — almost universal; rewarm actively
3. Neurological status — level of consciousness, response to commands, pupils
4. Oxygen — supplemental oxygen at 10-15 L/min by non-rebreather mask if available
5. Evacuation — all resuscitated drowning victims require hospital evaluation for pulmonary complications, aspiration pneumonia, rhabdomyolysis (muscle breakdown from CPR), and metabolic disturbances

There is no such thing as a fully stable post-drowning patient in the field. Even patients who appear completely recovered after resuscitation are at risk for delayed pulmonary edema and should not be left alone.