Drowning is respiratory impairment resulting from submersion in a liquid medium. It can be nonfatal (previously called near drowning) or fatal. Drowning results in hypoxia, which can damage multiple organs, particularly the brain. Treatment is supportive, including reversal of respiratory arrest and cardiac arrest, hypoxia, hypoventilation, and hypothermia.
Drowning is among the top 10 causes of mortality for children and young people worldwide. In 2018 in the US, drowning was the leading cause of injury mortality in children aged 1 to 4 years and was second only to motor vehicle collisions for children aged 5 to 9 years; drowning also was among the top 10 causes of unintentional death in all ages under 55 years (1). Groups at high risk of drowning death include the following:
- Children from African American, Native American, immigrant, or impoverished families (2)
- Males (80% of victims over age 1 year are male)
- People who have used alcohol or sedatives
- People with conditions that cause temporary incapacitation (eg, epilepsy , with a 20 times increased chance of drowning among children and adolescents)
- People with a long QT syndrome (swimming can trigger arrhythmias that cause unexplained drowning in people with a long QT syndrome, particularly LQT1)
- People who engage in dangerous underwater breath-holding behaviors (DUBBs)
Drowning is common in pools, hot tubs, and natural water settings, and, among infants and toddlers, in toilets, bathtubs, and buckets of water or cleaning fluids. About 4 times as many people are hospitalized for nonfatal drowning as die as a result of drowning.
Pathophysiology of Drowning
Hypoxia is the major insult in drowning, affecting the brain, heart, and other tissues; respiratory arrest followed by cardiac arrest may occur. Brain hypoxia may cause cerebral edema and, occasionally, permanent neurologic sequelae. Generalized tissue hypoxia may cause metabolic acidosis. Immediate hypoxia results from aspiration of fluid or gastric contents, acute reflex laryngospasm (previously called dry drowning), or both. Lung injury due to aspiration or hypoxia itself may cause delayed hypoxia (previously called secondary drowning). Aspiration, especially with particulate matter or chemicals, may cause chemical pneumonitis or secondary bacterial pneumonia and may impair alveolar secretion of surfactant, resulting in patchy atelectasis. Extensive atelectasis may make the affected areas of the lungs stiff, noncompliant, and poorly ventilated, potentially causing respiratory failure with hypercapnia and respiratory acidosis. Perfusion of poorly ventilated areas of the lungs (V/Q mismatch) worsens hypoxia. Alveolar hypoxia may cause noncardiogenic pulmonary edema.
Exposure to cold water induces systemic hypothermia, which can be a significant problem. However, hypothermia can be protective by stimulating the mammalian diving reflex, slowing the heart rate, and constricting the peripheral arteries, shunting oxygenated blood away from the extremities and the gut to the heart and brain. Also, hypothermia decreases the oxygen needs of tissues, possibly prolonging survival and delaying the onset of hypoxic tissue damage. The diving reflex and overall clinically protective effects of cold water are usually greatest in young children.
Laryngospasm often limits the volume of fluid aspirated. Distinction between freshwater and seawater drowning was once considered important due to the potential electrolyte shifts, hemolysis, and fluid compartment shifting that possibly could occur. However, studies have shown that in most patients, too little liquid is aspirated to have these effects. Aspiration can lead to pneumonia, sometimes with anaerobic or fungal pathogens, and pulmonary edema.
Dangerous underwater breath-holding behaviors (DUBBs)
Dangerous underwater breath-holding behaviors are practiced mostly by healthy young men (often good swimmers) trying to prolong their capacity to remain submerged. There are 3 described types of DUBB:
- Intentional hyperventilation—blowing off carbon dioxide before submerged swimming, thereby delaying central hypercarbic ventilatory responses
- Hypoxic training—extending capacity for underwater distance swimming or breath-holding
- Static apnea—breath-holding for as long as possible while submerged and motionless, including as a game
In DUBB, while submerged, hypoxia occurs first, followed by loss of consciousness (hypoxic blackout, breath-hold blackout) and then drowning.
Skeletal, soft-tissue, head, and internal injuries may occur, particularly among surfers, water skiers, boaters, flood victims, and occupants of submerged vehicles. People who dive into shallow water may sustain cervical and other spine injuries (which may be the cause of drowning).
- Ten Leading Causes of Death and Injury, United States, 2018. Accessed January 6, 2021.
- Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Racial/Ethnic disparities in fatal unintentional drowning among persons aged ≤29 years – United States 1999-2010. MMWR 63:421-426, 2014.
- Sillanpää M, Shinnar S: SUDEP and other causes of mortality in childhood-onset epilepsy. Epilepsy Behav 28(2):249-255, 2013. doi: 10.1016/j.yebeh.2013.04.016
Symptoms and Signs of Drowning
During drowning, panic and air hunger occur. Children who are unable to swim may become submerged in < 1 minute, more rapidly than adults. After rescue, anxiety, vomiting, wheezing, and altered consciousness are common. Patients may have respiratory failure with tachypnea, intercostal retractions, or cyanosis. Respiratory symptoms are sometimes delayed for up to 8 hours after submersion. Patients may have symptoms due to injuries or exacerbations of underlying disorders.
Pearls & Pitfalls
Diagnosis of Drowning
- Clinical evaluation
- For concomitant injuries, imaging studies as indicated
- Pulse oximetry and, if results are abnormal or if respiratory symptoms and signs are present, arterial blood gases (ABG) and chest x-ray
- Core temperature measurement to rule out hypothermia
- Evaluation for causative or contributing disorders (eg, seizure, hypoglycemia, myocardial infarction, intoxication, injury)
- Ongoing monitoring as indicated for delayed respiratory complications
Most people are found in or near water, making the diagnosis obvious clinically. Resuscitation, if indicated, should precede completion of the diagnostic assessment. Cervical spine injury is considered, and the spine is immobilized in patients who have altered consciousness or whose mechanism of injury involves diving or trauma. Secondary head injury and conditions that may have contributed to drowning (eg, hypoglycemia, myocardial infarction, stroke, intoxication, arrhythmia) are considered.
All patients undergo assessment of oxygenation by oximetry or, if results are abnormal or if there are respiratory symptoms or signs, arterial blood gas (ABG) and chest x-ray. Because respiratory symptoms may be delayed, even asymptomatic patients are transported to the hospital and observed for several hours.
In patients with symptoms or a history of prolonged submersion, core body temperature is measured, electrocardiography and serum electrolytes are obtained, and continuous oximetry and cardiac monitoring are done. Patients with possible cervical spine injury undergo cervical spine imaging.
Patients with altered consciousness undergo head CT. Any other suspected predisposing or secondary conditions are evaluated with appropriate testing (eg, fingerstick glucose for hypoglycemia, electrocardiography for myocardial infarction, cardiac monitoring for arrhythmia, evaluation for intoxication). Patients who drown without apparent risk factors are evaluated for long QT syndrome and torsades de points ventricular tachycardia. In patients with pulmonary infiltrates, bacterial or fungal pneumonia is differentiated from chemical pneumonitis and pulmonary edema using blood cultures and sputum Gram stain and culture. If indicated (eg, bacterial or fungal pneumonia is suspected but the pathogen cannot be otherwise identified), bronchial washings are obtained for testing, including culture.
Prognosis for Drowning
Factors that increase the chance of surviving submersion without permanent injury include the following:
- Rapid institution of resuscitation (most important)
- Brief duration of submersion
- Cold water temperature
- Young age
- Absence of underlying medical conditions, secondary trauma, and aspiration of particulate matter or chemicals
Survival may be possible in cold water submersion that lasts >1 hour, especially among children; thus, even patients with prolonged submersion are vigorously resuscitated.
Treatment of Drowning
- Correction of oxygen and carbon dioxide levels and other physiologic abnormalities
- Intensive respiratory support
Treatment aims to correct cardiac arrest, hypoxia, hypoventilation, hypothermia, and other physiologic insults.
Resuscitation after drowning
In apneic patients, rescue breathing is started immediately—in the water, if necessary. If spinal immobilization is necessary, it is done in a neutral position, and rescue breathing is done using a jaw thrust without head tilt or chin lift. Emergency medical services are called. If the patient does not respond to rescue breathing, cardiac compression is started, followed by advanced cardiac life support. Although the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) recommend chest compressions as the first step in resuscitation of patients in cardiac arrest, drowning is an exception to this recommendation (1). Attempts to remove water from the lungs are avoided because they delay ventilation and increase the risk of vomiting. Oxygenation, endotracheal intubation, or both should proceed as soon as possible. Hypothermic patients are warmed as soon as possible. Immediate treatment measures may include removing clothing, drying, and insulation. Prolonged resuscitation efforts should be considered especially in young patients involved in cold water drownings.
Pearls & Pitfalls
Hospital care for drowning patients
All hypoxic or moderately symptomatic patients are hospitalized. In the hospital, supportive treatment continues, aimed primarily at achieving acceptable arterial oxygen and carbon dioxide levels. Mechanical ventilation may be necessary. Patients are initially given 100% oxygen; the concentration is titrated lower based on ABG results. Positive end-expiratory pressure ventilation is usually necessary to help expand or maintain patency of alveoli to maintain adequate oxygenation. Pulmonary support may be necessary for hours or days. If adequate oxygenation is impossible despite maximizing ventilator settings, extracorporeal membrane oxygenation may be considered. Nebulized beta-2 agonists may help reduce bronchospasm and wheezing. Surfactant administration may be helpful in critically ill patients with significant lung compliance issues after drowning, although no large clinical trials have addressed this. Patients with pneumonia are treated with antibiotics targeting organisms identified or suspected based on results of sputum testing and/or blood cultures. Corticosteroids are not used. Core body temperature is monitored, and hypothermia is treated.
Fluids or electrolytes are rarely required to correct significant electrolyte imbalances. Fluid restriction is rarely indicated, unless pulmonary or cerebral edema occurs. Concomitant injuries and disorders (eg, head or cervical injury, seizure, arrhythmia) may also require treatment.
Discharge of drowning patients
Patients with mild symptoms, clear lungs, and normal mentation and oxygenation should be observed in the emergency department for at least 8 hours (2, 3). If symptoms resolve and the examination and oxygenation remain normal, patients can be discharged with instructions to return if symptoms recur.
- 1. Panchal AR, Bartos JA, Cabanas JG, et al: Adult Basic and Advanced Life Support Writing Group. Part 3: Adult Basic and Advanced Life Support: 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation.142(16_suppl_2):S366-S468, 2020. doi: 10.1161/CIR.0000000000000916
- 2. Brennan C, Hong T, et al: Predictors of safe discharge for pediatric drowning patients in the emergency department. Am J Emerg Med 2018, 36(9):1619-1623.
- 3. Shenoi RP, Allahabadi S, Rubalcava DM, et al: The pediatric submersion score predicts children at low risk for injury following submersions. Acad Emerg Med 24(12):1491-1500, 2017. doi: 10.1111/acem.13278
Prevention of Drowning
Drugs, alcohol, and drowning
Use of alcohol or drugs, a major risk factor, should be avoided before and during swimming and boating and when supervising children around water.
Swimmers should use common sense and be aware of weather and water conditions. Swimmers should be accompanied by an experienced swimmer or swim only in guarded areas. Swimming should stop if the swimmer looks or feels very cold, because hypothermia may impair judgment. Ocean swimmers should learn to escape rip currents by swimming parallel to the beach rather than toward the beach. Swimmers should be discouraged from dangerous underwater breath-holding behaviors (DUBBs). If they practice them, they should be supervised and should know their dangers. Swimmers should avoid swimming near a boat exhaust port, which can cause carbon monoxide poisoning.
Public swimming areas should be supervised by lifeguards trained in water safety and resuscitation as well as rescue techniques. Life preservers, life jackets, and a shepherd's crook should be available close to poolside. Emergency airway equipment, automated external defibrillators (AEDs), and immediate telephone access to emergency medical services should be available. Comprehensive community prevention programs should target high-risk groups, teach children to swim as early as possible, and teach cardiopulmonary resuscitation (CPR) to as many adolescents and adults as possible. Owners of private pools should comply with local laws regarding pool safety, have immediate telephone access to emergency medical services, and know about resuscitation after drowning.
Water safety for children
Children should wear US Coast Guard–approved flotation devices when in or around water. Air-filled swimming aids and foam toys (water wings, noodles, etc) are not designed to keep swimmers from drowning and should not be used as a substitute for US Coast Guard–approved equipment. Children must be constantly supervised by an adult when around water, including beaches, pools, and ponds. Infants and toddlers should also be supervised, ideally within arm’s length, when near toilets, bathtubs, or any collection of water. Studies in the US and China have shown that formal swimming lessons reduce the risk of fatal drowning among children ages 1 to 4; however, even children who have been taught how to swim require constant supervision when in or around water. Adults should remove water from containers such as pails and buckets immediately after use. Swimming pools should be surrounded with a locked fence ≥ 1.5 m in height.
Before embarking, boaters should wear US Coast Guard–approved life jackets and should check weather and water conditions. Nonswimmers and small children in a boat should wear US Coast Guard–approved life jackets at all times. Because consuming any quantity of alcohol increases the risk of drowning, operators and passengers on recreational boats should generally avoid consuming alcohol.
Special populations at risk for drowning
People who are debilitated or elderly or have seizure disorders or other medical conditions that can alter consciousness require constant supervision when they are boating or swimming and when in bathtubs.
People with a personal or family history of unexplained drowning not attributable to alcohol use, drug use, or a seizure disorder merit evaluation for a long QT syndrome.
- Evaluate patients for suspected or feasible causes of drowning (eg, cervical spine injury, head injury, seizure arrhythmias, hypoglycemia) as well as injuries or consequences of drowning (eg, head or cervical spine injury, aspiration).
- Vigorously resuscitate cold water drowning victims even if submersion was prolonged; survival is possible even after 1 hour of submersion, particularly in young children.
- Resuscitation begins with rescue breathing, not chest compressions.
- Preventive measures (eg, swimming lessons, child supervision, use of US Coast Guard–approved flotation devices or life jackets, avoiding alcohol, access to trained lifeguards and emergency medical services) can have significant public health benefits.