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Submersion Injury

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Other Names

  • Drowning
  • Near drowning
  • Fatal drowning
  • Nonfatal drowning


  • This page refers to submersion injury, which is a a broad term which includes fatal and nonfatal drowning.



  • General
    • Drowning is one of the leading causes of accidental deaths across the world[1]
    • US: 10 people die due to unintentional drowning daily, with one in five being children aged 14 and younger[2]
  • Pediatrics
    • Children ages one to four have the highest drowning rates; #2 cause of death in that age range second to congenital anomalies[2]
    • For each child who dies from drowning, another five children require ED care for nonfatal submersion[1]
  • Location
    • Home pool is most common for children under 5
    • Natural water sources (rivers, lakes, ocean) rates increase as age increases


  • General
    • Submersion injury is a broad term which includes fatal and nonfatal drowning events
    • Biggest predictor of poor outcome related to duration of submersion
  • Primary drowning
    • Most common in aquatic sports
    • Occurrs by misjudgement of the ability to cope with the aquatic environment or falling into the water while participating in the sport
  • Secondary drowning
    • Any other injury/trauma or sudden illness acting as a precipitant factor
    • This produces loss of consciousness or mentally or physically weakening the ability of the athlete to cope with the water


  • General
    • Submersion, voluntary breath holding followed by aspiration
    • Aspiration causes coughing and laryngospasm, aspiration continues, hypoxia and subsequently death[3]
  • Pulmonary
    • Hypoxemia varies with severity
    • Hypoxia is the leading cause of cardiac arrest in submersion injuries
    • Occurs due to loss of surfactant leading to alveolar collapse, atelectasis, pulmonary edema, and V/Q mismatch
    • Pulmonary symptoms may be seen even with small volume aspiration (1-3mL) due to interference with alveolar gas exchange[4]
  • Neurologic
    • CNS most susceptible to hypoxemia
    • Typically develops cerebral edema, elevated intracranial pressure (ICP)
    • Severity correlates to duration of hypoxia
  • Cardiovascular
    • Arrhythmias include atrial fibrillation, sinus tachycardia, sinus bradycardia
  • Metabolic
    • Mixed respiratory and metabolic acidosis
    • Electrolyte disturbances are uncommon
  • Fresh vs Salt water aspiration
    • Distinction between fresh and salt water drowning is no longer considered important[5]
    • Volume of water aspirated is too small to cause clinically relevant electrolyte shifts

Associated Conditions

  • Hypothermia
    • Hypothermia is neuroprotective[6]
    • Case reports showing complete recovery of patients in cardiac arrest with hypothermia even with several hours of resuscitation required[7]

Risk Factors

  • Demographic
  • Behavioral
    • Risk taking behavior
    • Drug or alcohol use
  • Swimming related
    • Inadequate supervision by an adult
    • Overestimation of abilities at swimming or poor swimming skills
  • Environmental
  • Pediatric
    • Seizure disorder
    • Developmental delay
  • Sports

Differential Diagnosis

Differential Diagnosis Dive Medicine

Clinical Features

  • History
    • Pulmonary: shortness of breath, crackles, wheezing, respiratory distress[9]
    • Neurologic: altered mental status, unresponsive
    • Cardiovascular: syncope
  • Physical Exam
    • Pulmonary: hypoxemia, crackles, distress
    • Neuro: altered mental status, neuro deficits
    • Cardiovascular: syncope, cardiac arrest, arrhythmias including sinus tach, bradycardia or a-fib
    • Hypothermia


  • Diagnosis is primarily clinical



  • CBC
  • CMP
  • ABG
    • Metabolic acidosis
  • Lactate
    • Typically elevated


  • Rhythms
    • Sinus tachycardia
    • Sinus bradycardia
    • Atrial fibrillation


Classification proposed by Szpilman[10]

Grade Presentation Emergency Department Treatment Survival
0 Responds normally, lungs clear to auscultation, no cough Do not transport 100%
1 Responds normally, lungs clear to auscultation, has a cough Discharge 100%
2 Responds normally, rales in some lung fields, has a cough Nasal cannula, observe in ED 99.4%
3 Responds normally, rales in all lung fields, has a cough, normotension Non-rebreather, progress to positive pressure or intubation if needed, admit 94.8%
4 Responds normally, rales in all lung fields, has a cough, hypotension Non-rebreather with likely progression to positive pressure or intubation, IV fluids and pressors as needed, admit to ICU ~80%%
5 Unresponsive but has a pulse Positive pressure ventilation with likely progression to intubation, IV fluids and vasopressors if needed, admit to ICU ~60%
6 Unresponsive with no pulse after 5 rescue breaths ACLS protocol 7%



  • ACLS/ Airway
    • Provide two rescue breaths immediately
    • If chest doesn't rise, initiate CPR[11]
  • Hypothermia
    • Pulses may be difficult to palpate
    • Especially in a patient who is bradycardic or in atrial fibrillation.
    • Take time more time to palpate pulse, up to 60 seconds
    • Hypothermia is neuroprotective[6].

ED/ Hospital Management

  • Airway
    • Endotracheal intubation if necessary
  • Breathing
    • Maintain SpO2 > 94% (nasal cannula, non-rebreather, or NIPPV)
    • If intubated, use ARDS settings and follow ARDSnet protocol
    • Extra Corporeal Membrane Oxygenation: data limited by encouraging
  • Circulation
    • Common initial arrhythmias: sinus tachycardia, sinus bradycardia, and atrial fibrillation[12]
    • Swimming and diving can induce fatal arrythmias in patients with prolonged QT syndrome
  • Hypothermia
    • Neuroprotective effects
    • Studies have shown neurological intact outcomes in even prolonged resuscitations[13]
  • Duration of monitoring
    • All symptomatic patients should be monitored in the ED or hospital for a minimum of 6 hours[14]
  • Antibiotics
    • Indicated if water is grossly contaminated[15]
  • Not recommended
    • Glucocorticoids are not recommended and may interfere with healing and should not be given.
    • Surfactant: data is limited on the use of exogenous surfactant


  • General
    • Supervision in and around water
    • Use a life vest
    • Avoid alcohol or drugs while swimming
    • Know local weather conditions
    • Have a swimming buddy
    • Know where lifeguards are

Rehab and Return to Play


  • Needs to be updated

Return to Play/ Work

  • Needs to be updated

Complications and Prognosis

Drowning outcomes by Duration[16]
Duration of submersion Risk of death or poor outcome
0–5 min 10%
6–10 min 56%
11–25 min 88%
>25 min nearly 100%

^Signs of brain-stem injury predict death or severe neurological consequences


  • Predictors of good outcome
    • Spilzman class 0-3 which represents the vast majority of cases[10]
  • Predictors of poor outcome[17]
    • Increased duration of submersion is the biggest predictor of poor outcome[18]
    • Serum potassium >10 mmol/L (in children >12 years old) is high predictor of poor outcomes.
    • End tidal CO2 <2 kPa with high quality chest compressions has a poor prognosis.


  • Neurological injury
    • Common in nonfatal drowning injuries
    • Ranges from memory or learning disabilities to permanent vegetative state

See Also


  1. 1.0 1.1 Centers for Disease Control and Prevention (CDC). Nonfatal and fatal drownings in recreational water settings–United States, 2001-2002. MMWR Morb Mortal Wkly Rep. 2004;53(21):447-452.
  2. 2.0 2.1 Centers for Disease Control and Prevention (CDC). Home and recreational safety: water safety. October 7, 2020. 2020. Accessed October 8, 2020. https://www.cdc.gov/homeandrecreationalsafety/water-safety/waterinjuries-factsheet.html.
  3. Szpilman, D., Bierens, J. J., Handley, A. J., & Orlowski, J. P. (2012). Drowning. N Engl J Med, 366(22), 2102-2110. doi: 10.1056/NEJMra1013317
  4. Layon et al. Drowning: Update 2009. Anesthesiology 2009; 110: pp. 1390
  5. Orlowski JP, Szpilman D. Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am. 2001;48(3):627-646. doi:10.1016/s0031-3955(05)70331-x
  6. 6.0 6.1 Bierens JJ, Knape JT, Gelissen HP. Drowning. Curr Opin Crit Care. 2002;8(6):578-586. doi:10.1097/00075198-200212000-00016
  7. Burke CR, Chan T, Brogan TV, et al. Extracorporeal life support for victims of drowning. Resuscitation. 2016;104:19-23. doi:10.1016/j.resuscitation.2016.04.005
  8. Papa L, Hoelle R, Idris A. Systematic review of definitions for drowning incidents. Resuscitation. 2005;65(3):255-264. doi:10.1016/j.resuscitation.2004.11.030.
  9. Olshaker JS. Near drowning. Emerg Med Clin North Am. 1992;10(2):339
  10. 10.0 10.1 Szpilman D. Near-drowning and drowning classification:a proposal to stratify mortality based on the analysis of 1,831 cases. Chest 112(3):660-665, 1997.
  11. DeNicola LK, Falk JL, Swanson ME, Gayle MO, Kissoon N. Submersion injuries in children and adults. Crit Care Clin. 1997;13(3):477-502. doi:10.1016/s0749-0704(05)70325-0
  12. Schmidt AC, Sempsrott JR, Hawkins SC, Arastu AS, Cushing TA, Auerbach PS. Wilderness Medical Society Practice Guidelines for the Prevention and Treatment of Drowning. Wilderness Environ Med. 2016;27(2):236-251. doi:10.1016/j.wem.2015.12.019.
  13. Quan L, Mack CD, Schiff MA. Association of water temperature and submersion duration and drowning outcome [published correction appears in Resuscitation. 2014 Sep;85(9):1304]. Resuscitation. 2014;85(6):790-794. doi:10.1016/j.resuscitation.2014.02.024.
  14. Noonan L, Howrey R, Ginsburg CM. Freshwater submersion injuries in children: a retrospective review of seventy-five hospitalized patients. Pediatrics. 1996;98(3 Pt 1):368-371.
  15. Layon AJ, Modell JH. Drowning: Update 2009. Anesthesiology. 2009;110(6):1390-1401. doi:10.1097/ALN.0b013e3181a4c3b8
  16. Szpilman, David; Bierens, Joost J.L.M.; Handley, Anthony J.; Orlowski, James P. (4 October 2012). "Drowning". The New England Journal of Medicine. 366 (22): 2102–2110. doi:10.1056/NEJMra1013317. PMID 22646632.
  17. Rudolph SS, Barnung S. Survival after drowning with cardiac arrest and mild hypothermia. ISRN Cardiol. 2011;2011:895625. doi:10.5402/2011/895625
  18. Bierens JJLM, edWarner D, Knape J. Recommendations and consensus: brain resuscitation in the drowning victim. In: Bierens JJLM, ed. Drowning: Prevention, Rescue, Treatment. Berlin, SpringerVerlag, 2006; pp. 436–439
Created by:
John Kiel on 4 August 2022 16:38:47
Last edited:
12 August 2022 15:57:06