Treatment and Prevention of Drowning

Publication Date: December 1, 2019
Last Updated: March 14, 2022


Rescue of the Drowning Patient

Reaching the Patient

Persons without formal water rescue training should attempt rescues from a safe location by reaching, throwing, or rowing to the drowning patient. Persons with formal water rescue training should perform in-water rescues according to their level of training and with personal protective and safety equipment. There is insufficient evidence to recommend specific rescue devices. If specialized rescue equipment is available, participants should be familiar with the location and purpose of this equipment, and designated rescue personnel with proper training should be tasked with its use in the event of a water rescue. (1 – Strong, C)


The safest time to escape from a submerging vehicle is immediately after it enters the water, during the initial floating phase. If the vehicle remains floating, persons should climb out and remain on top of the vehicle. If it is sinking, they should move away from the vehicle and toward safety after exiting. (2 – Weak, C)


IWR should only be considered by a rescuer with adequate training, ability, and equipment to safely and effectively perform the skill in the aquatic environment. The aquatic conditions must be sufficiently safe for the rescuer to perform IWR, and the point of extrication from the water must be sufficiently distant to warrant an attempt of this technically difficult task. If conditions are too hazardous to safely perform the task, rapid extrication is indicated without a delay for IWR. Chest compressions should not be attempted in the water; all drowning patients without a pulse should be extricated as quickly and safely as possible so that early, effective chest compressions and ventilations can be initiated. (1 – Strong, C)

Initial Resuscitation


Suspect and treat hypothermia. (1 – Strong, C)


Supplying oxygen to the brain is critical to successful resuscitation of the drowning patient. Establishing an airway and providing oxygen are priorities in initial resuscitation. For the patient in cardiac arrest, provide positive pressure ventilations in addition to chest compressions using the traditional Airway-Breathing-Circulation model of resuscitation. If an advanced airway is available and properly placed, provide breaths at specified time intervals (every 6 to 8 s) while continuous compressions are administered. For lay people without training in rescue breathing, compression-only CPR is a preferred alternative to no intervention. (1 – Strong, C)


When resuscitating a drowning patient, oxygen should initially be delivered at the highest concentration available. For the patient in respiratory distress or arrest, positive pressure is preferred over passive ventilation. If multiple modalities are available, the method that most effectively delivers the highest concentration of oxygen should be used. If a modality or device fails, bag-valve-mask (BVM) or mouth-to-mouth ventilation should be attempted. (1 – Strong, C)


ventricular fibrillation (VF) is rare in drowning, so incorporation of an automated external defibrillator (AED) in the initial minutes of drowning resuscitation should not interfere with oxygenation and ventilation. If available, an AED should be used during resuscitation of a drowning patient; its use is not contraindicated in a wet environment. (1 – Strong, A)


Owing to the possibility of delaying ventilations, the Heimlich maneuver is not recommended for resuscitation of the drowning patient. (1 – Strong, B)


The most current Wilderness Medical Society Practice Guidelines concerning the field treatment of possible spinal injuries should be reviewed when developing or reviewing agency protocols. Drowning patients who display evidence of spine injury, such as focal neurologic deficit, have a history of high-risk activity, or exhibit altered mental status are considered to be at a higher risk for spine injury. This does not include patients with altered mental status who were witnessed to have no trauma as an inciting event. Treatment considerations for this population should be carried out in accordance with the most current version of Wilderness Medical Society Clinical Practice Guidelines for Spinal Cord Protection. (1 – Strong, C)

Postresuscitation Management


Mechanical ventilation
Mechanical ventilation for the drowning patient should follow acute respiratory distress syndrome (ARDS) protocols. (1 – Strong, C)

Noninvasive positive pressure ventilation (NIPPV)

NIPPV may be usd in the alert drowning patient with mild to moderate respiratory symptoms. Caution should be taken with any patient displaying altered mental status and/or active emesis owing to the potential for aspiration. (2 – Weak, C)



Initial chest radiograph findings do not correlate with arterial blood gas measurements or outcome; x-rays may be useful in tracking changes in patient condition, but not for determining prognosis if obtained at the time of presentation. A normal initial head CT does not have prognostic value in the drowning patient. Routine use of neuroimaging in the awake and alert drowning patient is not recommended unless dictated by a change in clinical status. (1 – Strong, C)


Routine use of complete blood count or electrolyte testing in the drowning patient is not recommended. Arterial blood gas testing in patients with evidence of hypoxemia or respiratory distress (eg, cyanosis, low oxygen saturation, tachypnea, persistent tachycardia) may be indicated to guide respiratory interventions. For patients whose mental status fails to respond to resuscitation or in whom the initial cause of submersion is unknown, laboratory testing for causes of altered mental status or any inciting event should be considered. (1 – Strong, C)

Other Treatments


There is no evidence to support empiric antibiotic therapy in the initial treatment of drowning patients. After initial resuscitation, if pneumonia is present, treatment should be guided by expectorated sputum or endotracheal aspirate bacterial culture, blood cultures, or urinary antigen tests. In the absence of these tests, decision to treat should be based on clinical examination focusing on physical evidence of pulmonary or systemic infection (eg, fever, increased sputum, abnormal lung auscultation). (1 – Strong, A)


Given limited data, corticosteroids should not be routinely administered specifically for treatment of drowning patients. (1 – Strong, C)


Although current literature recommend targeted temperature management in postcardiac arrest care, there is insufficient evidence to either support or discourage induction or maintenance of TH in drowning patients. (2 – Weak, C)

Disposition in the Wilderness


  1. Any patient with abnormal lung sounds, severe cough, frothy sputum, foamy material in the airway, depressed mentation, or hypotension warrants immediate evacuation to advanced medical care if risks of evacuation do not outweigh potential benefit.
  2. Any patient who is asymptomatic (other than a mild cough) and displays normal lung auscultation may be considered for release from the scene. Ideally, another individual should be with them for the next 4 to 6 h to monitor for symptom development or the patient should be advised to seek medical assistance if symptoms develop.
  3. If evacuation is difficult or may compromise the overall expedition, patients with mild symptoms and normal mentation should be observed for 4 to 6 h. Any evidence of decompensation warrants prompt evacuation if the risks of evacuation do not outweigh the potential benefit.
  4. If evacuation of a mildly symptomatic patient has begun and the patient becomes asymptomatic for 4 to 6 h, canceling further evacuation and continuing previous activity may be appropriate.
(1 – Strong, C)


  1. Based on resources, it might be reasonable to cease rescue and resuscitation efforts when there is a known submersion time of greater than 30 min in water >6°C (43°F), or greater than 90 min in water <6°C (43°F), or after 25 min of continuous cardiopulmonary resuscitation.
  2. If at any point during search and rescue efforts the safety of the rescue team becomes threatened, rescue efforts should be ceased.
  3. If resources are available and recovery team safety is maintained, body recovery efforts may continue beyond the search and rescue period with the understanding that resuscitation attempts will likely be futile.
(1 – Strong, C)

Disposition in the Emergency Department

After an observation period of 4 to 6 h, it is reasonable to discharge a drowning patient with normal mental status in whom respiratory function is normalized and no further deterioration in respiratory function has been observed. (2 – Weak, C)



All patients with coronary artery disease, prolonged QT syndrome or other ion channel disorder, autism, seizure disorders, or other medical and physical impairments should be counseled about the increased risk of drowning and about steps to mitigate the risk, such as buddy swimming and rescue devices, should they choose to participate in water activities. Given the extremely high rate of drowning in patients with epilepsy, patients should be counseled to never swim without direct supervision. (2 – Weak, C)


All persons who participate in activities conducted in or around water should have, at a minimum, enough experience and physical capability to maintain their head above water, tread water, and make forward progress for a distance of 25 m (82 ft). (2 – Weak, C)


Properly fitted lifejackets that meet local regulatory specifications should be worn by participants when boating or engaging in any water sports for which lifejackets are recommended. (1 – Strong, C)


Alcohol and other intoxicating substances should be avoided before and during water activities. (1 – Strong, C)


Despite a lack of definitive evidence, all groups operating in or near aquatic environments, regardless of size, should consider water safety during planning and execution of excursions. This includes contingencies for prevention, rescue, and treatment of drowning persons. In high-risk environments or large groups, consider including personnel with technical rescue training and appropriate rescue equipment. (1 – Strong, C)

Special Situations


  1. Upon falling into cold water, distance oneself from any immediate life threats (eg, fire, sinking vehicle, whitewater, hazardous waves, rocks). Then, remain calm and focused and control breathing by taking slow deep breaths.
  2. Consider physical capabilities, location, resources, and chances of rescue to determine whether to swim to safety.
  3. If a decision is made to swim to safety, this should be done as soon as possible before physical capabilities deteriorate from the effects of cold stress.
  4. If a decision is made to await rescue, an attempt should be made to remove as much of the body from the water as possible. All clothing should remain on, unless it hampers buoyancy. Most clothing does not compromise buoyancy and will not pull one down, although the water within the garment may impede movement. If the person remains immersed and has a flotation garment on, the heat escape lessening position should be maintained if possible. In a group, the huddle position may be used.
  5. If prolonged rescue is expected, it might be beneficial to attach oneself to a buoyant object or to a surface out of the water to improve the chance for survival.
(2 – Weak, C)

Recommendation Grading




Treatment and Prevention of Drowning

Authoring Organization

Publication Month/Year

December 1, 2019

Last Updated Month/Year

April 13, 2023

Supplemental Implementation Tools

Document Type


External Publication Status


Country of Publication


Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital

Intended Users

Paramedic emt, nurse, nurse practitioner, physician, physician assistant


Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D004332 - Drowning


hypothermia, Drowning, submersion, immersion, cold water submersion