Drowning: ventilate in CPR and who to observe

A seven-year-old girl is pulled from the deep end of a pool by an adult who noticed she was not coming back to the surface. No one knows for sure how long she was underwater, but the adult thinks it was less than a minute. At the edge, she coughs a lot, vomits a little water and cries. Ten minutes later, when the health team arrives, she is awake but breathing fast and still coughing. The mother asks if she can take her home, since "she is fine now". The scene is fictional and was written for teaching. This text uses this picture as a clinical reasoning scenario: why drowning is, above all, an oxygen problem, why ventilation plays a central role in resuscitation, when to think of spinal injury and who needs to be observed even when they seem well.

NEXO is a daily medical diagnosis game: one clinical case a day, up to six progressive clues, and ICD-10 proximity feedback across five levels.

The text is not a water rescue course nor a resuscitation protocol. Rescue, resuscitation and advanced support follow their own guidelines and practical training. The interest here is reasoning: how to organize the assessment of someone who has come out of the water, which clues indicate severity and why the calm appearance of the first minutes can mislead. If you play the case of the day on NEXO, you will recognize the movement: a small symptom, such as a cough that will not go away, can be the most important clue in the case.

Key points

• In drowning, cardiac arrest is usually a consequence of lack of oxygen, not of a primary heart problem.
• For this reason, resuscitation of a drowning victim must pay attention to ventilation, not only to compressions.
• The duration of submersion is the factor most linked to prognosis, while water temperature and age did not help predict the outcome in the reviews cited.
• Cervical spine injury is rare in drowning without trauma and does not justify routine immobilization.
• Anyone who comes out of the water with persistent cough, rapid breathing, altered auscultation or falling saturation needs assessment and observation.

Why drowning is a reasoning scenario

Drowning is often thought of as an all-or-nothing event: the person either dies or comes out well. In practice, there is a wide spectrum between these extremes. Some come out of the water with no symptoms at all, some cough for a few minutes, some develop respiratory failure hours later and some arrive in cardiac arrest. The assessment must recognize where on this spectrum the patient is and where they may go.

The European Resuscitation Council guideline for special circumstances notes that drowning is among the leading causes of death from unintentional injury worldwide and that the most important consequence is hypoxia, caused by aspiration of liquid into the lungs (Lott et al., 2021). When hypoxia is severe or prolonged, it leads to cardiac arrest. Early and effective intervention is what most changes survival and sequelae.

What the scene teaches

In the opening scene, the short submersion, the cough, the vomiting, the rapid breathing and the time that has already passed form a pattern. The girl is awake and crying, which is reassuring, but the persistent cough and the accelerated breathing are clues that water may have reached the lungs. The post on signs, symptoms and history shows how small findings change the weight of the picture when the context is taken into account.

Immersion and submersion

Bierens et al. describe the physiology of drowning in two moments (Bierens et al., 2016). In immersion, the airways are still above the water, and the body responds to the cold with initial cold shock, progressive loss of strength and changes in circulation. In submersion, the airways are under the water, and fear, airway reflexes, aspiration and swallowing of water, vomiting and electrolyte changes come into play. The final outcome is determined by injury to the heart, lungs and brain.

Why hypoxia comes first

The update from the American Heart Association and the American Academy of Pediatrics on drowning reminds us that the condition usually progresses from a respiratory arrest caused by the hypoxia of submersion to a cardiac arrest (McCallin et al., 2024). The authors explain that it can be hard to tell respiratory arrest from cardiac arrest, because the pulse is hard to feel accurately within the short recommended time. That is why resuscitation after a drowning needs to focus both on restoring breathing and on restoring circulation.

A different sequence from ordinary cardiac arrest

In sudden cardiac arrest in an adult, the initial problem is usually an electrical rhythm of the heart, and the blood still carries oxygen in the first minutes. In drowning, the blood reaches the arrest already low in oxygen. The European guideline notes that the chance of a shockable rhythm is lower in drowning than in primary cardiac causes and therefore recommends prioritizing ventilations and compressions while the defibrillator is being prepared (Lott et al., 2021). The defibrillator remains useful, but it should not delay ventilation.

The physiology behind the cough

Bierens et al. note that aspiration of water and vomiting are part of the physiology of submersion and that lung injury is one of the determinants of the outcome (Bierens et al., 2016). In practice, a cough that does not go away, rapid breathing and sounds on auscultation are signs that water reached the lower airways. These signs can be subtle at first and worsen over the following hours.

Resuscitation: ventilation at the center

The European guideline recommends starting resuscitation as soon as it is safe and possible, beginning with five ventilations, preferably with oxygen when available, and then continuing with thirty compressions alternating with two ventilations if the victim remains unresponsive and without normal breathing (Lott et al., 2021). The same guideline recommends connecting the defibrillator when available and following the prompts, and intubating only when the professional has a high success rate with the procedure.

Compressions alone or resuscitation with ventilation

Bierens et al., in a systematic review for the international resuscitation committee, found two observational studies that compared compression-only resuscitation with resuscitation using compressions and ventilations after drowning (Bierens et al., 2023). Most outcomes showed no difference, but one of the studies found higher survival to hospital discharge in the group that received ventilation. The certainty of the evidence was very low, and the authors concluded that it seems reasonable for those who are trained, able and willing to ventilate to do so.

Ventilation still in the water

Bierens et al. found a single observational study on ventilation still in the water, carried out with lifeguards on the coast, in which victims who received ventilations in the water had a better outcome than those taken directly to land (Bierens et al., 2023). The evidence was also of very low certainty. The European guideline reserves this technique for highly trained teams with water rescue equipment, and advises that, outside that context, the victim be taken directly to land or to a boat before resuscitation begins (Lott et al., 2021).

On the boat and when resuscitation takes long

The European guideline considers resuscitation inside a boat possible and recommends that whoever is resuscitating focus on good-quality compressions, watch for fatigue and swap rescuers regularly (Lott et al., 2021). When the initial measures do not work, the same guideline suggests considering, according to local protocols, extracorporeal oxygenation in selected patients, in services where this resource exists. For the clinician, the point is that resuscitation of the drowning victim does not end on the beach: it continues during transport and in the hospital, with the same attention to oxygenation.

Safety of the rescuer

The European guideline recommends a dynamic risk assessment before the rescue, taking into account feasibility, the chances of survival and the risks to the rescuer (Lott et al., 2021). For the layperson, this means that entering the water unprepared can create a second victim. Throwing a floating object, extending a pole or calling trained help is usually safer than swimming to the victim.

What changes the prognosis

Quan et al., in a systematic review with meta-analysis, looked for factors available at the drowning site that could help predict the outcome (Quan et al., 2016). The strongest factor was the duration of submersion: the shorter it is, the greater the chance of a good outcome. Faster emergency service responses were also associated with better outcomes, but the victim's age, the water temperature and whether the drowning was witnessed or not showed no difference.

The cold water myth

Quan et al. studied open water drowning victims in a cold water region and found no protective effect of cold water (Quan et al., 2014). The estimated duration of submersion was the strongest factor, and most of those with a good outcome were submerged for only a few minutes. The European guideline, following the international committee, advises against using age, response time, type of water, water temperature or witness accounts to make prognostic decisions (Lott et al., 2021).

Why we have few answers

Koon et al. reviewed the studies on on-site prognostic factors and found many gaps (Koon et al., 2021). Most studies came from high-income countries, used a single data source, included only those who received medical care and measured survival or death, without assessing neurological function. Few studies analyzed factors from the rescue and resuscitation. For the clinician, this means that the decision to start and continue resuscitation must rest on a few solid factors, not on impressions.

The cervical spine: when to suspect injury

Watson et al. studied submersion victims in a region over more than two decades and found cervical spine injury in a very small proportion of them (Watson et al., 2001). All the victims with injury had drowned in open water, had clinical signs of severe injury and had a history of diving, motor vehicle crash or a fall from a height. No spine injury was found in submersions without impact.

What this changes in practice

Watson et al. concluded that routine immobilization of the cervical spine does not seem justified by the history of submersion alone (Watson et al., 2001). For the reasoning, the right question is not "did they drown?" but "was there trauma?". Diving into shallow water, a fall from a height, a boat or vehicle crash and signs of severe injury change the approach. In the absence of these clues, immobilizing the spine can delay opening the airway and ventilation, which are the priority.

Those who came out of the water and seem fine

The European guideline advises assessing consciousness and breathing in every victim pulled from the water (Lott et al., 2021). If the person is conscious or breathing normally, the goal becomes preventing cardiac arrest. The assessment includes respiratory rate, use of accessory muscles, ability to speak full sentences, oxygen saturation, percussion and auscultation of the chest, and the guideline suggests ordering a chest X-ray.

Oxygen in the right amount

The European guideline recommends high-concentration oxygen for life-threatening hypoxia until saturation or blood gases can be measured reliably, and then adjusting oxygen to keep saturation within a target range (Lott et al., 2021). The same guideline suggests considering non-invasive ventilation when there is respiratory distress and the procedure is safe, and invasive ventilation when non-invasive ventilation is not safe or cannot be started.

Temperature, circulation and consciousness

The European guideline also advises measuring heart rate and blood pressure, placing a cardiac monitor, obtaining venous access, assessing the level of consciousness and measuring core temperature (Lott et al., 2021). When core temperature is below thirty-five degrees, the hypothermia algorithm comes into play. The uniform data recording guideline on drowning recommends describing the severity of lung injury, for example whether auscultation is normal, whether the patient is coughing and whether there are crackles on one or both sides (Idris et al., 2017).

Why observe

Persistent cough, rapid breathing, crackles and lower saturation are signs that water reached the lungs. These signs can be subtle in the first minutes and worsen later. The exact observation time for someone who leaves the water without symptoms varies between protocols and is a point the local team needs to define. What does not vary is the principle: anyone with any respiratory sign after a drowning needs to be assessed by a professional, and not released based on appearance. The post about diagnostic uncertainty shows how to handle conditions that can change in the following hours.

After discharge

Someone who has had a drowning with lung injury may be discharged with recommendations about warning signs, such as shortness of breath, fever, worsening cough or drowsiness. Bierens et al. recall that the final outcome depends on injury to the heart, lungs and brain (Bierens et al., 2016). For this reason, children and adults who needed resuscitation deserve follow-up of development, memory and behavior, in addition to respiratory assessment. The family also usually needs support after such a frightening event.

Severity and management: a table for care

The table below summarizes, in a teaching format, common situations after a drowning and what usually weighs on the decision. It simplifies a complex topic and does not replace current guidelines, practical training or local protocols.

Situation	What weighs on the decision	Frequent management
No cough, normal breathing, normal auscultation	Low risk of lung injury	Assessment by a professional and guidance on warning signs
Persistent cough or rapid breathing	Possible aspiration of water	Assessment with saturation, auscultation and observation
Crackles, low saturation or discomfort	Lung injury	Adjusted oxygen, radiography, admission and ventilatory support
Unconscious, no normal breathing	Severe hypoxia	Resuscitation with ventilations and compressions
Diving, fall from height or signs of trauma	Possible spinal injury	Consider spinal protection without delaying ventilation
Low core temperature	Associated hypothermia	Follow the hypothermia algorithm

Prevention: the treatment that comes first

The World Health Organization, in its global report on drowning, describes drowning as one of the leading causes of death among children and young people and proposes evidence-based prevention measures (World Health Organization, 2014). Among them are barriers that control access to water, safe and supervised places for small children away from water, swimming and water safety instruction for school-age children, and training of ordinary people in safe rescue and resuscitation.

The clinician's role in prevention

For the clinician, the consultation after a drowning is also a moment for prevention. Asking who was supervising, whether there was a barrier around the pool, whether the child can swim and whether anyone in the family knows how to perform resuscitation turns the episode into guidance. The update from the American Heart Association and the American Academy of Pediatrics recalls that children are among the main victims of drowning (McCallin et al., 2024). The post about clinical reasoning exercises in pediatrics shows how family context enters the assessment of the child.

The biases that get in the way of assessment

Drowning is rarely managed poorly for lack of knowledge. It is usually managed poorly because of predictable habits and biases:

1. Releasing the victim because they are awake and crying, without assessing breathing.
2. Focusing only on compressions and forgetting that the central problem is the lack of oxygen.
3. Immobilizing the spine routinely and delaying ventilation when there was no trauma.
4. Relying on cold water as a protective factor to decide about resuscitation.
5. Forgetting to measure core temperature and to think of hypothermia.

Croskerry describes anchoring and premature closure among the most frequent cognitive errors in diagnosis (Croskerry, 2003). The post about diagnostic pause shows how a short moment of verification helps to notice what was left out. The post about heuristics in clinical reasoning helps to recognize when the first impression is deciding in place of the assessment.

What to ask and observe

Some questions and observations organize the care:

• How long was the victim underwater, according to those who saw it?
• Was there a dive, a fall from a height, a boating accident or other trauma?
• Is the victim coughing, breathing fast or working hard to breathe?
• How are the oxygen saturation, the auscultation and the level of consciousness?
• What is the core temperature?
• Who was supervising and what prevention measures exist at the site?

Back to the scene

In the opening scene, the professional who organizes the reasoning does not let herself be carried away by the reassuring crying. She observes the fast breathing, listens to the cough, measures the oxygen saturation, auscultates the chest and measures the temperature. She explains to the mother that the persistent cough may indicate that water reached the lungs and that, for this reason, the girl needs to be assessed and observed in a health service, even if she seems well. She asks whether there was a dive or a fall and, since there was no trauma, she does not immobilize the spine. At the end, she talks about supervision and barriers around the pool. The reasoning starts with breathing, not with appearance.

How NEXO helps train this reasoning

In NEXO, the case of the day is fictional, with a real clinical presentation and up to six progressive clues. You propose a diagnosis by searching for the ICD-10 code and receive proximity feedback at five levels, which shows whether the guess landed on the exact code, the same category, the same group, the same chapter or a different chapter. This format connects with the theme of this text: a discreet symptom, such as a cough that does not go away, can change the reading of a patient who seemed well.

To use the case of the day as training, try three habits. Before each guess, ask which organ is suffering first. When a reassuring clue appears, ask what it does not explain. After the result, note which clue would have anticipated the diagnosis.

Three exercises with cases

Look for the mechanism. In each case, ask whether the problem started in the heart, the lungs or elsewhere.

Be suspicious of improvement. Reread a case asking what could get worse in the following hours.

Separate trauma from non-trauma. Faced with an accident, ask which clues justify protecting the spine.

The post about case-based learning in clinical practice shows how cases help fix patterns that rarely appear in daily practice.

The limits on using the game are described on the NEXO economy page. If you research teaching of clinical reasoning, the page for researchers explains how to get in touch. Professionals who write or review cases find information on curation and on creators, and institutions can learn about the proposal on the partnerships page.

Frequently asked questions

Why is ventilation so important in drowning?

Because cardiac arrest in drowning is usually a consequence of lack of oxygen. Without ventilation, compressions circulate blood with little oxygen.

Should you try to remove water from the lungs before resuscitating?

The cited guidelines do not include maneuvers to remove water from the lungs. The recommendation is to start resuscitation with ventilations and compressions as soon as it is safe.

Does every drowning victim need spine immobilization?

No. The cited study found spine injury only in victims with trauma, such as a dive, a fall from a height or a vehicle accident.

Does cold water protect the victim?

The cited reviews found no protective effect of water temperature. The duration of submersion was the factor most linked to the outcome.

Can someone who came out of the water coughing go home?

Persistent cough, fast breathing, altered auscultation or low oxygen saturation call for assessment and observation in a health service.

Does the defibrillator help in drowning?

It helps and it is safe, but shockable rhythms are less common in drowning. Ventilations and compressions should not be delayed while the device is prepared.

Final checklist

• I assessed safety before the rescue.
• I started resuscitation with ventilations when the victim was not breathing normally.
• I asked about trauma before deciding on spine protection.
• I assessed breathing, oxygen saturation, auscultation, consciousness and core temperature.
• I referred anyone with any respiratory sign for observation.
• I talked about supervision, barriers and resuscitation as prevention.

Want to practice your reasoning with progressive clues? Play today's case.

References

1. Bierens JJ, Lunetta P, Tipton M, et al. Physiology of drowning: a review. Physiology (Bethesda). 2016. PMID 26889019.
2. Bierens J, Bray J, Abelairas-Gomez C, et al. A systematic review of interventions for resuscitation following drowning. Resusc Plus. 2023. PMID 37424769.
3. Croskerry P. The importance of cognitive errors in diagnosis and strategies to minimize them. Acad Med. 2003. PMID 12915363.
4. Idris AH, Bierens JJLM, Perkins GD, et al. 2015 revised Utstein-style recommended guidelines for uniform reporting of data from drowning-related resuscitation: an ILCOR advisory statement. Circ Cardiovasc Qual Outcomes. 2017. PMID 28716971.
5. Koon W, Clemens T, Bierens J, Quan L. Studying outcome predictors of drowning at the scene: why do we have so few answers? Am J Emerg Med. 2021. PMID 33069542.
6. Lott C, Truhlář A, Alfonzo A, et al. European Resuscitation Council Guidelines 2021: cardiac arrest in special circumstances. Resuscitation. 2021. PMID 33773826.
7. McCallin TE, Dezfulian C, Bierens J, et al. 2024 American Heart Association and American Academy of Pediatrics focused update on special circumstances: resuscitation following drowning. Pediatrics. 2024. PMID 39530213.
8. Quan L, Bierens JJ, Lis R, et al. Predicting outcome of drowning at the scene: a systematic review and meta-analyses. Resuscitation. 2016. PMID 27154004.
9. Quan L, Mack CD, Schiff MA. Association of water temperature and submersion duration and drowning outcome. Resuscitation. 2014. PMID 24607870.
10. Szpilman D, Bierens JJ, Handley AJ, et al. Drowning. N Engl J Med. 2012. PMID 22646632.
11. Watson RS, Cummings P, Quan L, et al. Cervical spine injuries among submersion victims. J Trauma. 2001. PMID 11586155.
12. World Health Organization. Global report on drowning: preventing a leading killer. 2014. Document.