Part of the ICU Emergencies Hub — browse every related guide in one place.
Drowning is respiratory impairment from submersion or immersion in liquid — and whether or not the patient survives the water, the injury that lands them in the ICU is almost always in the lungs. Aspirated water washes out surfactant, floods and inflames the alveoli, and sets up a picture that can progress to ARDS over hours. Layered on top is the hypoxic-ischemic brain injury from the minutes without oxygen, which ultimately determines neurologic outcome. The nurse manages oxygenation and ventilation, watches for the delayed pulmonary deterioration, and supports the brain and temperature after a near-fatal event. This guide covers the modern terminology, the pathophysiology, and the ICU course.
Consensus guidelines have retired the confusing older terms. There is no clinically useful "dry drowning" or "secondary drowning," and "near drowning" and "wet/dry drowning" are no longer recommended. The reason matters at the bedside: those labels implied distinct diseases and sometimes led families or clinicians to expect a mysterious delayed collapse days later in an asymptomatic child. The accurate picture is simpler — drowning is a single process with a spectrum of outcomes, and a patient who actually aspirated and is symptomatic needs care and monitoring, while a truly asymptomatic patient with a normal exam and oxygenation after an observation window is reassuring.
When water reaches the alveoli, it washes out surfactant — the substance that keeps alveoli open — so they collapse and the lung becomes stiff and poorly oxygenating. The aspirated fluid and any contaminants trigger inflammation and pulmonary edema, creating a ventilation-perfusion mismatch and shunt that drives hypoxemia. Whether the water was fresh or salt makes little practical difference to how you support the patient; both damage the alveolar-capillary interface, and the treatment — oxygen and lung-protective ventilation — is the same. Over the following hours this can evolve into full acute respiratory distress syndrome, which is why a patient can arrive talking and later require intubation.
Support scales with severity. Mild cases need supplemental oxygen and observation. Worsening hypoxia is met with noninvasive support (CPAP/BiPAP) or high-flow to recruit collapsed alveoli, and frank respiratory failure requires intubation and mechanical ventilation. When ARDS develops, the same principles apply as in any ARDS: lung-protective, low-tidal-volume ventilation, adequate PEEP to keep alveoli open, and permissive strategies to limit further injury. Prophylactic antibiotics are not routine — they are reserved for suspected infection or drowning in grossly contaminated water, and bronchospasm may need bronchodilators.
The other half of drowning is the hypoxic-ischemic insult to the brain during the minutes of impaired oxygenation, and this is usually what determines survival with good function. Post-arrest care applies: support oxygenation and perfusion, avoid hypoxia and hypotension that would extend the injury, and manage temperature carefully — fever is harmful to the injured brain and is aggressively avoided. Many drowning patients, especially in cold water, are also hypothermic, which complicates the picture: cold can be neuroprotective, and a cold, pulseless drowning victim is resuscitated with the same "not dead until warm and dead" caution used in hypothermia. Seizures, cerebral edema, and prolonged coma are all possible, and neurologic prognosis is deliberately deferred until enough time and rewarming have passed.
Pair this with the accidental hypothermia guide for the cold-water victim, the delayed sequence intubation guide for securing the hypoxic airway, and the heat stroke guide for the other end of the environmental spectrum.
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