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DrowningWorkup
Author:GPatriciaCantwell,MD,FCCMChiefEditor:JoeAlcock,MD,MSmore...
Updated:Aug25,2014

ApproachConsiderations
Managementofhypoxemiaisthekeytothemanagementofdrowning.Asurprisingdegreeofhypoxiamaybe
presentinarelativelyasymptomaticpatient.Obtaincontinuouspulseoximetry.
Obtainarterialbloodgas(ABG)levelsinallpatientswithanyhistoryofsubmersioninjury.ABGanalysisis
probablythemostreliableclinicalparameterinpatientswhoareasymptomaticormildlysymptomatic.ABG
analysisshouldincludecooximetrytodetectmethemoglobinemiaandcarboxyhemoglobinemia.
Rememberthatcervicalspinetraumamaybepresentinanyvictimofshalloworrockywaterimmersioninjury.
Ifthevictimisunabletogiveaclearhistoryoftheevents,hasevidenceofheadorfacialinjury,orisfound
unresponsiveinapoolorothershallowbodyofwater,protectthecervicalspineuntilinjuryisexcluded.
Obtainbloodforarapidglucosedetermination,completebloodcount(CBC),electrolytelevels,lactatelevel,and
coagulationprofile,ifindicated.Collecturineforurinalysis,ifindicated.Measureliverenzymes,especially
aspartateaminotransferaseandalanineaminotransferase.Considerabloodalcohollevelandurinetoxicology
screenforuseofdrugs.CardiactroponinItestingmaybeusefulasamarkertopredictchildrenwhohavean
elevatedriskofnotsurvivingtohospitaldischarge.

Renalfunctiontests
Ifinitialtestresultsshowelevatedserumcreatininelevel,markedmetabolicacidosis,abnormalurinalysis,or
significantlymphocytosis,serialestimationsofserumcreatinineshouldbeperformed.
Acuterenalimpairmentisknowntooccurfrequentlyindrowning,and,whileusuallymild(serumcreatininelevel
<0.3mmol/Lor3.4mg/dL),severerenalimpairmentrequiringdialysismayoccur.

Radiography
Chestradiographymaydetectevidenceofaspiration,pulmonaryedema,orsegmentalatelectasissuggesting
thepresenceofforeignbodies(eg,siltorsandaspiration).Itmayalsobeusedforevaluationofendotracheal
(ET)tubeplacement.Extremity,abdominal,orpelvicimagingmaybeusedifclinicallyindicated.

Computedtomography
Acervicalspineradiographorcomputedtomography(CT)scanisindicatedinindividualswithahistoryof
possiblecervicaltraumaorwithneckpainorifdoubtexistsaboutthecircumstancessurroundingthesubmersion
injury.NoncontrastheadCTscanningisalsoindicatedinanindividualwithalteredmentalstatusanda
suggestiveorunclearhistory.

Electrocardiography
Electrocardiography(ECG)shouldbeperformedinpatientswithsignificanttachycardia,bradycardia,or
underlyingcardiacdisease.ConsiderECGifthepatienthasarrhythmiasorifarrhythmiasaresuspected. [10]
MonitorthepatientwithECGifrewarmingisnecessary,becausedysrhythmiasarecommonwhenrewarming
patientswhosuffercoldwaterimmersioninjuries.

Cathetermonitoring
ASwanGanzcatheterformonitoringcardiacoutputandrelatedhemodynamicparametersmaybeusefulin
patientswithunstablecardiovascularstatusorinthosewhorequiremultipleinotropicandvasoactivemedication
requirements.
Intracranialpressuremonitoringisusedinpatientswithtraumaticbraininjuryormasslesions(eg,hematomas).
Urinarycatheterizationforongoingurineoutputmeasurementmaybewarranted.

ContributorInformationandDisclosures
Author
GPatriciaCantwell,MD,FCCMProfessorofClinicalPediatrics,Chief,DivisionofPediatricCriticalCare
Medicine,UniversityofMiami,LeonardMMillerSchoolofMedicineMedicalDirector,PalliativeCareTeam,
Director,PediatricCriticalCareTransport,HoltzChildren'sHospital,JacksonMemorialMedicalCenterMedical
Manager,FEMA,UrbanSearchandRescue,SouthFlorida,TaskForce2PediatricMedicalDirector,TilliKids
PediatricInitiative,DivisionofHospiceCareSoutheastFlorida,Inc
GPatriciaCantwell,MD,FCCMisamemberofthefollowingmedicalsocieties:AmericanAcademyofHospice
andPalliativeMedicine,AmericanAcademyofPediatrics,AmericanHeartAssociation,AmericanTrauma
Society,NationalAssociationofEMSPhysicians,SocietyofCriticalCareMedicine,andWildernessMedical
Society
Disclosure:Nothingtodisclose.
Coauthor(s)
MichaelJVerive,MD,FAAPMedicalDirector,PediatricIntensiveCare,DepartmentofPediatrics,StMary's
HospitalforWomenandChildren
MichaelJVerive,MD,FAAPisamemberofthefollowingmedicalsocieties:AmericanAcademyofPediatrics,
AmericanCollegeofChestPhysicians,PediatricSedation,andSocietyofCriticalCareMedicine
Disclosure:Nothingtodisclose.

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WilliamHShoff,MD,DTM&HDirector,PENNTravelMedicineAssociateProfessor,Departmentof
EmergencyMedicine,HospitaloftheUniversityofPennsylvania,UniversityofPennsylvaniaSchoolofMedicine
WilliamHShoff,MD,DTM&Hisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians,
AmericanSocietyofTropicalMedicineandHygiene,InternationalSocietyofTravelMedicine,Societyfor
AcademicEmergencyMedicine,andWildernessMedicalSociety
Disclosure:Nothingtodisclose.
ChiefEditor
JoeAlcock,MD,MSAssociateProfessor,DepartmentofEmergencyMedicine,UniversityofNewMexico
HealthSciencesCenter
JoeAlcock,MD,MSisamemberofthefollowingmedicalsocieties:AmericanAcademyofEmergencyMedicine
Disclosure:Nothingtodisclose.
AdditionalContributors
BarryJEvans,MDAssistantProfessorofPediatrics,TempleUniversityMedicalSchoolDirectorofPediatric
CriticalCareandPulmonology,AssociateChairforPediatricEducation,TempleUniversityChildren'sMedical
Center
BarryJEvans,MDisamemberofthefollowingmedicalsocieties:AmericanAcademyofPediatrics,American
CollegeofChestPhysicians,AmericanThoracicSociety,andSocietyofCriticalCareMedicine
Disclosure:Nothingtodisclose.
EddySLang,MDCM,CCFP(EM),CSPQAssociateProfessor,SeniorResearcher,DivisionofEmergency
Medicine,DepartmentofFamilyMedicine,UniversityofCalgaryFacultyofMedicineAssistantProfessor,
DepartmentofFamilyMedicine,McGillUniversityFacultyofMedicine,Canada
EddySLang,MDCM,CCFP(EM),CSPQisamemberofthefollowingmedicalsocieties:AmericanCollegeof
EmergencyPhysicians,CanadianAssociationofEmergencyPhysicians,andSocietyforAcademicEmergency
Medicine
Disclosure:Nothingtodisclose.
JamesMartin,MDFellow,DepartmentofEmergencyMedicine,DivisionofHyperbaricMedicine,Hospitalofthe
UniversityofPennsylvania
Disclosure:Nothingtodisclose.
RobertLNorris,MDProfessor,DepartmentofSurgery,Chief,DivisionofEmergencyMedicine,Stanford
UniversityMedicalCenter
RobertLNorris,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofEmergencyPhysicians,
AmericanMedicalAssociation,CaliforniaMedicalAssociation,InternationalSocietyofToxinology,Societyfor
AcademicEmergencyMedicine,andWildernessMedicalSociety
Disclosure:Nothingtodisclose.
SuzanneMooreShepherd,MD,MS,DTM&H,FACEP,FAAEMProfessorofEmergencyMedicine,Education
Officer,DepartmentofEmergencyMedicine,HospitaloftheUniversityofPennsylvaniaDirectorofEducation
andResearch,PENNTravelMedicineMedicalDirector,FastTrack,DepartmentofEmergencyMedicine
SuzanneMooreShepherdisamemberofthefollowingmedicalsocieties:AlphaOmegaAlpha,American
AcademyofEmergencyMedicine,AmericanSocietyofTropicalMedicineandHygiene,InternationalSocietyof
TravelMedicine,SocietyforAcademicEmergencyMedicine,andWildernessMedicalSociety
Disclosure:Nothingtodisclose.
FranciscoTalavera,PharmD,PhDAdjunctAssistantProfessor,UniversityofNebraskaMedicalCenterCollege
ofPharmacyEditorinChief,MedscapeDrugReference
Disclosure:MedscapeSalaryEmployment

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