Pediatric Drowning & Submersion Injuries

Every summer, emergency departments care for children pulled from pools, lakes, rivers, and oceans —many arriving without the dramatic rescues seen in the movies.  Pediatric drowning is quick, quiet, and remains one of the leading causes of preventable death in children, with the minutes after rescue often determining the child’s outcome.  From initial resuscitation to avoiding common management pitfalls, here’s a sun-soaked scrumptious morsel with everything emergency clinicians needs to know before the next submersion injury rolls through the ED doors.  Aquaman can’t save them all… many will depend on YOU.

Pediatric Submersion Injuries: Terminology…

The most widely accepted and universally endorsed definition of drowning, established at the 2002 World Congress on Drowning and adopted by the WHO, is “the process of experiencing respiratory impairment from submersion/immersion in liquid.” [1-3]

Importantly:

• Submersion: airway goes below the water surface (leading to aspiration and drowning)
• Immersion: airway remains above the water surface (hypothermia, rather than aspiration, may be the primary concern) [2]

• Fatal drowning: the person dies as a result of drowning
• Non-fatal drowning with morbidity: survival with injury (further subdivided into moderate disability, severe disability, vegetative state/coma, brain death)
• Non-fatal drowning without morbidity: survival without injury [1-2]

Terms such as “near drowning,” “dry drowning,” “wet drowning,” “secondary drowning,” “active drowning,” and “passive drowning” are no longer recommended and should be abandoned, as they are imprecise, confusing, and hinder accurate data collection and clinical communication. [1-2,4]

Pediatric Submersion Injuries: Epidemiology

• Drowning is the leading cause of unintentional injury death in US children aged 1–4 years
• Drowning is the third leading cause among children and adolescents aged 5–19 years [3]

Globally, the WHO estimates over 350,000 drowning deaths annually, with an average of 5,000 fatal and 8,000 non-fatal drownings per year in the United States alone [5]

Pediatric Submersion Injuries: Risk Factors

• Age: Toddlers (especially 2-year-olds) and male adolescents are at highest risk [3,6]
• Sex: Males are disproportionately affected (62.3% of hospitalizations) [6]
• Underlying medical conditions: Seizure disorders, undiagnosed cardiac defects and arrhythmias, and autism spectrum disorder increase drowning risk [3]

Pediatric Submersion Injuries: Pathophysiology

The drowning process follows a predictable physiological cascade: 

• When water enters the airway, the initial reflex is coughing; brief laryngospasm may occur but is rapidly terminated by hypoxia [1]
• Continued aspiration leads to surfactant dysfunction and washout, disruption of the alveolar-capillary membrane, increased permeability, and fluid shifts, which produces a non-cardiogenic pulmonary edema with decreased lung compliance, atelectasis, bronchospasm, and ventilation-perfusion mismatch [1,8]

Progressive hypoxemia leads to loss of consciousness, apnea, and a characteristic cardiac rhythm deterioration sequence: tachycardia → bradycardia → PEA → asystole

• This entire process can occur within seconds to minutes, though hypothermia or ice-water submersion may prolong it [1]

Saltwater and freshwater aspiration cause similar degrees of injury through different osmotic mechanisms but share the same final common pathway: hypoxemia! [1,8]

Pediatric Submersion Injuries: Management

Initial ED evaluation should typically include [11]:

• Pulse oximetry and capnography
• Chest radiography
• POC glucose and electrolyte levels
• Venous/arterial blood gas (for more substantial cases)

Cervical spine immobilization is not routinely recommended unless history or physical findings suggest spinal injury [5,10]

A low hemoglobin/hematocrit should lead you to consider other occult trauma… not hemodilution! [1-2]

• Typically, humans aspirate 1-3 mL/kg [2]
• In order to see significant electrolyte changes, a person has to aspirate >11mL/kg [2]
  • If a person were to aspirate either >11 mL/kg, it would be evident clinically!!

The 2024 AHA/AAP Focused Update and the 2025 AHA Guidelines represent the most current evidence-based recommendations for drowning resuscitation!

• Ventilation. Is. Paramount. Because drowning-related cardiac arrest is fundamentally hypoxic in etiology, CPR with rescue breathing should be initiated for any unconscious, non-breathing child removed from the water [3,5,9-10]
• Initiate BiPAP early for patients with evidence of increased work of breathing, or evidence of atelectasis or pulmonary edema on chest x-ray.
• High Quality CPR prioritized over Shocking: In a significant departure from general cardiac arrest management, CPR is prioritized over AED application in drowning:
  • Only 2–12% of drowning-related cardiac arrests present with an initial shockable rhythm
  • One study found that pre-EMS AED application was associated with decreased likelihood of favorable neurological outcome (aOR 0.42; 95% CI 0.23–0.77), likely due to delays in initiating high-quality CPR [5,9-10]

• For our fellow lifeguards and EMS first responders: in-water rescue breathing, when it can be done safely by trained professionals, has demonstrated higher odds of ROSC, survival to discharge, and favorable neurological outcome compared with delayed resuscitation, according to one retrospective study [5]

Skip routine antibiotics after drowning. Treat only if pulmonary infection develops or after submersion in grossly contaminated water (e.g., a septic tank)

Ventilatory settings for an intubated pediatric drowning patient should follow a lung-protective ventilation (LPV) strategy modeled on ARDS protocols, as the lung injury pattern in drowning — surfactant dysfunction, alveolar flooding, noncardiogenic pulmonary edema — closely mirrors ARDS pathophysiology [1-2]

• No drowning-specific ventilator trials exist, so recommendations are extrapolated from PARDS (Pediatric ARDS) guidelines [1][3]

Recommended Initial Vent Settings:

• Tidal volume (Vt): 5–8 mL/kg predicted body weight if respiratory system compliance is preserved; 3–6 mL/kg if compliance is significantly reduced (as is common in severe drowning with extensive aspiration) [1-2,8,13]
• Plateau pressure: ≤ 28 cm H₂O (up to 30–32 cm H₂O if high chest wall elastance is seen)
• Driving pressure (Pplat − PEEP): ≤ 15 cm H₂O, the variable most strongly associated with survival in PARDS
• PEEP: Start at 5–8 cm H₂O for infants, 5–10 cm H₂O for children, and 5–12 cm H₂O for adolescents, then titrate upward using the ARDSNet lower PEEP/FiO₂ table. For severe PARDS, moderately elevated PEEP of 10–15 cm H₂O is recommended, with higher levels considered if needed. Importantly, using lower PEEP relative to FiO₂ than recommended by the ARDSNet table has been associated with higher mortality in PARDS. [4][6-8]
• Respiratory rate: Age-appropriate — approximately 30–40 for infants, 20–30 for children, 10–16 for adolescents
• SpO₂ targets: 92–97% for mild-to-moderate PARDS
  • 88–92% is acceptable for severe PARDS once PEEP is ≥10 cm H₂O
• Permissive hypercapnia: pH 7.15–7.30 to adhere to lung-protective pressure limits

Targeted Temperature Management (TTM)?

• Current evidence does not support a protective effect of colder water temperatures for drowning victims. [3,12]
• The THAPCA-OH trial found that children with drowning-associated cardiac arrest treated with TTM to 32–34°C did not have better outcomes than those treated with TTM to 36–37.5°C.

Extracorporeal Membrane Oxygenation (ECMO): has been used for rewarming and cardiopulmonary support in cold-water drowning

• According to the ELSO registry, survival was 54% among 198 children who received ECMO after drowning, though outcomes for those requiring ECPR were lower (23.4%)
• A case analysis of children ≤6 years with drowning-associated hypothermia and cardiac arrest found 92% survival with conventional rewarming vs. 41% with ECMO, though the ECMO group had more severe presentations [12]

Pediatric Submersion Injuries: Prognostic Factors and Outcomes

Submersion duration is the single strongest predictor of outcome [3]:

• Good outcomes (survival without neurologic sequelae) are associated with submersion <6 minutes and EMS response <10 minutes
• Poor outcomes are associated with submersion ≥6 minutes, with low likelihood of good outcome after >10 minutes
• Submersion >25 minutes is invariably fatal

Additional poor prognostic indicators include: prolonged apnea, fixed/dilated pupils, asystole or bradycardia on presentation, GCS <5, hypothermia, prolonged CPR duration, and need for intubation or inotropes [3]

• Contrary to previous belief, young age does not confer a protective effect on outcome

Pediatric Submersion Injuries: Prevention

Prevention remains the most effective intervention, as in-hospital treatment has not been demonstrated to independently improve drowning outcomes. [3] The AAP emphasizes multiple “layers of protection”: [3,5]

• Close, constant, attentive, and capable adult supervision around water
• Physical barriers (four-sided pool fencing with self-closing, self-latching gates)
• Water competency education (swimming and water safety skills)
• Life jacket use
• Bystander CPR training with ventilation
• Cultural- and community-based interventions targeting high-risk populations

Moral of the Morsel

• BiPAP early! BiPAP often! Submersion injuries lead to a plethora of lung irritating, lung collapsing, and lung maddening mechanisms.  Early initiation of positive pressure ventilation helps extensively!
• Don’t Blame the Fresh Water!  If the patient has a low hemoglobin, search for where the bleeding is. Don’t blame it on hemodilution. While there may be small clinical complications based on the salinity, temperature, and cleanliness of the water later on in the post-resuscitation course, it rarely, if at all, changes the management of your initial resuscitation and management.
• Drowning is Preventable. The AAP emphasizes multiple “layers of protection,” not only literally from the source of water, but from a community perspective as well. See how you can get involved in the community to help prevent drowning!

References:

1. Drowning. The New England Journal of Medicine. 2012. Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Published May 31, 2012. N Engl J Med 2012;366:2102-2110. DOI: 10.1056/NEJMra1013317. VOL. 366 NO. 22
2. Medical Society Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2024. Christopher A. Davis, MD, Andrew C. Schmidt, DO, Justin R. Sempsrott, MD, Seth C. Hawkins, MD, Ali S. Arastu, MD, Gordon G. Giesbrecht, PhD, Tracy A. Cushing, MD. Wilderness & Environmental Medicine Volume 35, Issue 1, March 2024, Pages 94S-111S
3. Council on Injury, Violence, and Poison Prevention. Prevention of Drowning. Sarah A. Denny, Linda Quan, Julie Gilchrist, Tracy McCallin, Rohit Shenoi, Shabana Yusuf, Jeffrey Weiss, Benjamin Hoffman.  Pediatrics August 2021; 148 (2): e2021052227. 10.1542/peds.2021-052227
4. van Beeck EF, Branche CM, Szpilman D, Modell JH, Bierens JJ. A new definition of drowning: towards documentation and prevention of a global public health problem. Bull World Health Organ. 2005 Nov;83(11):853-6. Epub 2005 Nov 10. PMID: 16302042; PMCID: PMC2626470.
5. 2024 American Heart Association and American Academy of Pediatrics Focused Update on Special Circumstances: Resuscitation Following Drowning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. Volume 150, Number 23.
6. Theodorou CM, Rajasekar G, McFadden NR, Brown EG, Nuño M. Epidemiology of paediatric drowning hospitalisations in the USA: a population-based study. Inj Prev. 2022 Apr;28(2):148-155. doi: 10.1136/injuryprev-2021-044257. Epub 2021 Aug 30. PMID: 34462333; PMCID: PMC9668587.
7. Clemens T, Moreland B, Lee R. Persistent Racial/Ethnic Disparities in Fatal Unintentional Drowning Rates Among Persons Aged ≤29 Years – United States, 1999-2019. MMWR Morb Mortal Wkly Rep. 2021 Jun 18;70(24):869-874. doi: 10.15585/mmwr.mm7024a1. PMID: 34138831; PMCID: PMC8220955.
8. Szpilman D, Morgan PJ. Management for the Drowning Patient. Chest. 2021 Apr;159(4):1473-1483. doi: 10.1016/j.chest.2020.10.007. Epub 2020 Oct 14. PMID: 33065105.
9. Arnold MJ MD, MHPE. Resuscitation After Drowning in Children: Updated Guidelines from the AHA and AAP. Am Fam Physician. 2026 Apr;113(4):402-403. PMID: 42101612.
10. Adult and Pediatric Special Circumstances of Resuscitation: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care; Part 10.  Circulation. Volume 152, Number 16
11. Prevention of and Emergency Response to Drowning. The New England Journal of Medicine. 2022. Girasek, DC; Hargarten, S. Published October 5, 2022. N Engl J Med 2022;387:1303-1308. DOI: 10.1056/NEJMra2202392. VOL. 387 NO. 14
12. Pediatric Post–Cardiac Arrest Care: A Scientific Statement from the American Heart Association. Circulation. Volume 140, Number 6.
13. Kneyber MCJ, Khemani RG, Bhalla A, Blokpoel RGT, Cruces P, Dahmer MK, Emeriaud G, Grunwell J, Ilia S, Katira BH, Lopez-Fernandez YM, Rajapreyar P, Sanchez-Pinto LN, Rimensberger PC. Understanding clinical and biological heterogeneity to advance precision medicine in paediatric acute respiratory distress syndrome. Lancet Respir Med. 2023 Feb;11(2):197-212. doi: 10.1016/S2213-2600(22)00483-0. Epub 2022 Dec 22. PMID: 36566767; PMCID: PMC10880453.