Wilderness Medical Society Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2024 Update

Abstract

The Wilderness Medical Society convened a panel to review available evidence supporting practices for acute management of drowning in out-of-hospital and emergency care settings. Literature about definitions and terminology, epidemiology, rescue, resuscitation, acute clinical management, disposition, and drowning prevention was reviewed. The panel graded available evidence supporting practices according to the American College of Chest Physicians criteria and then made recommendations based on that evidence. Recommendations were based on the panel's collective clinical experience and judgment when published evidence was lacking. This is the second update to the original practice guidelines published in 2016 and updated in 2019.

Full text

Wilderness Medical Society Clinical
Practice Guidelines for the Treatment and
Prevention of Drowning: 2024 Update
Christopher A. Davis, MD
1
, Andrew C. Schmidt, DO
2
,
Justin R. Sempsrott, MD
3
, Seth C. Hawkins, MD
1
,
Ali S. Arastu, MD
4
, Gordon G. Giesbrecht, PhD
5
,
and Tracy A. Cushing, MD
6
Abstract
The Wilderness Medical Society convened a panel to review available evidence supporting practices for acute management
of drowning in out-of-hospital and emergency care settings. Literature about definitions and terminology, epidemiology,
rescue, resuscitation, acute clinical management, disposition, and drowning prevention was reviewed. The panel graded
available evidence supporting practices according to the American College of Chest Physicians criteria and then made rec-
ommendations based on that evidence. Recommendations were based on the panel’s collective clinical experience and
judgment when published evidence was lacking. This is the second update to the original practice guidelines published
in 2016 and updated in 2019.
Keywords
submersion, immersion, cold water submersion, hypothermia
Introduction
Approximately 236,000 deaths globally are attributed to
drowning every year, although this number is believed to
underestimate the true number.
1
Drowning particularly
affects young persons and can have profound personal, emo-
tional, and financial consequences for patients, families, and
society. The goal of these practice guidelines is to reduce the
burden of drowning through improvements in treatment and
prevention. We present accepted drowning terminology as
part of a review and evaluation of literature regarding
acute care for drowning patients in both out-of-hospital
and emergency medical care settings, with a particular
focus on the wilderness context. The authors relied upon
the experience and knowledge of a panel of wilderness
and emergency medicine practitioners to make recommen-
dations where little or uncertain evidence was available.
This is the second update of these guidelines. The original
guidelines were published in 2016, and they were first
updated in 2019.
2,3
Methods
The authors of this update reviewed each section of the
original document to determine the relevance and need
for updating. Articles published between 2018 and 2022
were identified through PubMed, MEDLINE, and Google
Scholar using a keyword search appropriate to each topic.
Randomized controlled trials, observational studies, case
series, and review articles were reviewed and evidence
assessed. Abstracts for which the full article could not be
obtained were excluded. If no relevant studies were identi-
fied, recommendations were based on the panel’s clinical
experience and judgment. Recommendations were graded
using the updated 2018 American College of Chest
Physicians classification scheme, which is consistent with
1
Department of Emergency Medicine, Wake Forest University School of
Medicine, Winston-Salem, NC
2
Department of Emergency Medicine, University of Florida College of
Medicine-Jacksonville, Jacksonville, FL
3
International Drowning Researchers Alliance, Kuna, ID
4
Division of Pediatric Critical Care, Stanford University School of
Medicine, Palo Alto, CA
5
Laboratory for Exercise and Environmental Medicine, Faculty of
Kinesiology and Recreation, University of Manitoba, Winnipeg, Manitoba,
Canada
6
Emergency Medicine, US Acute Care Solutions, Boulder, CO
Received November 2023; accepted January 2024
Corresponding Author:
Christopher A. Davis, Assistant Professor of Emergency Medicine, Wake
Forest University School of Medicine, Winston-Salem, NC.
Email: christda@wakehealth.edu.
Wilderness Medical Society Clinical Practice Guidelines
Wilderness & Environmental Medicine
1-18
© Wilderness Medical Society 2024
Article reuse guidelines:
sagepub.com/journals-permissions
DOI: 10.1177/10806032241227460
www.wemjournal.org

all other Wilderness Medical Society Clinical Practice
Guidelines beginning in 2023
4
(see Supplemental File).
Terminology
The standard definition for drowning, according to the
World Congress on Drowning in 2002, is “the process of
experiencing respiratory impairment due to submersion or
immersion in liquid.”
2
Inspired by the Utstein Style for
reporting cardiac arrest data, the standard definition allows
for only 3 outcomes after drowning: nonfatal drowning
(with or without morbidity) and fatal drowning. This defini-
tion is based on the understanding that “respiratory impair-
ment occurs as the person’s airway goes below the surface
of the liquid (submersion) or water splashes over the face
(immersion).”
5
However, the inclusion of both submersion
and immersion in this definition may cause confusion with
the large body of work on survival and rescue related specif-
ically to cold water immersion, which focuses more on
hypothermia than on drowning. For the purposes of these
guidelines, which could include cold water conditions, a
further distinction is necessary. “Immersion”refers to a sit-
uation in which the airway is above water, whereas “sub-
mersion”refers to a situation in which the airway is
underwater. Thus, immersion in cold water may lead to
hypothermia (and only drowning if there is sufficient
airway exposure through splashes), and submersion at any
water temperature may lead to drowning. The following
modifiers should not be used in association with drowning:
near, wet, dry, active, passive, saltwater, freshwater, or sec-
ondary. Sufficient data related to human drowning patho-
physiology show that none of these modifiers is valid
because the final common pathway is hypoxemia and even-
tual cardiopulmonary arrest and because their definitions are
vague and sometimes erroneously linked to any type of
drowning at all.
2,5–7
By understanding and using
the standard definition for drowning and abstaining from
using incorrect terminology, communication among
medical practitioners, data collection entities, researchers,
and policymakers has become more consistent. Accurate
communication better reflects the true incidence, preva-
lence, and sequelae of drowning and should improve clinical
dialogue and management as well as promote a correct
understanding of drowning and its management in the
public—critically important in this condition that must
often initially be managed by bystanders.
7–9
Epidemiology
The highest-risk age group for drowning worldwide is chil-
dren 1 to 4 y old, primarily owing to unintentional falls into
water; the next highest-risk group is adolescents and young
adults in natural bodies of water. In the United States, there
were, on average, 4012 drowning deaths per year from 2005
to 2014, plus an additional 658 boating-related deaths.
10
In
2021, 81% of which were from drowning.
11
Although the
incidence of drowning has been gradually decreasing over
time, drowning remains the leading cause of injury-related
death for children aged 1 to 4 y. More than 90% of the
world’s drowning deaths occur in low- and middle-income
countries where reporting systems are underdeveloped and
significantly understate the true occurrence.
1
In the context
of low- and middle-income countries, natural sources of
water are often ubiquitous and lack barriers to entry. They
are used for transportation, cleaning, food, and hydration.
Based on the World Health Organization and Centers for
Disease Control and Prevention systems for classifying
drowning statistics, these numbers exclude deaths from
homicide, suicide, and those occurring during transport,
floods, storms, and other natural disasters. In 2010, there
were 12,900 emergency department (ED) visits in the
United States for drowning, with 20% of patients admitted
to the hospital. Drowning deaths were 48% more likely to
occur on weekends compared to weekdays. Fifty-three
percent of all male and 26% of all female drowning deaths
occurred in natural bodies of water.
10
The burden of drowning in high-income countries is
underreported because most studies only address the issue
of fatal drowning. In the United States, there were an
average of 8061 estimated emergency department visits
due to nonfatal drowning each year between 2011–2022.
12
Internationally, the burden of nonfatal drowning is more dif-
ficult to estimate because many patients may not present to
an emergency medical system or hospital, where data collec-
tion typically occurs.
10,13,14
In Bangladesh, a large
population-based study showed fatal and nonfatal drowning
rates of 15.8 per 100,000 and 318.4 per 100,000, respec-
tively, compared to 1.17 per 100,000 and 10 per 100,000
in the United States.
15,16
Risk factors for nonfatal drowning
are similar to those for fatal drowning.
15,17–21
Rescue of the Drowning Patient
Reaching the Patient
Rescuer safety is paramount during rescue operations; in the
aquatic environment, specific skills, training, and physical
capabilities are required. The physical characteristics of
aquatic environments vary widely, ranging from pools to
lakes, rivers, oceans, swift river water, and ice scenarios,
among others, each requiring different sets of equipment
and training for technical rescue. Few studies objectively
measure the effectiveness of in-water rescue techniques.
Much of the literature on this topic is based on the experi-
ences and policies of the writers or organizational authori-
ties. There is a high prevalence of fatal and nonfatal
drowning of untrained persons attempting to perform
in-water rescues, with 1 study reporting 114 rescuer
deaths during a 3-y period in Turkey alone.
22–24
Hazardous water conditions that led to the initial person
2Wilderness & Environmental Medicine

drowning often persist and place the well-intentioned
rescuer at risk of becoming an additional drowning
patient.
25
Rescue by untrained persons should be attempted
without entering hazardous conditions by reaching out to the
drowning patient with a paddle or branch; throwing a rope,
buoy, cooler, or any floating object; or rowing a boat, canoe,
or paddleboard to the patient. Trained rescue personnel
should operate according to their level of training, expertise,
equipment, and comfort level. Entering the water to perform
a rescue should be attempted only by persons with specific
training to operate in that dangerous environment. Few
studies have been conducted on the effectiveness of differ-
ent water safety devices (eg, rescue tubes, rescue cans,
throw bags, life rings), but what has been demonstrated is
that proper and effective use of these devices requires
basic knowledge of their function combined with regular
practice.
26
Recommendation: We recommend persons without
formal water rescue training attempt rescues from a safe
location by reaching for, throwing a rope or floating
object to, 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 evi-
dence to recommend specific rescue devices. If specialized
rescue equipment is available, participants should be famil-
iar with the location and purpose of this equipment, and des-
ignated rescue personnel with proper training should be
tasked with its use in the event of a water rescue. Strong rec-
ommendation, low-quality evidence.
Patients in Submerged Vehicles
Death from entrapment and drowning in submerged vehi-
cles is often not classified as a drowning death, confounding
attempts to accurately track the epidemiology of this type of
drowning.
27
Studies suggest that 10% of drowning deaths
may be due to entrapment in submerged vehicles, especially
during disasters, and that in the case of inland flooding, as
many as 10% of motor vehicle crashes result in a drowning
death.
28–31
There is a small body of medical and rescue lit-
erature on the topic of vehicle submersions.
29,32–37
A formal
review of educational and public service information identi-
fied “three probable significant contributors to [the] high
fatality rate [of drowning in submerged vehicles]: 1)
‘authorities’provide an inadequate description of vehicle
sinking characteristics; 2) contradictory and inadequate
advice is often provided; and 3) a poor public perception
of how to escape.”
32
Several sources recommend question-
able escape practices without supporting evidence. These
practices include allowing the passenger compartment to
fill with water so that it will be easier to open doors,
waiting until the vehicle sinks to the bottom of a body of
water to maintain orientation, relying on kicking out the
windshield or opening doors after the vehicle has fully
sunk, and relying on breathing trapped air in the passenger
compartment. In a formal survey, more than half of the
general public identified an option that involves staying in
a vehicle while it sinks to the bottom as being the safest
option when trapped in a submerging vehicle; this advice
often appears in the popular media.
36
Research data
derived from 35 vehicle submersions conducted in diverse
locations and seasons suggest this advice is erroneous.
The best time to escape from a submerging vehicle is imme-
diately during the initial floating phase, ideally during the
initial 30 s to 2 min after water entry when most vehicles
remain partially above the surface.
36
An algorithm, using
the acronym SWOC, has been developed to advise those
entrapped in water how to sequence escape actions. The
SWOC algorithm recommends the following sequencing
of actions before mobile phone use: Seatbelts off, Window
open (upstream window), Out immediately, Children
first.
37
The available research points out that electric
windows should work if engaged quickly; if necessary,
windows should be broken before water rises high enough
to push against them; children should be helped from the
oldest to youngest and before adults.
38,39
The rationale for
evacuating from oldest to youngest is that older children
are more likely to be able to follow instructions to exit the
vehicle and hold on or quickly be helped out of the
vehicle, allowing the adult to focus on the other children.
If starting with the youngest first, it is likely that the adult
would not be able to help the other children if they had to
assist other children while holding an infant. If the vehicle
is in moving water, recommendations are to open the
upstream window for egress, which will only be possible
if the water level is below the level of the window. The ratio-
nale behind this is that if one attempts to exit through the
downstream window, it increases the likelihood of being
swept away by a strong current. Therefore, exiting via the
upstream window would increase the chance that the
victim could climb on top of the roof to await rescue. In
2008, Priority Dispatch, a US-based proprietary
out-of-hospital emergency medical dispatcher system
added an addendum to its standardized protocols that
instructed emergency medical dispatchers not to persist in
getting a location for a caller in a submerging vehicle.
Instead, it recommends that a caller exit the vehicle immedi-
ately if it is submerging—before using precious time to
determine location—and using the SWOC protocol.
38,40
In
2010, the International Academies of Emergency Dispatch
(IAED) began work on revising their sinking vehicle proto-
col; in 2013, they approved a new protocol shifting
dispatcher priorities from establishing location to first
instructing victims on how to self-rescue and escape the
vehicle before it sinks.
38,39
An additional protocol was
developed in 2013 to address the subset of patients
drowning in floodwaters. Differences here include the
survival benefitinfloodwaters to a vehicle not floating
(vs survival benefit to vehicles floatingindeeperwater),
Davis et al. 3

the possibility of using a door, and specific recommenda-
tions to get on the roof after exiting rather than into the
water.
38,39
Recommendation. We recommend escaping from a sub-
merging vehicle immediately after it enters the water, during
the initial floating phase. If the vehicle remains floating, we
recommend people 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. Strong recommenda-
tion, moderate-quality evidence.
In-Water Resuscitation
The primary physiologic insult in a drowning patient is cere-
bral hypoxia; its rapid reversal is the primary objective of
drowning resuscitation. For the purpose of these guidelines,
in-water resuscitation (IWR) is defined as an attempt to
provide ventilation to a drowning patient who is still in
the water. This does not apply to chest compressions. It is
impossible to perform adequate chest compressions while
the victim and rescuer are in the water, and so they should
not be attempted.
41
Successful use of IWR was first
described in 1976, with a mannequin-based feasibility
study reported in 1980; however, the first clinical study to
show a positive patient outcome was not published until
2004.
42–44
Available outcome data for IWR are based on a single
retrospective analysis of lifeguard rescues in Brazil and
show significant improvement in survival and neurologic
outcome in persons receiving IWR. These rescues were per-
formed by trained, professional lifeguards in the ocean envi-
ronment. Lifeguards would frequently tow the patient
beyond breaking waves and perform mouth-to-mouth venti-
lations while awaiting helicopter pickup.
44
Subsequent
studies, primarily using mannequins, evaluated the ease of
performing this task in controlled aquatic environments
and found that IWR increases overall rescue time, subjective
rescue difficulty, number of submersions, and water aspira-
tion.
45,46
A single study comparing lifeguards to lay rescuers
when using IWR found that lifeguards showed improved
rescue times and decreased estimated pulmonary aspira-
tion.
47
A scoping review was conducted that showed
limited evidence, but a formal recommendation is forthcom-
ing from the International Liaison Committee on
Resuscitation. IWR may be considered in situations where
a trained rescuer determines that the rescuer’s safety, equip-
ment available, and distance to shore warrant its use, with
the understanding that rescuers should maintain their own
safety and stop at any time.
48
Similarly, there are no studies directly measuring patient
outcomes when CPR is performed in boats, but there are
numerous studies that show it is feasible.
48–53
We recom-
mend that CPR with or without chest compressions can be
performed in a moving boat if sufficiently safe for the rescu-
ers. Rescuer safety and prevention of communicable
diseases are of utmost importance, so consideration should
be given to the use of barrier devices during IWR. Food
and Drug Administration–approved, IWR-specific devices
are available that use a self-purging mechanical one-way
valve instead of the paper valve on standard CPR
masks.
54,55
Recommendation: We recommend that IWR be con-
sidered only by a rescuer with adequate training, ability,
and equipment to perform the skill safely and effectively
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 at this technically difficult
task. If conditions are too hazardous to safely perform
the task, rapid extrication is indicated without a delay for
IWR. We recommend not attempting chest compressions
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. Strong recommendation, low-quality
evidence.
Initial Resuscitation
Cardiopulmonary Resuscitation and Prioritization of
Airway
Because of the central role of hypoxemia in the pathophys-
iology of drowning, initial resuscitation should focus on
establishing and maintaining a patent airway and providing
oxygen at the highest concentration available, which may
include positive pressure ventilations. Recent updates to car-
diopulmonary resuscitation (CPR) algorithms, specifically
for the lay rescuer, include recommendations for
compression-only CPR and prioritization of compressions
before airway maneuvers.
56,57
Compression-only CPR is
likely to be of little to no benefit in drowning resuscitation,
and its use should be limited to bystanders not trained to
provide full (rescue breath and compression) CPR.
Bystander CPR for infants and children includes compres-
sions and ventilations, regardless of which is started first.
Professional rescuer CPR should emphasize prioritization
of airway and breathing with positive pressure ventilation
before initiation of chest compressions. If the airway is over-
looked in initial resuscitation, ongoing hypoxemia leads to
decreased survival and worse neurologic outcomes.
Incorrect administration of rescue breaths can delay care
and cause gastric insufflation and pulmonary aspiration.
For persons who are not trained, able, and/or willing to
give rescue breaths, compression-only CPR is still the rec-
ommended method of resuscitation. All persons who
might respond to a drowning person (eg, parents, trip
leaders, lifeguards) should take CPR classes that include
training on the proper use of chest compressions and
rescue breathing.
4Wilderness & Environmental Medicine

Recommendation: Supplying oxygen to the brain is crit-
ical to successful resuscitation of the drowning patient. We
recommend establishing an airway and providing oxygen as
priorities in initial resuscitation. For the patient in cardiac
arrest, we recommend positive pressure ventilation in addi-
tion 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 laypeople without train-
ing in rescue breathing, we recommend compression-only
CPR over no intervention. Strong recommendation, low-
quality evidence.
Oxygenation
Few large-scale studies have evaluated the use of different
airway adjuncts for resuscitating drowning patients.
Although ideal rescue breathing includes supplemental
oxygen and a positive pressure delivery device, any amount
of oxygen delivery (eg, mouth-to-mouth, bag-valve-mask
[BVM] with ambient air) is better than none if supplemental
oxygen is not available. Mannequin studies of supraglottic
airways have shown that lifeguards can successfully insert
them, but there is concern that this does not replicate real-world
usage.
58,59
Additional concern is that because of pulmonary
edema from drowning, certain supraglottic airway devices
may perform poorly for oxygenation based on leak pres-
sures.
60,61
If the supraglottic airway fails to achieve adequate
chest rise, a BVM or other method to oxygenate and ventilate
the patient should be used. BVM usage is a complex task that
is difficult to perform correctly, even with regular training.
Those with a duty to act should use a BVM only if it is part
of a competency-based training program with regular retrain-
ing and maintenance of equipment. Otherwise,
mouth-to-mouth or mouth-to-mask should be considered.
62
Recommendation: When resuscitating a drowning
patient, we recommend that oxygen initially be delivered
at the highest concentration available. For the patient in
respiratory distress or arrest, we recommend positive pres-
sure over passive ventilation. If multiple modalities are
available, the method that most effectively delivers the
highest concentration of oxygen should be used. If a modal-
ity or device fails, we recommend attempting BVM or
mouth-to-mouth ventilation. Strong recommendation, low-
quality evidence
Automated External Defibrillator
Although cerebral hypoxia is the primary cause of morbidity
in the drowning patient, hypoxic myocardial injury is also
likely to occur with prolonged hypoxemia. Typically,
drowning patients initially experience sinus tachycardia, fol-
lowed by bradycardia, pulseless electrical activity, and then
asystole, owing to the hypoxic nature of the event.
63
In
drowning patients, ventricular fibrillation (VF) is rare,
occurring in less than 10% of patients; thus, reversal of hyp-
oxemia with ventilations and compressions should not be
delayed in an attempt to apply an automated external defib-
rillator (AED).
63–69
Once resuscitation is established, early
application of an AED might be beneficial, given the possi-
bility of VF as the cause or result of drowning. In the drown-
ing patient, if global myocardial hypoxia persists, attempts
at defibrillation may be unsuccessful without concomitant
oxygenation and ventilation. Experimental animal models
have shown that as long as AED pads are placed firmly
on a patient’s chest and a rescuer is not in direct contact
with that patient, the use of an AED in a wet environment
does not pose an increased risk to the patient or rescu-
ers.
70–72
AEDs have been tested and noted to correctly
detect simulated arrhythmias and deliver shocks on
moving boats.
73
Recommendation: Shockable rhythms are rare in
drowning, so we recommend not incorporating an AED in
the initial minutes of drowning resuscitation to prevent inter-
ference with oxygenation and ventilation. If available and
resources allow, after oxygenation and ventilation have
been addressed, an AED should be used during the resusci-
tation of a drowning patient. AED use is not contraindicated
in a wet environment. Strong recommendation, high-quality
evidence.
Abdominal Thrusts
Drowning involves water obstructing the airway and
causing cerebral hypoxia; in some cases, small amounts of
water are aspirated into the lungs. This can cause atelectasis,
direct cellular injury, and pulmonary edema. Even after
unconsciousness, reflex swallowing of water from the hypo-
pharynx into the stomach may occur. Dr Henry Heimlich
advocated use of abdominal thrusts in initial treatment of
the drowning patient, claiming that aspirated water must
first be cleared from the airway to allow proper ventila-
tions.
74–76
In the 30 y since his original report, concern
has been raised about this recommendation, resulting in an
Institute of Medicine report and a systematic literature
review by the American Red Cross.
77,78
All of these inves-
tigations failed to identify quality data to support use of the
Heimlich maneuver before providing ventilations. Its use
during initial resuscitation delays delivery of ventilations
and prolongs hypoxemia.
77
In drowning resuscitation, the
upper airway is frequently occluded by water or vomit,
which should be cleared by standard suction techniques,
not abdominal thrusts. If the drowning was precipitated by
choking on food or a solid object, or if the airway is
occluded by a solid object that is preventing ventilation,
then the standard guidance for clearing foreign body
airway obstruction applies, which may include abdominal
thrusts/back blows if they are conscious or chest compres-
sions if unconscious.
Davis et al. 5

Recommendation: Owing to the possibility of delaying
ventilations, failing to clear liquid from the airway, and
worsening vomiting, abdominal thrusts (Heimlich maneu-
ver) are not recommended for resuscitation of the drown-
ing patient. Strong recommendation, moderate-quality
evidence.
Cervical Spine Precautions
Recent discussions and research in the field of
out-of-hospital medicine have brought to question the
utility, safety, and clinical benefit of what once was called
routine spine immobilization. The most current published
review of this topic specific to austere environments is the
Wilderness Medical Society Clinical Practice Guidelines
for Spinal Cord Protection: 2019 Update.
79
We recommend
reviewing the updated guidelines for current evidence on the
utility of this procedure.
Retrospective studies of drowning patients found the
incidence of cervical spine injuries was low (0.5% to 5%)
and that most injuries were related to diving from a height.
In patients without obvious signs of trauma or a known fall
or diving event, the risk of spine injury is low.
80,81
Another
recent study further suggests that patients with no history to
suggest axial spine loading are at exceptionally low risk of
cervical spine injury.
82
In patients without this specifictrau-
matic mechanism, treatment maneuvers focused on restricting
spine motion may distract rescuers from the critical role of
oxygenation and ventilation.
Recommendation: We recommend consulting the most
current Wilderness Medical Society Practice Guidelines
concerning the field treatment of possible spinal injuries
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.
Strong recommendation, low-quality evidence.
Hypothermia
Water is thermally neutral at approximately 33
°
C (91
°
F).
Because most patients drown in water at a lower temperature
than this, concomitant hypothermia is not uncommon.
28
The
main physiologic problem with drowning is brain hypoxia.
Current practice suggests that the brain can withstand longer
periods of hypoxia if the body is cooler than the normal
physiologic range. On one hand, leaving a patient moder-
ately cool, or warming them to a moderately cool degree,
could be beneficial or at least innocuous. On the other
hand, moderate-to-severe hypothermia should be corrected,
with the understanding that warming may be operationally
difficult in some drowning situations. Beyond initiation of
basic warming measures, the details of hypothermia treat-
ment, including augmented advanced life support measures,
are beyond the scope of these guidelines. Readers are
encouraged to review the most current version of the
Wilderness Medical Society Clinical Practice Guidelines
for the Out-of-Hospital Evaluation and Treatment of
Accidental Hypothermia.
83
Recommendation: We recommend evaluation for and
treatment of hypothermia. Strong recommendation, low-
quality evidence.
Postresuscitation Management
Oxygenation/Ventilation
Mechanical Ventilation. No literature is available comparing
out-of-hospital or in-hospital mechanical ventilation (MV)
strategies for the drowning patient. Current practice recom-
mends a lung protective ventilation (LPV) strategy similar to
that used for patients with acute respiratory distress syn-
drome (ARDS), on the premise that the lung injury pattern
after drowning is similar.
5,84,85
This includes MV starting
with a tidal volume (V
T
) of 6 to 8 mL/kg
−1
, augmentation
of V
T
and respiratory rate to maintain plateau pressure <
30 mm Hg, and augmentation of positive-end expiratory
pressure and fraction of inspired oxygen (F
I
O
2
) to maintain
partial pressure of arterial oxygen (P
a
O
2
)at55to80mmHg
(SpO
2
89–95%).
86
As many patients who require MV also
suffer from hypoxic cerebral injuries, it is difficult to deter-
mine the value of MV alone for survival.
87
Recommendation: We recommend following lung pro-
tective ventilation protocols for mechanical ventilation for
the drowning patient. Strong recommendation, low-quality
evidence.
Noninvasive Positive Pressure Ventilation. Noninvasive posi-
tive pressure ventilation (NIPPV) has been used success-
fully in the out-of-hospital setting. There are case reports
describing its successful use in drowning.
88–91
Similar to
MV, the addition of airway pressure to prevent atelectasis
and support respiratory muscle use while preventing hypox-
emia can be achieved with NIPPV. However, NIPPV can
only be used in spontaneously breathing patients and
should be used with caution in the drowning patient with
altered mental status because there may be an increased
risk of vomiting and aspiration. Drowning patients who
have mild to moderate hypoxemia and are being treated in
out-of-hospital and emergency medical systems using
NIPPV might benefit from this therapy. One small retro-
spective study showed similar neurologic outcomes and cor-
rection of hypoxemia and acidosis between patients treated
with early endotracheal intubation versus NIPPV after
6Wilderness & Environmental Medicine

drowning; in addition, patients receiving NIPPV had a lower
incidence of infection and decreased hospital and intensive
care unit length of stay.
92
This study also showed similar
levels of oxygenation and correction of hypoxemia with
MV and NIPPV; the limiting factor in use of NIPPV
remains the patient’s mental status and ability to cooperate
with the intervention.
92
Recommendation: We suggest considering the use of
noninvasive positive pressure ventilation only in alert
drowning patients with mild-to-moderate respiratory symp-
toms. Caution should be taken with any patient displaying
altered mental status and/or active emesis owing to the
potential for aspiration. Weak recommendation, low-quality
evidence.
Diagnostics
Radiologic Testing
Several retrospective ED studies of drowning patients found
that the initial chest radiograph did not correlate with arterial
blood gas levels, outcome, or disposition.
93–95
A study of
admitted drowning patients showed that those who went
on to develop acute lung injury or ARDS had abnormal
chest radiograph findings within the first few hours but
not necessarily on arrival to the ED.
84
Head computed
tomography (CT) has been studied in an attempt to quantify
anoxic brain injury in drowning patients. Retrospective
studies have found that patients with abnormal initial CT
all went on to develop severe brain injury or die, whereas
initially normal head CT had no prognostic value.
96
Recommendation: We do not recommend routine initial
chest radiographs, as 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 deter-
mining prognosis if obtained at the time of presentation.
We do not suggest a routine initial head CT, as a normal
initial head CT does not have prognostic value in the drown-
ing patient. Routine use of neuroimaging in the awake and
alert drowning patient is not recommended unless dictated
by a change in clinical status. Strong recommendation, low-
quality evidence.
Laboratory Testing
Canine studies performed in the 1960s showed clinically
significant hemodilution and red blood cell lysis associated
with salt, chlorine, and freshwater drowning.
97–99
These
studies were based on instilling up to 44 mL/kg
−1
of fluid
into the trachea of anesthetized dogs, far greater than the 1
to 3 mL/kg
−1
typically aspirated by human drowning
patients. Electrolyte abnormalities and hemodilution only
occurred in dogs that had 11 mL/kg
−1
or more instilled.
No studies have identified clinically significant electrolyte
or hematologic abnormalities in drowning patients that
help guide initial therapy or provide prognostic information.
In patients with altered mental status or decreased level of
consciousness, laboratory evaluation for alternative causes
that might have led to the drowning event, such as hypogly-
cemia or intoxication, can be helpful. Arterial blood gas
analysis in symptomatic patients can be used to help guide
respiratory resuscitation.
Recommendation: We do not recommend routine use of
complete blood count or electrolyte testing in the drowning
patient. 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, labora-
tory testing for causes of altered mental status or any inciting
event should be considered. Strong recommendation, low-
quality evidence.
Other Treatments
Antibiotics
Although microorganisms present in aspirated water may
eventually cause pneumonia, no study to date has shown
benefit from empiric administration of antibiotics in drowning
patients. This is in part because microorganisms found in
drowning-associated pneumonia are atypical bacteria or
fungi and often are resistant to standard empiric treat-
ments.
100–102
Aspiration of even small volumes of water
can produce abnormalities on chest radiograph that can
mimic pneumonia. The psychological trauma of the drowning
event and hypoxemia can cause leukocytosis from stress
demargination as well as fever from inflammation and irrita-
tion caused by water in the airways, making it difficult to dif-
ferentiate inflammatory from infectious pneumonitis.
103
The
decision to administer antibiotics should be made after
initial resuscitation and ideally be based on expectorated
sputum or endotracheal aspirate bacterial culture, blood cul-
tures, or urinary antigen tests.
100–102
Because these tests are
not available in the wilderness setting, treatment should be
initiated for symptoms consistent with pulmonary infection
(eg, fever, increased sputum, abnormal lung auscultation)
that continue after initial resuscitation and treatment phases.
Recommendation: We do not recommend 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,thedecisiontotreatshouldbebasedonclinical
examination focusing on physical evidence of pulmonary
or systemic infection (eg, fever, increased sputum, abnor-
mal lung auscultation). Strong recommendation, high-
quality evidence.
Davis et al. 7

Corticosteroids
Corticosteroids were historically used in drowning patients
to facilitate pulmonary recovery and surfactant production.
However, there is not sufficient evidence to support
empiric corticosteroid administration for drowning
patients.
104
Recommendation: We do not suggest routine adminis-
tration of corticosteroids specifically for treatment of drown-
ing patients. Strong recommendation, low-quality evidence.
Targeted Temperature Management
Mild therapeutic hypothermia (TH) has been shown to
decrease cerebral oxygen utilization and improve neurolog-
ically intact survival in patients with witnessed VF cardiac
arrest.
85
There has been more recent evidence that suggests
there may be no difference in neurologically intact survival
in out-of-hospital cardiac arrest between normothermia and
mild TH, and this is an area of active investigation.
105
Current American Heart Association/International Liaison
Committee on Resuscitation guidelines recommend targeted
temperature management (TTM) for adults after cardiac
arrest, at a temperature between 32 and 34°C (90 to 93°F)
for at least 24 h.
106
Many institutions have extrapolated
these data to include non-VF causes of cardiac arrest.
The 2002 World Congress on Drowning provided a con-
sensus statement recommending TH of 32 to 34°C for
patients achieving return of spontaneous circulation
(ROSC) after cardiac arrest due to drowning.
107
Our litera-
ture search yielded multiple case reports and retrospective
reviews supporting neurologically intact survival in hypo-
thermic patients, but several older studies showed no
benefit.
108–120
There is no prospective study comparing
TTM to normothermia after ROSC in drowning patients.
There might be benefit to discontinuing rewarming interven-
tions after a hypothermic drowning patient has reached
TTM temperature range, but this has been insufficiently
studied to support an evidence-based recommendation.
Recommendation: Although current literature recom-
mends TTM in post–cardiac arrest care, there is insufficient
evidence to either encourage or discourage induction or
maintenance of TTM in drowning patients. Weak recom-
mendation, very low-quality evidence.
Disposition in the Wilderness
Ceasing Water-based Rescue and Resuscitation
Efforts
The care of drowning patients in the wilderness can range
from a small group of untrained bystanders/volunteers to a
highly trained search-and-rescue team with extensive
resources. In the wilderness setting, available resources,
risk to rescuers, and team/volunteer safety must be
considered when deciding how long to search for a sub-
merged patient. Although each drowning episode has
unique patient and environmental factors, the most impor-
tant predictor of outcome is the duration of submer-
sion.
69,121,122
Available evidence shows that prognosis is
poor with submersion times greater than 30 min, regardless
of water temperature.
123
There are case reports of survival
with good neurologic outcomes despite prolonged submer-
sion—predominantly young children (around 6 y old) in
water < 6°C (43°F) and with the use of advanced treatment
modalities, such as extracorporeal membrane oxygena-
tion.
124–129
There are also case studies of patients in
cardiac arrest, also young, having full neurological recovery
after CPR for more than 90 min.
130
These cases are consid-
ered exceptional. For the purpose of these guidelines, rec-
ommendations are based on available evidence relevant to
a typical drowning patient and on the probability of neuro-
logically intact survival in specific conditions. A literature
review of 43 cases serves as the evidence for water-based
rescue.
131
The report concludes that there is minimal
chance of neurologically intact survival with a submersion
time of more than 30 min in water warmer than 6°C
(43
◦
F) or more than 90 min in water that is colder than 6°
C (43°F). It is important to note that “submersion time”
was defined as beginning upon arrival of emergency ser-
vices personnel; total submersion time is often unknown.
If a drowning patient is removed from the water and
resuscitation takes place, it might be necessary to decide
when to cease resuscitation efforts if no signs of life
return. Based primarily on retrospective studies, submersion
times of >10 min appear to correlate with increased mortal-
ity or survival with severe neurologic dysfunction.
69,122,132
In addition, more than 25 min of resuscitation or prolonged
time to advanced medical care also correlates with negative
outcomes but without the statistical significance of submer-
sion time. In a Dutch retrospective review of 160 hypother-
mic drowning patients under the age of 16 y, 98 children
received CPR for more than 30 min, with only 11 surviving
to discharge, all of whom were neurologically devas-
tated.
123,132–134
Recommendation:
•Based on resources, we suggest cessation of rescue
and transition to body recovery operations when
there is a known submersion time of greater than
30 min in water warmer than 6°C (43°F), or longer
than 90 min in water < 6
◦
C (43°F). Cessation of
resuscitation is recommended after 30 min of contin-
uous cardiopulmonary resuscitation.
•If at any point during search-and-rescue efforts the
safety of the rescue team becomes unacceptably
threatened, we recommend rescue efforts be ceased.
•If resources are available and recovery team activities
are appropriately safe, we suggest body recovery
efforts continue beyond the search-and-rescue
8Wilderness & Environmental Medicine

period with the understanding that resuscitation
attempts will likely be futile.
Strong recommendation, low-quality evidence.
Decision to Evacuate
If a victim survives a drowning event in the wilderness,
objective physical examination findings may assist in the
decision to evacuate the victim to advanced medical care.
A single large retrospective study of nearly 42,000 ocean
lifeguard rescues serves as the primary evidence for
on-scene decision-making.
135
This study found that
victims who experienced a drowning event but had no
symptoms other than mild cough and who did not have
abnormal lung sounds had 0% mortality(Grade 0, 1;
Table 1). As symptoms worsened and victims developed
abnormal lung sounds (Grades 2, 3), mortality increased.
Hypotension (systolic blood pressure < 90 mm Hg or mean
arterial pressure < 60 mm Hg) accounted for the next-largest
increase in mortality (Grade 4). In a retrospective study of
children who experienced nonfatal drowning, any clinical
deterioration occurred within the first 4 h in victims present-
ing with mild symptoms and Glasgow Coma Scale score 13
or above.
93
These findings are similar to those from another
retrospective study of pediatric victims in which new
symptom development after arrival to the hospital occurred
within 4.5 h in all but 1 victim; the 1 outlier developed
symptoms in 7 h and had a good outcome.
93
Additional
recent emergency department studies are discussed in the
Disposition in Emergency Department section of these
guidelines. These studies had similar results—clinical
decompensation, if present, occurred in the first few hours
of observation.
136
Recommendation:
•We recommend immediate evacuation to advanced
medical care if risks of evacuation do not outweigh
potential benefits for any victim with abnormal
lung sounds, severe cough, frothy sputum, foamy
material in the airway, depressed mentation, or
hypotension.
•We suggest considering release from the scene any
victim who is asymptomatic (other than a mild
cough) and displays normal lung auscultation.
Ideally, another individual should be with them for
the next 4 to 6 h to monitor for symptom develop-
ment or the victim should be advised to seek
medical assistance if symptoms develop.
•We suggest observation of victims with mild symp-
toms and normal mentation for 4 to 6 h in the event
that evacuation is difficult or may compromise the
overall expedition. Any evidence of decompensation
warrants prompt evacuation if the risks of evacuation
do not outweigh the potential benefit.
•If evacuation of a mildly symptomatic victim has
begun and the victim becomes asymptomatic for 4
to 6 h, we suggest cancelling further evacuation and
continuing previous activity.
Strong recommendation, low-quality evidence.
Disposition in the Emergency Department
Although many studies have addressed prognostic factors
for neurologic survival at hospital discharge, only a few
have addressed the question of which patients can be
safely discharged from the ED. The first, a prospective
study of primarily pediatric patients, included follow-up
phone interviews with 33 patients who were either released
on the scene or discharged from the ED within 1 to 6 h of
arrival and found that none of these patients experienced
delayed effects.
137
A retrospective review of 48 pediatric
drowning patients who presented to a single ED with
Glasgow Coma Scale score 13 or above studied whether
factors predicting safe ED discharge could be identified.
93
Initial chest radiograph did not correlate with severity of
disease, and all patients who deteriorated did so within 4 h
of ED arrival. The authors concluded that patients could
be safely discharged home if normalized and if there
wasnodeteriorationinrespiratoryfunctionafter4to
6 h of observation in the ED. A retrospective review of
hospitalized pediatric patients found that in all patients
who were initially asymptomatic but who went on to
develop symptoms during their stay, these symptoms
developedwithin4.5hinallbut1patientanddidso
within 7 h in the final patient.
138
In the 6 y preceding
this current guideline update, 4 more pertinent retrospec-
tive studies investigating safe discharge of pediatrics
patients were published.
95,139–141
The findings of these
articles are in line with the aforementioned studies in
that patients who initially presented as normal or with
minimal symptoms, with normal mentation, and with no
need for airway support generally could be safely dis-
charged. Patients in this group who had a clinical
decline did so within the first few hours and had
Table 1. Out-of-hospital management and classification of
drowning patients.
Grade Pulmonary exam
Cardiac
exam
Mortality
(%)
0 Normal auscultation,
without cough
Radial pulses 0
1 Normal auscultation, with
cough
Radial pulses 0
2 Rales, small foam in airway Radial pulses 0.6
3 Acute pulmonary edema Radial pulses 5
4 Acute pulmonary edema Hypotension 19
5 Respiratory arrest Hypotension 44
6 Cardiopulmonary arrest 93
Adapted from Semsprott et al.
27
Davis et al. 9

subsequent safe discharge. One of the studies derived and
validated a clinical score to assist in determining which
patients may be safely discharged after 8 h of ED observation.
The study found that the presence of 4 or more of the follow-
ing factors predicted safe discharge: normal mentation,
normal respiratory rate, absence of dyspnea, absence of
need for airway support, and absence of hypotension.
140
Recommendation: After an ED observation period of 4
to 6 h, we suggest it is reasonable to discharge a drowning
patient with normal mental status in whom respiratory func-
tion is normalized and no further deterioration in respiratory
function has been observed. Weak recommendation, low-
quality evidence.
Prevention
Prevention has the potential to save far more lives than
rescue or treatment of drowning persons. A comprehensive
prevention program includes participant screening for
medical diseases that increase the risk of drowning, demon-
strated ability to swim, use of safety devices, and use of safe
practices when in and around water.
Participant Screening
Retrospective studies have linked coronary artery disease,
prolonged QT syndrome, autism, and seizure disorders
with higher-than-normal rates of drowning and drowning
deaths.
64,142–148
Preparticipation screening should focus
on uncovering any medical or physical condition that may
potentially impair decision-making, physical ability, and
thus swimming ability in the event of drowning. These
include a history of spontaneous syncope, exertional
syncope, and a family history of sudden cardiac death.
There remains no reliable screening tool for the evaluation
of cardiac conduction disorders, but screening electrocardio-
gram and family history of sudden cardiac death can help
clinicians differentiate which patients might benefit from
further evaluation or genetic testing if indicated.
Recommendation: We recommend that all patients with
coronary artery disease, prolonged QT syndrome or other
ion channel disorder, autism, seizure disorders, or other
medical and physical impairments be counseled about the
increased risk of drowning and about steps to mitigate the
risk, such as buddy swimming and use of rescue devices,
should they choose to participate in activities in or around
water. Given the extremely high rate of drowning in patients
with epilepsy, we recommend patients be counseled to never
swim without direct supervision. Strong recommendation,
low-quality evidence.
Swimming Ability
Common sense dictates that an individual who is a compe-
tent swimmer and has the neurocognitive ability to make
appropriate decisions about water safety has a decreased
likelihood of drowning. However, the best ages to learn
technique and specific swimming skills that reduce a
person’s chance of drowning are not well established.
Most literature evaluates infant and pediatric populations
for the effects of swimming and infant survival lessons on
drowning and mortality.
136,149
There is concern that by pro-
viding swim lessons to young children, parents may develop
a false sense of security in their child’s swimming ability,
which might lead to increased drowning incidents.
150–152
The American Academy of Pediatrics has always main-
tained that children should learn to swim at some point in
their lives. Currently, they recommend that most children
over the age of 1 y will benefit from swim lessons, but those
under 1 y are unlikely to benefit as they are developmentally
unable to learn the complex movements required.
136,153
Children typically develop the motor skills to swim by ages
2–4 y and most are developmentally able to swim at age 4.5
y. Most children can master the front crawl by 5–6 y old.
149
There is considerable debate regarding the definition of
“swimming”or “survival-swimming”and what constitutes
the most protective approach to swim instruction.
Although the ability to swim farther distances can be per-
ceived as increased swim ability, for the purpose of swim-
ming as a tool for drowning prevention, the distance of
25 m (82 ft) has been adopted by international lifesaving
agencies and a large population-based study in
Bangladesh.
154,155
Despite the lack of definitive evidence
showing clear benefit to formal swim lessons, panel
members agree that familiarity with and, more importantly,
confidence in an aquatic environment would be beneficial in
the event of accidental immersion or submersion. In addi-
tion, unique aquatic environments, such as whitewater,
should be approached only after focused instruction on
swimming techniques specific to that environment.
Recommendation: We suggest that all persons who par-
ticipate in activities conducted in or around water should
have, at a minimum, enough experience and physical capa-
bility to maintain their head above water, tread water, and
make forward progress for a distance of 25 m (82 ft).
Weak recommendation, low-quality evidence
Personal Flotation Devices
Personal flotation devices include lifejackets, manually or
automated inflation systems, and neoprene wetsuits,
among others. Currently, lifejackets are the only devices
with injury prevention data available and will, therefore,
be used as the prototypical model for this category. In
2019, according to the US Coast Guard, there were 613
boating-related deaths—79% due to drowning.
10
In 86%
of the cases due to drowning, no life jacket was worn.
Three other retrospective studies have found an association
between life-jacket use and decreased mortality in boating
accidents.
156–158
One of these studies compared drowning
deaths before and after increased life-jacket regulations,
10 Wilderness & Environmental Medicine

revealing improved survival rates after regulations went into
effect. These data suggest that activities in and around water,
especially while boating, should include life-jacket use.
156
Recommendation: We recommend properly fitted life
jackets that meet local regulatory specifications be worn
by participants when boating or engaging in any water
sports for which life jackets are recommended. Strong rec-
ommendation, low-quality evidence.
Alcohol Use
Alcohol is a known contributing factor to drowning deaths.
Data obtained primarily from telephone studies likely under-
represents the true burden of alcohol in drowning causation.
In 2017, alcohol was a leading factor in boating-related
deaths.
10
A 2004 review found that 30% to 70% of drowning
fatalities have a measurable blood alcohol level, with 10% to
30% of deaths being directly attributed to alcohol use.
159
Recommendation: We recommend avoiding alcohol
and other intoxicating substances before and during water
activities. Strong recommendation, low-quality evidence.
Lifeguards
There are no specific peer-reviewed studies on the utility of
lifeguards on expeditions or wilderness trips.
160
A 2001
Centers for Disease Control and Prevention working
group report recommends the presence of lifeguards for
drowning prevention in open-water settings. In 2021, the
United States Lifesaving Association reported nearly 7
million preventative actions and over 50,000 water rescues
covering a population of almost 260 million beachgoers.
There were 30 reported drowning deaths at guarded
beaches compared with 80 deaths at beaches without life-
guards.
161
Among nationally recognized lifeguard-
certifying agencies (Ellis & Associates, American Red
Cross, Starfish Aquatics Institute, and National Aquatic
Safety Company), there are no specific guidelines or recom-
mendations for the number of lifeguards per number of par-
ticipants in an event or at an aquatic facility.
Recommendation: Despite a lack of definitive evidence,
we recommend all groups operating in or near aquatic envi-
ronments, regardless of size, consider water safety during
planning and execution of excursions. This includes contin-
gencies 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. Strong recommendation,
low-quality evidence.
Special Situations
Cold Water Survival
No single recommendation can address all possible sce-
narios in a water setting. An unintentional fall into a
swift-moving river, deep offshore ocean, inland water-
ways, backyard swimming pool, or through ice into
static or moving water are all treated according to the
skill level, preparation, and equipment available to
patient and rescuer. Immediate attention must always be
given to self-rescue and extricating oneself from a hazard-
ous environment.
There are 4 phases of cold water immersion (airways
above water), each of which can contribute to aspiration
and drowning.
28,162
The first phase, the “cold shock
response,”causes gasping and hyperventilation lasting 30–
90 s. If the head is submersed (airway under water) during
this phase, uncontrolled breathing can lead to immediate
aspiration and drowning. The second phase, “cold incapac-
itation,”results as cooling of muscle and nerve fibers causes
weakness and incoordination. Weakness may be evident
after only a few minutes of submersion and progresses to
incapacitation after 10 or more min; this may manifest as
swim failure or inability to carry out other survival tasks.
“Hypothermia”can take 30 or more minutes to occur in
an adult who is not wearing specific thermal protective gar-
ments. A victim can only survive this long if flotation is
available. In this case, drowning may occur if waves cover
the airways. Finally, drowning may occur due to “rescue
collapse”(otherwise known as circum-rescue collapse),
which can occur just before, during, or shortly after
rescue. It is thought that a main cause of this collapse (symp-
toms range from collapse to syncope to death) is that rescue
can result in mental relaxation and a sudden reduction in epi-
nephrine levels, leading to increased peripheral blood flow
resulting in decreased blood pressure, decreased core tem-
perature, and transport of metabolic byproducts from the
periphery to the irritable heart.
After immersion in cold water, a person has a limited
amount of time before fatigue and incapacitation render self-
rescue impossible. Likelihood of survival is increased by
having appropriate gear (eg, a PFD or lifejacket) and train-
ing and by dressing for water temperature, not just air tem-
perature, in the event of immersion.
Extensive controlled trials of cold water survival are
lacking, and the available literature is not generalizable to all
scenarios. For example, sea state, weather, physical fitness,
clothing, the presence of a lifejacket, and mental preparedness
all contribute to survivability in cold water. Whitewater is dif-
ferent from still water or the ocean in polar regions. A single
large literature review serves as the source for recommenda-
tions about cold water survival under ideal conditions and
must be interpreted according to the level of training, prepara-
tion, and situation presented to the patient.
163
After immersion, the most important decisions a person
must make are: 1) assessment of the presence of any potential
immediate threats to life and 2) whether to swim to safety or
await rescue. Should a person choose to await rescue, pre-
venting loss of body heat becomes paramount. By position-
ing the body to protect major areas of heat loss, a patient
Davis et al. 11

may lengthen immersion survival time. A position that has
been proven in a laboratory setting to decrease heat loss is
the heat escape lessening position. The goal of this position
is to decrease heat loss from areas such as the armpits;
groin; and, to a lesser extent, neck. This position is achieved
by pressing the arms against the sides of the chest and squeez-
ing the legs together. If possible, additional protection may
be obtained by flexing the hips and knees and shrugging
the shoulders. In some cases, it may be possible to pull the
knees to the chest with the hands. Some individuals will be
unstable in this position; in this case, the arms can simply
be folded across the chest. In the event of group immersion,
huddle formation has been recommended to lessen heat loss,
assist injured or weak persons, and improve group morale.
Although this position has been shown to decrease cooling
in participating individuals in a controlled environment,
the effort needed to assist debilitated individuals in an
actual emergency may result in increased heat loss (Figures
1and 2).
164
Swimming or treading water should be limited to mini-
mize heat loss. Life jackets should be worn to aid insulation
and flotation. If possible, the ideal location to await rescue is
out of the water, even if only partially, to reduce heat loss
and delay onset of hypothermia. Prolonged cold water expo-
sure eventually results in motor disabilities, which can
appear within 10 m of immersion, making advanced maneu-
vers difficult. For this reason, it may be beneficial to affix
one’s body or clothing to a floating object using rope or
freeze clothing to the ice surface if exit is not possible.
Prolonged immersion will also eventually lead to cognitive
disabilities, rendering decision-making difficult.
Should a person decide to swim to safety, some impor-
tant physiologic changes may occur. The initial cold
shock, which lasts seconds to a few minutes, may
prompt gasping and hyperventilation and can have a dis-
orienting effect, making self-rescue attempts difficult.
Upon immersion in cold water, if no immediate life
threats are present, a person should focus on remaining
calm and controlling breathing by taking slow, deep
breaths. Once a person is able to obtain his or her bear-
ings, he or she may have far less than 10 m of effective
swimming and up to 1 h of consciousness before suc-
cumbing to hypothermia. All of these statements assume
the person is wearing an appropriate life jacket. Further
detailed discussion of the science behind cold water
immersion is available in chapter 8 of Auerbach’s
Wilderness Medicine (7th edition).
28
Conclusions
Drowning is a process with outcomes ranging from no mor-
bidity to severe morbidity to death. Persons who drown and
survive with or without morbidity should be described as
having had a nonfatal drowning. Those who do not
survive should be described as having had a fatal drowning.
The most important aspect of treatment is to reverse cerebral
hypoxia by providing oxygen to the brain. Drowning
Figure 1. Heat escape lessening position (used with permission from http://www.boat-ed.com).
12 Wilderness & Environmental Medicine

prevention strategies can be effective and should be thor-
oughly deployed.
Author Contributions
All authors contributed to drafting, revision, and approval of final
manuscript.
Declaration of Conflicting Interests
The author(s) declared the following potential conflicts of interest
with respect to the research, authorship, and/or publication of this
article: The authors report the following disclosures. AS, JS, and
SH are directors of Lifeguards Without Borders. SH is Medical
Director for Landmark Learning, Starfish Aquatics, and North
Carolina State Parks as well as owner of Hawk Ventures. TC is
section editor for WMS Practice Guidelines. AA, GG, and CD
have no disclosures to report.
Funding
The authors received no financial support for the research, author-
ship, and/or publication of this article.
ORCID iD
Christopher A. Davis https://orcid.org/0000-0002-8037-5771
Supplemental Material
Supplementary material associated with this article can be found in
the online version at https://doi.org/10.1177/10806032241227460.
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