Drowning

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 13 Sep 2025

Last updated: 15 Apr 2025

Drowning is defined as the process of experiencing respiratory impairment from submersion or immersion in liquid. Outcomes are classified as death, survival with morbidity, and survival with no morbidity.

Drowning is a leading cause of injury and death among young people.

It has been estimated that 80% to 90% of all drownings are preventable.

Hypoxemia is the primary cause of morbidity and mortality, and its reversal must remain the focus of treatment.

The "Drowning Chain of Survival" refers to a series of interventions that, when put into action by laypersons or professionals, may reduce morbidity and mortality associated with drowning.

Definition

Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid.[1] This process is a continuum from respiratory impairment as the person's airway goes below the surface of the liquid (submersion) to water splashing over the face (immersion). If the person is rescued at any time, the process of drowning is interrupted, resulting in a nonfatal drowning. Any submersion or immersion incident without evidence of respiratory impairment (aspiration) should be considered a water rescue rather than a drowning. Terms such as "near-drowning," "dry or wet drowning," "active and passive drowning," "secondary," and "delayed onset of respiratory distress" should not be used.[1][2]

Adult and pediatric patients are covered in this topic. The approach to adults and children who have drowned is similar; any differences will be made explicit in the text.

History and exam

Key diagnostic factors

presence of risk factors
respiratory impairment
evidence of submersion or immersion

Full details

Other diagnostic factors

hypothermia
signs of trauma

Full details

Risk factors

age (1-4 years)
male sex
alcohol or drug intake
swimming alone/diving
lack of awareness of water hazard risks
exposure to water
lack of swimming ability
cardiac disease
seizure disorder

Full details

Diagnostic investigations

1st investigations to order

pulse oximetry/blood gas
chest radiography
basic metabolic panel

Full details

Investigations to consider

cervical spine CT
creatine kinase
serum alcohol and urine drugs of misuse
ECG
serum cardiac biomarkers
anticonvulsant drug levels

Full details

Treatment algorithm

INITIAL

all patients

ACUTE

grade 1 (cough with normal lung auscultation)

grade 2 (rales in some pulmonary fields)

grade 3 (acute pulmonary edema with no hypotension or shock)

grade 4 (acute pulmonary edema with hypotension or shock)

grade 5 (no spontaneous ventilation, carotid pulse present)

grade 6 (cardiopulmonary arrest)

Contributors

Authors

David Szpilman, MD

Medical Director - Brazilian Lifesaving Society - Sobrasa

Lieutenant Colonel MD, retired - Fire Department of Rio de Janeiro

Civil Defense Rio de Janeiro City - Education adviser Defesa Civil Municipal do Rio de Janeiro

Co-founder - International Drowning Researcher's Alliance - IDRA

Rio de Janeiro

Brazil

Disclosures

DS is an author of several references cited in this topic.

Justin Sempsrott, MD, FAAEM

Executive Director: Lifeguards Without Borders

Medical Director: International Surf Lifesaving Association

Medical Director: Innovative Attraction Management Starguard Elite

Kuna

Disclosures

JS has received compensation for expert testimony in court cases involving drowning on behalf of plaintiffs and defense. JS received a monthly stipend as the medical director for a lifeguard training and risk management company, StarGuard Elite.

Andrew Schmidt, DO, MPH

Associate Professor

Department of Emergency Medicine

University of Florida College of Medicine - Jacksonville

Medical Director: Jacksonville Beach Ocean Rescue

Deputy Medical Director: Trauma One

Jacksonville

Disclosures

AS has received compensation for expert testimony in court cases involving drowning on behalf of plaintiffs and defense.

Acknowledgements

Dr David Szpilman, Dr Justin Sempsrott, and Dr Andrew Schmidt would like to gratefully acknowledge Dr Bhakti K. Patel and Dr D. Kyle Hogarth, previous contributors to this topic.

Disclosures

BKP and DKL declare that they have no competing interests.

Peer reviewers

Ajeet G. Vinayak, MD

Assistant Professor of Internal Medicine

Department of Medicine

Division of Pulmonary and Critical Care Medicine

Charlottesville

Disclosures

AGV declares that he has no competing interests.

Richard Franklin, PhD

Associate Professor

James Cook University

Townsville

Queensland

Australia

Disclosures

RF declares that he has no competing interests.

Peer reviewer acknowledgements

BMJ Best Practice topics are updated on a rolling basis in line with developments in evidence and guidance. The peer reviewers listed here have reviewed the content at least once during the history of the topic.

Disclosures

Peer reviewer affiliations and disclosures pertain to the time of the review.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

European Resuscitation Council. European Resuscitation Council Guidelines 2021. 2021 [internet publication].Full text

Panchal AR, Bartos JA, Cabañas JG, et al. Part 3: adult basic and advanced life support: 2020 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation. 2020 Oct 20;142(16 suppl 2):S366-468.Full text

The Resuscitation Council (UK). Resuscitation guidelines. 2021 [internet publication].Full text

Davis CA, Schmidt AC, Sempsrott JR, et al. Wilderness Medical Society clinical practice guidelines for the treatment and prevention of drowning: 2024 update. Wilderness Environ Med. 2024 Mar;35(suppl 1):94-111S.Full text Abstract

Dezfulian C, McCallin TE, Bierens J, et al. 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. 2024 Dec 3;150(23):e501-16.Full text Abstract

International Life Saving Federation. International Life Saving Federation position statements. 2016 [internet publication].Full text

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Guidelines
- Practice guidelines for the prevention and treatment of drowning
- 2024 American Heart Association and American Red Cross guidelines for first aid
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Drowning

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

all patients

grade 1 (cough with normal lung auscultation)

grade 2 (rales in some pulmonary fields)

grade 3 (acute pulmonary edema with no hypotension or shock)

grade 4 (acute pulmonary edema with hypotension or shock)

grade 5 (no spontaneous ventilation, carotid pulse present)

grade 6 (cardiopulmonary arrest)

Contributors

Authors

David Szpilman, MD

Disclosures

Justin Sempsrott, MD, FAAEM

Disclosures

Andrew Schmidt, DO, MPH

Disclosures

Acknowledgements

Disclosures

Peer reviewers

Ajeet G. Vinayak, MD

Disclosures

Richard Franklin, PhD

Disclosures

Peer reviewer acknowledgements

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Guidelines

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice