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Last reviewed: 6 Nov 2023
Last updated: 13 Jul 2021



History and exam

Key diagnostic factors

  • presence of risk factors
  • respiratory impairment
  • evidence of submersion or immersion
More key diagnostic factors

Other diagnostic factors

  • hypothermia
  • signs of trauma
Other diagnostic factors

Risk factors

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

Diagnostic investigations

1st investigations to order

  • pulse oximetry/arterial blood gases
  • chest radiography
  • basic metabolic panel
More 1st investigations to order

Investigations to consider

  • cervical spine CT
  • creatine kinase
  • serum alcohol and urine drugs of abuse
  • ECG
  • serum cardiac biomarkers
  • anticonvulsant medication levels
More 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)



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



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: Starfish Aquatics Institute

Medical Director: Innovative Attraction Management Starguard Elite

Board of Directors: Safer 3 Water Safety Foundation

Staff: Global Outreach Doctors

Jacksonville Beach



JS has given expert testimony in court cases involving drowning.

Andrew Schmidt, DO, MPH

Assistant Professor

Department of Emergency Medicine

University of Florida College of Medicine - Jacksonville

Medical Director

Jacksonville Beach Ocean Rescue

Deputy Medical Director

Trauma One




AS declares that he has no competing interests.


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. 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




AGV declares that he has no competing interests.

Richard Franklin, PhD

Associate Professor

James Cook University





RF declares that he has no competing interests.

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