Pediatric Drowning Resuscitation (AHA 2024-2025)

Algorithm Steps

1. ▶

   Start

   Pediatric Drowning/Submersion

   Child pulled from water - unresponsive

   1. ●

      Action

      Remove from Water Safely

      Water rescue + initial assessment

      • Remove victim from water as quickly as possible
      • Maintain horizontal position during removal if possible
      • Assume C-spine injury if mechanism suggests (diving, fall)
      • In-water resuscitation:
      • • Trained rescuers may begin rescue breaths in water
      • • Chest compressions not effective in water
      1. ◆

         Decision

         Responsive or Breathing?

         Quick assessment on land

         1. ●

            Action

            Responsive/Breathing

            Recovery position and monitor

            • Place in recovery position
            • Remove wet clothing, prevent hypothermia
            • Administer O2 if available
            • Monitor for deterioration
            • Transport to ED even if appears well
            • (risk of delayed pulmonary edema)
         2. ●

            Action

            Unresponsive - Start CPR

            Prioritize ventilation

            • DROWNING = HYPOXIC ARREST
            • Ventilation is critical!
            • LAY RESCUERS: Begin CPR (may start with compressions)
            • TRAINED RESCUERS:
            • • Consider starting with rescue breaths (A-B-C)
            • • Or compressions first (C-A-B) - both acceptable
            • • 5 rescue breaths initially reasonable
            • Compression:ventilation = 30:2 (single) or 15:2 (two rescuers)
            1. ●

               Action

               Apply AED/Monitor

               Assess rhythm when available

               • Dry chest before applying pads
               • Shockable rhythm (VF/pVT) less common in drowning
               • If VF/pVT: Defibrillate per PALS
               • If asystole/PEA: Continue CPR, epinephrine
               • Drowning cardiac arrest usually asystole/PEA (hypoxic)
               1. ●

                  Action

                  PALS Protocol

                  Standard pediatric resuscitation

                  • Continue high-quality CPR
                  • Epinephrine 0.01 mg/kg IV/IO q3-5 min
                  • Advanced airway when appropriate
                  • O2 100% during resuscitation
                  • Address hypothermia:
                  • • Remove wet clothing
                  • • Warm blankets, warm IV fluids
                  • • Do not delay resuscitation for rewarming
                  1. ◆

                     Decision

                     ROSC?

                     Return of spontaneous circulation

                     1. ✓

                        Outcome

                        Post-Drowning Care

                        ROSC achieved

                        • Maintain SpO2 94-99% (avoid hyperoxia)
                        • Avoid hyperventilation
                        • Treat hypothermia (target normothermia)
                        • Consider targeted temperature management
                        • Monitor for:
                        • • Pulmonary edema (CXR)
                        • • Aspiration pneumonia
                        • • ARDS
                        • • Electrolyte abnormalities
                        • ICU admission for all drowning arrests
                     2. ⚠

                        Warning

                        Prognostication

                        When to consider stopping

                        • POOR PROGNOSTIC FACTORS:
                        • • Submersion >25 minutes
                        • • Resuscitation >25 minutes without ROSC
                        • • Asystole as presenting rhythm
                        • • No pupillary response
                        • • No bystander CPR
                        • Cold water submersion may have better outcomes
                        • Consult team before termination
                        • No absolute cutoff - individualize decision