Submersion injury


  • Definition: "The process of experiencing respiratory impairment from submersion/immersion in liquid"[1]
    • Term "near-drowning" no longer used
  • Three possible outcomes = death, survival with morbidity, survival without morbidity
  • Consider secondary causes such as intoxication, syncope, cardiac arrhythmia, ACS, non-accidental trauma, etc.


  • Submersion → voluntary breath holding → aspiration → coughing/laryngospasm → aspiration continues → hypoxia → death[2]
  • Aspiration destroys surfactant which → alveolar collapse, atelectasis, non-cardiogenic pulmonary edema, and V-Q mismatch.

Clinical Features

Differential Diagnosis

Water-related injuries


  • CXR (on arrival and after 4 hours)
  • ABG - lactic acidosis
  • Serum sodium does not correlate to fresh water vs. salt water drowning
  • Other work-up generally not needed unless specifically indicated by history or exam[2], but may consider:
    • Labs, EKG
    • CT head/C-spine (if history of trauma) - C-spine injury extremely unlikely without evidence or history of trauma (<0.5% in large cohort study)[3]


  • Supportive care based on presentation is cornerstone of management.


  • Discharge after 4-6 hours of observation if:
    • Normal mental status, SpO2 >95% on room air, normal CXR and respiratory exam
  • Admit all others

See Also



  1. World Health Organization (WHO) "Global Report on Drowning". (Accessed 02/01/2017)
  2. 2.0 2.1 Szpilman, D., Bierens, J. J., Handley, A. J., & Orlowski, J. P. (2012). Drowning. N Engl J Med, 366(22), 2102-2110. doi: 10.1056/NEJMra1013317
  3. Watson RS, Cummings P, Quan L, et al. Cervical Spine Injuries Among Submersion victims. J Trauma 2001; 51:658.


Ross Donaldson