Drowning for paramedics: a hypoxic arrest that starts with breaths

Most cardiac arrests paramedics see begin in the heart. Drowning does not. It begins with the airway and the lungs, and the heart stops because it has run out of oxygen. That single fact changes the order of almost everything a drowning paramedic response should do.

Canadian summers bring lakes, cottages, pools and rivers, and with them a predictable rise in water-related calls. This case breakdown walks through one of them and the reasoning behind each decision. As always, your service's medical directives and the provincial ALS/BLS standards set the specifics.

#The call

A child's birthday party at a lakeside cottage. A teenager is pulled from the water by an uncle after friends notice he has not surfaced. By the time the crew arrives, a bystander has started chest compressions on the dock. The patient is unresponsive and not breathing normally.

It looks like any other arrest. The temptation is to run it like one, with compressions and the monitor first. The crew paused for a beat to think about mechanism. A teenager with no cardiac history, found under water, is far more likely to have arrested from lack of oxygen than from a primary heart rhythm problem. That changed what they did first.

#Hypoxia first: why ventilation leads in drowning

In a typical adult arrest from a cardiac cause, the blood is still reasonably oxygenated at the moment of collapse, which is part of why compressions-first approaches make sense. In drowning, the patient has usually been hypoxic for some time before the heart stops. Compressions alone circulate blood that has little oxygen to deliver.

Resuscitation guidance for drowning therefore puts early, effective ventilation at the centre:

• Open the airway and give rescue breaths early. Many guidelines recommend starting with ventilations before compressions in drowning.
• Use a BVM with oxygen as soon as it is available, with good technique and a two-person seal where possible.
• Combine ventilation with high-quality compressions in the ratio your protocols specify.
• Expect resistance and fluid. Water or vomit in the airway is common. Suction as needed, but do not delay ventilation trying to drain water from the lungs; it is not effective.

On this call, the crew took over from the bystander, gave ventilations with a BVM and oxygen, and continued CPR. They placed the monitor and followed their arrest protocol from there.

#Spinal precautions: only when indicated

A reflex in many trauma-trained providers is to immobilise anyone pulled from water. In drowning, that reflex can cause harm. Spinal injury is uncommon in drowning, and full immobilisation can delay or interfere with airway management and ventilation.

Spinal precautions are generally reserved for situations such as:

1. Diving into shallow water
2. Signs of significant trauma
3. Water-slide or high-impact water sport injuries
4. A history or clinical picture suggesting injury, per local protocol

In the absence of those, the priority is the airway. On this call, the teenager had been swimming, not diving, and there was no sign of trauma. The crew did not delay ventilation for immobilisation.

#Other considerations on scene

A few factors often change drowning calls:

• Scene safety. Paramedics should not enter the water unless trained and equipped for water rescue. Many rescuers become victims.
• Hypothermia. Cold water can cause hypothermia, which affects rhythms, drug response and how long resuscitation should continue. Follow your directives for cold patients.
• Multiple patients. Rescuers and bystanders may also need assessment.
• Time submerged. Useful context for the receiving team, but rarely precise. Report what witnesses say without overinterpreting it.
• Family on scene. Drowning calls often involve distressed relatives and bystanders. Assigning someone to keep them informed frees the crew to work.

#Aftercare: the patient who "seems fine"

Not every drowning call is an arrest. Many patients are coughing, frightened and breathing on their own by the time paramedics arrive. These patients still need careful assessment.

Breathing problems after a drowning event can appear or worsen after the initial rescue. Signs that warrant concern include persistent cough, increased work of breathing, abnormal lung sounds, low oxygen saturation and altered mental status. Most services expect patients who needed rescue or who have any symptoms to be assessed in hospital, even if they appear well.

On the cottage call, the teenager regained a pulse after a period of resuscitation and was transported with ongoing ventilatory support. A cousin who had gone in after him, and who had swallowed water, was assessed by a second crew and also taken to hospital.

#For training leads: rehearsing the reversal

Drowning scenarios are useful precisely because they challenge a well-drilled pattern. Crews who run cardiac arrests on autopilot may default to compressions-first.

• Build arrest scenarios where mechanism changes priorities, and assess whether learners adapt.
• Drill BVM ventilation with simulated airway fluid, using suction and a two-person seal.
• Include a "seems fine" patient to test reassessment and the decision to transport.
• Add a diving mechanism in some cases so learners practise deciding when spinal precautions are indicated.
• Debrief on reasoning, asking learners to explain why they ordered their actions as they did.

Decision-training scenarios, including those on platforms like Imedica, are a practical way to rehearse these less common calls before summer brings them to the dock.

#The takeaway

Drowning is a hypoxic arrest. Lead with oxygenation and ventilation, reserve spinal precautions for the patients whose mechanism calls for them, and treat the survivor who "seems fine" as someone who still needs a hospital. Getting that order right is what separates a drowning resuscitation from a routine one.

Drafted for Imedica Field Notes. Physician review of this article is pending.