Action
Drowning victim arrives to the ED in a moderate (28°C-32°C) or severe (<28°C) hypothermic state with presumed cardiac arrest
- Start CPR, as per PALS/AHA guidelines
- Defibrillate VF, VT, PEA, and asystole up to a maximum of 3 shocks
- Attempt, confirm, secure airway
- Establish IV access
- In addition to routine drowning labs, obtain CK and coagulation studies
- Passive and active rewarming:
- Ventilate with warm, humidified O2 (42°C-46°C)
- Infuse warm normal saline (40°C-44°C)
Decision
Temperature ≤30°C?
Yes
- Continue CPR, as per PALS/AHA guidelines
- Withhold all IV meds
- Limit shocks for VF/pulseless VT to maximum of 3
No
- Continue CPR, as per PALS/AHA guidelines
- Give IV medications as indicated (double the interval time)
- Repeat defibrillation for VF/VT as core temperature increases
- Treat hyperkalemia (limit sodium bicarbonate to 1 dose)
⬇️
Immersion in icy water <10°C?
Yes
- Consider cardiopulmonary bypass (CPB) and extracorporeal membrane oxygenation (ECMO) based on hospital capabilities (Class IIl) If CBP or CMO are unavailable, consider thoracic lavage or transport, if safe.
No
- Continue to warm to 32°C-34°C
- Consider CPB and ECMO (although this may be less successful) (Class IIl)
If temperature is 32°C-34°C and cardiac arrest continues, consider termination of resuscitation
