• Record vital signs
• Full history & examination
• Consider ECG
• Any safeguarding concerns?
• Discharge with safety-net advice or observe for a maximum of 8 hours

• Support respiration (oxygen, high flow, NIV, I&V)
• CXR
• Record temperature and rewarm
• Consider ECG
• IV/IO access and consider FBC, U&Es, LFTs, blood gas
• Cardiovascular support required? IV fluids (warm)

• Intubate and ventilate
• Nasogastric tube
• IV/IO access
• Check: FBC, U&Es, LFTs, blood gas, glucose
• Measure core temperature & rewarm if appropriate
• Treat shock with 10-20 ml/kg boluses of 0,9% sodium, chloride or isotonic fluid (e.g. Plasmalyte 148)
• Imaging: CXR +/- CT Head
• Consider ECG

Passive rewarming:

• Remove wet clothes
• Warm blankets
• Warmed IV fluids (40°C)
• Forced air warmers
• Warm air system (e.g. Bair Hugger)
• Radiant lamp 
• Ensure warm ambient temperature
• Heated humidified ventilator gases

Active rewarming:

• First line - bladder irrigation with warm sodium chloride (42°C)
• Second line -gastric lavage with warm sodium chloride (42°C)
• Warm IV fluids (39°C)
• Warm ventilator gases (42°C)
• Consider for adult size patients:
  • ICY catheter/CVVH
  • Liaise early with ICU if appropriate

Important points:

• Case reports of good outcomes in ice cold water (hypothermia prior to arrest)
• Continue resuscitation until core temperature is at 32°C
• Discuss with paediatric critical care early (ECMO  or stop resuscitation)

Good prognosis:

• Short submersion time.
• GCS above 5.
• Cardiac output and spontaneous respiration in A+E.

Bad prognosis:

• Age below 3yrs.
• Submersion time over 5 min.
• CPR over 10min, asystole at the scene, resuscitation of cardiac arrest over 30mins.
• Multiple organ failure.

Extremely poor prognosis:

• Submerged over 25 min or no ROSC within 30 mins.

Discuss with PICU early

Airway:

• Assume cervical injury, immobilise C-spine
• High flow O₂
• Intubation with cuffed endotracheal tube

Breathing:

• Bag mask ventilation if required
• Once intubated:
  • Recruitment manoeuvres
  • Target TV 6-8 mls/kg
  • Limit PIP to 30 cmH₂O
  • Optimise PEEP (may need 10-15 cmH₂O)
• Permissive hypercapnia (caution in head injury)
• Permissive hypoxia (aim SpO₂ 90-94%)

Circulation:

• Obtain secure IV access (IO/peripheral/central)
• Aim for age appropriate MAP (inotropes if required) 
• If CV stable: restrict fluids to 50% maintenance
• If CV unstable follow changes to APLS Hypothermia algorithm:
  • Patient with temperature below 30°C:
    • Limit defibrillation to 3 shocks
    • Do not use inotropic or antiarrhythmic drugs (e.g. adrenaline)

  • Patient with temperature 30°C - 35°C:

    • Double the dose interval for inotropic or antiarrythmic drugs (e.g. adrenaline)
  • Continue resuscitation until core temperature is ≥32°C or cannot be raised

Disability/Neuroprotection:

• Core temp over 35°C (see rewarming methods)
• 30°head up tilt
• Ventilate to ETCO2, target 4-5kPa
• Normoglycaemia
• Sodium 145-150 mmol/L (2-5ml/kg of 2.7% NaCl over 30mins)

• Blood gas and glucose
• FBC, coagulation
• U&Es including CK –correct abnormalities
• LFTs, CRP, serum osmolality
• Consider drug and alcohol screen
• CXR
• Consider CT (trauma) if required
• Full secondary survey once resuscitation complete

• 2 x forced air warmers (Bair huggers) with under body and full body blankets
• Warmed IV fluids
  • Pre-prepare fluid boluses but keep in warming cabinet until required
  • Further warmed IV fluids available from theatre suit and labour ward
• Blood warmer (Ranger) can be used to give warmed fluid boluses
• Bladder and/or gastric lavage
  • Warmed 0.9%NaCl (40°C)
  • Appropriate size catheter or NG tube
  • Compatible syringes x2 –injection and aspiration
  • Foil bowls x2 –warmed and discarded fluids
  • Staff –2 members dedicated to each
  • Suggested Method: Inject calculated volume, leave 10 mins, aspirate original volume and repeat
  • Suggested bladder volumes (mls)³ use 2/3 volume to prevent overdistension:
    • Age under 1 year – [2.5 x age(months)] + 38
    • Age over 1 year – [age(yrs) +2] x 30

• Evans, Javaid, A. A., Scarrott, E., Bamber, A. R., & Morgan, J. (2020). Fifteen-minute consultation: Drowning in children. Archives of Disease in Childhood. Education and Practice Edition106(2), 88–93. https://doi.org/10.1136/archdischild-2020-318823
• Clinical Guidance: Paediatric Critical Care: Drowning; Guy’s and St Thomas NHS Foundation Trust; March 2018.
• Guerra, Keays, M. A., Purser, M. J., Wang, S. Y., & Leonard, M. P. (2018). Pediatric cystogram: Are we considering age-adjusted bladder capacity? Canadian Urological Association Journal, 12(12), 378–381. https://doi.org/10.5489/cuaj.5263