NEUROLOGIC
The majority of long term sequalae of drowning events are secondary to neurologic injury. Early efforts should be made to improve central nervous system oxygen delivery while providing evidence-based neuroprotection in the post-resuscitative period.
In patients who are still rewarming, aggressive shivering control should be implemented (See Figure 2 on right for an example of shivering management protocol). Significant adverse effects from prolonged shivering include lactic acidosis, elevated intracranial pressure, rhabdomyolysis, discomfort, and interference with monitoring devices.24
Aspiration of both seawater and freshwater in relatively small quantities can lead to disruptions in the surfactant equilibrium of the lungs. Reduced surfactant leads to atelectasis which can make patients more prone to atelectrauma and subsequent biotrauma (neutrophil migration and subsequent acute respiratory distress syndrome or sepsis).36,38 Osmotic shifts in the alveoli can lead to noncardiogenic pulmonary edema which results in reduced compliance, right to left shunting, and hypoxemia. Evidence-based care for mechanically ventilated patients should be followed. 2
Low output heart failure and lethal dysrhythmias are common in drowning victims. While hypoxemia is the primary driver of these conditions, correction of hypoxemia may not immediately restore normal cardiac function and ICU physicians should be prepared to manage these issues. Reduced cardiac output may lead to cardiogenic component of pulmonary edema or worsen additional organ failure (e.g., cardiorenal syndrome).1
HEMATOLOGIC, ENDOCRINE, AND RENAL
Drowning victims requiring the ICU are critically ill and can be prone to the same hematologic, metabolic, and renal pathologies as other ICU patients. There is no evidence that there is clinically significant hemolysis or electrolyte shifts in drowning patients. Rates of renal failure secondary to decreased perfusion during resuscitative efforts or subsequent decreased cardiac output are similar to other cardiac arrest patients.
There is no role for prophylactic antibiotics in drowning victims either in freshwater or saltwater. Furthermore, rates of antimicrobial resistance in bacteria obtained from seawater drowning victims is negligible and broad-spectrum coverage is not indicated.