SUMMARY OF CHANGES

1. Updates provided as the World Health Assembly adopted its first drowning resolution in 2023 with current estimate of over 90% of drowning related deaths are preventable. Updated epidemiology provided.

2. Clarification on automated external defibrillator (AED) use provided. AEDs do have a limited role in the care of drowning patients; however, the application of these devices should not interfere with compressions and ventilation as shockable rhythms are present in less than 6% of patients.

3. Updated ER disposition recommendations based on grade of severity and mortality with associated flow chart (Figure 1). Grades 2 and below may be safely observed and likely discharged within 4-6 hours.

4. Expanded ICU management recommendations.

- Recommendation for active physiologic positive end-expiratory pressure (PEEP) titration with maintenance for 48 hours prior to initiation of liberation trials.
- Current lung protection ventilation strategy updated. Extracorporeal Membrane Oxygenation (ECMO) neither recommended for, nor against.
- Metabolic derangements discussed – no evidence-based data for the routine use of bicarbonate for correction of these derangements.

5. Recommendation for aggressive fever prevention (for neuroprotection) but no recommendation for traditional targeted temperature management in the post-cardiac arrest patient per the recent Targeted Temperature Management 2 trial.

6. Recommendations for the management of shivering.

7. No role for the routine use of prophylactic antibiotics.

8. Updated Swimming Induced Pulmonary Edema (SIPE).

9. Risk factors: Cold water, pre-existing (Cardiovascular) CV disease, overhydration, horizontal positioning during swimming, tight fitting wetsuits, and concurrent respiratory infections.

10. Diagnostic findings typical chest x-ray findings of perifissural and interstitial thickening, widened azygos vein diameter, and enlarged cardiac silhouette.

11. Management: ß2-agonists, Positive Pressure, Positive Expiratory Pressure (PEP) Device.