Immersion injury


These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline. 

Read the full CAHS clinical disclaimer.


To guide PCH Emergency Department (ED) staff with the assessment and management of immersion injury.


An injury resulting in primary respiratory impairment from submersion or immersion in a liquid medium.1


  • Drowning is a major cause of death in children. However, most children who present to emergency following 'near drowning' will require nothing more than observation.
  • There is no clinical or therapeutically important difference between drowning in fresh or salt water.2
  • Water quality may influence the nature of acute lung injury due to secondary infection.
  • Hypothermia is an important issue following submersion, especially in small children who have a large body surface area to weight ratio
  • The cause of drowning should be fully considered including medical causes or issues around supervision and safety.
  • All immersion presentations in children under 2 years must have an Early Childhood Injury Proforma (MR301.3) completed. (internal WA Health only)


  • Aspiration of water results in pulmonary oedema and wash out of surfactant causing acute respiratory distress syndrome (ARDS) with the consequence of hypoxaemia.
  • Hypovolaemia may also occur as a result of tissue hypoxia and capillary leak.

Indicators of poor prognosis1

  • Immersion time > 5 minutes
  • Initial serum pH < 7.1
  • Lack of initial effective cardiopulmonary resuscitation (CPR) after rescue (delay longer than 10 minutes)
  • Lack of response to early resuscitation efforts
  • Comatose (Glasgow Coma Scale (GCS) <5) on arrival in the ED.


  • ABCDE approach - refer to Initial management below.


Important history points:

  • Immersion time
  • Basic life support required or administered
  • Mechanism of immersion - be aware of other injuries e.g. cervical spine or non-accidental injury
  • Pre-existing medical conditions.


  • Blood gas
  • Lactate
  • Blood glucose level
  • Electrolytes
  • Chest X-ray


  • If the child is in cardiorespiratory arrest continue CPR and follow the Advanced Paediatric Life Support algorithm.
  • Manage hypoxia and hypothermia
  • Treat associated injuries - suspect cervical spine injuries if mechanism of immersion is unclear.

Initial management

Airway (A)
  • Appropriate cervical spine precautions if history is suggestive of a fall or diving accident
  • Give 100% oxygen via face mask to all patients initially - hypoxaemic child may be alert and talking
  • Intubate and ventilate if:
    • Unable to maintain airway spontaneously
    • Inadequate respiration - hypoxaemia despite being given increased inspired oxygen
    • GCS < 9
    • Hypercapnia / severe respiratory distress
  • Ventilate hypothermic patient initially at approximately 50% of usual volume (reduced carbon dioxide production in hypothermia - excessive ventilation risks respiratory alkalosis and arrhythmia)
  • Monitor end-tidal carbon dioxide (ETCO2)
  • Set initial positive end expiratory pressure (PEEP) = 5cm H20
  • Nasogastric tube (NGT) if mechanical ventilation required - aspirate the stomach and leave NGT in-situ.
  • Treat bronchospasm with nebulised salbutamol
  • Ventilate as required.
Circulation (C)
  • Cardiac compressions if:
    • no signs of life
    • clinically pulseless (see note below)
    • echocardiogram (ECG) shows asystole / ventricular fibrillation (VF)
    • bradycardic and shocked
  • Note: ‘Pulseless’ may be due to marked vasoconstriction and bradycardia in the hypothermic patient.
  • Hypotension
    • This may be a result of fluid shifts, hypothermic/hypoxic myocardial dysfunction, rewarming vasodilation, possible cervical spine injury or other associated injury
    • Management
      • Treat appropriately with fluid boluses (20mL/kg of sodium chloride 0.9%) +/- inotropic support.
  • Minimal handling of hypothermic patient as increased risk of precipitating arrhythmias
  • Consider an indwelling urinary catheter to monitor urine output and fluid balance
Disability (D)
  • Prevent secondary brain injury – maintain oxygenation, cerebral perfusion and avoid hypercarbia
  • Treat any seizures appropriately. Refer to Status epilepticus - ED Guideline
  • Restrict fluid post resuscitation.
Exposure (E)
  • Hypothermia (core temperature < 35°C)
    • Check core temperature using a rectal thermometer.
    • Volume re-expansion is critical in the management of hypothermia – use sodium chloride 0.9% rather than lactate containing fluids.
    • Hypothermia is only neuro-protective if it occurs rapidly, prior to the onset of hypoxia (usually in water < 10ºC).

Effects of hypothermia:

  • Hypothermia substantially reduces effectiveness of defibrillation and resuscitation drugs. It is reasonable to attempt defibrillation, but if unsuccessful, continue cardiac compression until core temperature is > 30°C, when defibrillation / drugs are more likely to be effective.
  • Actively rewarm to 32°C then allow passive warming.
  • Never diagnose death and thus stop resuscitation until the patient is rewarmed to at least 32°C, or cannot be rewarmed despite active measures.

Admission criteria

  • Children who are asymptomatic, or only suffered mild, transient symptoms on arrival following a brief submersion require a minimum of 8 hours of in-hospital observation (Emergency Short Stay Unit) for signs of respiratory distress or compromise.2
    • Advise to see GP or return to the ED if febrile or unwell after discharge
  • If submerged for more than one minute, a period of cyanosis or apnoea, or the patient required any CPR - admit for observation for 24 hours or at least overnight in Emergency Short Stay Unit, even if they are well in the Emergency Department
    • In children who are asymptomatic initially (even with normal chest X-ray), cases of fulminant pulmonary oedema up to 12 hours after submersion have been reported. If any symptomatic deterioration, oxygen requirement or respiratory distress, for Paediatric Critical Care (PCC) admission.
  • Admit to PCC if:
    • required cardiopulmonary resuscitation
    • respiratory distress
    • supplemental oxygen requirement
    • abnormal blood gases on arrival
    • altered level of consciousness.


  • Provide water safety education for parents and carers.
  • Consider referral to Social Work Department.
  • Advise parents to seek further medical advice should they observe any signs of respiratory distress or fever.


  1. Chandy D, Weinhouse G. Drowning (submersion injuries). 2019, UptoDate. Retrieved from
  2. Szpilman D, Sempsrott J, Webber J et al. Dry Drowning and other myths. Cleveland Clinical Journal of Medicine. 2018. 85 (7), 529 - 535
  3. Paediatric Advanced Life Support Algorithm (APLS Website)
  4. Paediatric Basic Life Support Algorithm (with COVID-19 considerations) (APLS Website)

Endorsed by:  Executive Director, Medical Services  Date:  Oct 2021

 Review date:   Sep 2025

This document can be made available in alternative formats on request for a person with a disability.

Related CAHS internal policies, procedures and guidelines

Useful resources