Drowning is respiratory impairment resulting from submersion in a liquid medium. It can be nonfatal (previously called near drowning) or fatal. Drowning results in hypoxia, which can damage multiple organs, particularly the brain. Treatment is supportive, including reversal of respiratory arrest and cardiac arrest, hypoxia, hypoventilation, and hypothermia.
Drowning is among the top 10 causes of mortality for children and young people. Worldwide, drowning is the fourth leading cause of death in children aged 1 to 4 years, and the third leading cause of death for those aged 5 to 14 years (1). In the United States, drowning is the leading cause of injury mortality in children aged 1 to 4 years and is second only to motor vehicle collisions for children aged 5 to 14 years (2). Groups at higher risk of drowning death include the following:
People who have used alcohol or other medications or illicit drugs that affect judgment and alertness (3)
People with epilepsy (4)
People with arrhythmogenic cardiac disorders, including long QT syndrome (5, 6)
Children from African American or Native American families (7, 8, 9)
Children who have not received formal swimming lessons and are unsupervised around water (2)
Males (10)
People who engage in dangerous underwater breath-holding behaviors (DUBBs) (11)
Almost 50% of adult drowning deaths involve alcohol (3).
Medical conditions, such as ischemic heart disease, seizure disorders, and arrhythmogenic disorders play important roles in death by drowning (5, 6).
Males are at particular risk of drowning. In fact, 80% of victims over age 1 year are male (10).
Drowning is common in pools, hot tubs, and natural water settings; infants and toddlers can also drown in toilets, bathtubs, and buckets of water or cleaning fluids.
Nonfatal drownings are more common than fatal drownings (12); approximately 20% of those treated in emergency departments require admission to the hospital.
General references
1. World Health Organization (WHO). Drowning. May 1, 2026. Accessed June 11, 2026.
2. Centers for Disease Control and Prevention: Drowning Prevention. Drowning Data. Accessed May 26, 2026.
3. Hamilton K, Keech JJ, Peden AE, Hagger MS. Alcohol use, aquatic injury, and unintentional drowning: A systematic literature review. Drug Alcohol Rev. 2018;37(6):752-773. doi:10.1111/dar.12817
4. Sillanpää M, Shinnar S. SUDEP and other causes of mortality in childhood-onset epilepsy. Epilepsy Behav. 2013 Aug;28(2):249-55. doi: 10.1016/j.yebeh.2013.04.016
5. Tester DJ, Medeiros-Domingo A, Will ML, Ackerman MJ. Unexplained drownings and the cardiac channelopathies: a molecular autopsy series. Mayo Clin Proc. 2011;86(10):941-947. doi:10.4065/mcp.2011.0373
6. Dunne CL, Sweet J, Clemens T. The link between medical conditions and fatal drownings in Canada: a 10-year cross-sectional analysis. CMAJ. 2022;194(18):E637-E644. doi:10.1503/cmaj.211739
7. Clemens T, Moreland B, Lee R. Persistent Racial/Ethnic Disparities in Fatal Unintentional Drowning Rates Among Persons Aged ≤ 29 Years - United States, 1999-2019. MMWR Morb Mortal Wkly Rep. 2021;70(24):869-874
8. Day G, Holck P, Strayer H, et al. Disproportionately higher unintentional injury mortality among Alaska Native people, 2006-2015. Int J Circumpolar Health 77(1):1422671, 2018. doi: 10.1080/22423982.2017.1422671
9. Felton H, Myers J, Liu G, et al. Unintentional, non-fatal drowning of children: US trends and racial/ethnic disparities. BMJ Open 5(12):e008444, 2015. doi: 10.1136/bmjopen-2015-008444
10. Centers for Disease Control and Prevention: Drowning Prevention. Risk Factors for Drowning. Accessed May 26, 2026.
11. Boyd C, Levy A, McProud T, et al. Fatal and nonfatal drowning outcomes related to dangerous underwater breath-holding behaviors—New York State, 1988-2011. MMWR Morb Mortal Wkly Rep. 2015;64(19):518-521
12. Davis CA, Schmidt AC, Sempsrott JR, et al. Wilderness Medical Society Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2024 Update. Wilderness Environ Med. 2024;35(1_suppl):94S-111S. doi:10.1177/10806032241227460
Pathophysiology of Drowning
Hypoxia
Hypoxia is the major insult in drowning, affecting the brain, heart, and other tissues; respiratory arrest followed by cardiac arrest may occur. Brain hypoxia may cause cerebral edema and, occasionally, permanent neurologic sequelae. Generalized tissue hypoxia may cause metabolic acidosis. Immediate hypoxia results from aspiration of fluid or gastric contents, acute reflex laryngospasm (previously called dry drowning), or both. Lung injury due to aspiration or hypoxia itself may cause delayed hypoxia (previously called secondary drowning). Aspiration, especially with particulate matter or chemicals, may cause chemical pneumonitis or secondary bacterial pneumonia and may impair alveolar secretion of surfactant, resulting in patchy atelectasis. Extensive atelectasis may make the affected areas of the lungs stiff, noncompliant, and poorly ventilated, potentially causing respiratory failure with hypercapnia and respiratory acidosis. Perfusion of poorly ventilated areas of the lungs (V/Q mismatch) worsens hypoxia. Alveolar hypoxia may cause noncardiogenic pulmonary edema.
Hypothermia
Exposure to cold water induces systemic hypothermia, which can be a significant problem. However, hypothermia can be protective, in some cases, by stimulating the mammalian diving reflex, slowing the heart rate, and constricting the peripheral arteries, shunting oxygenated blood away from the extremities and the gut to the heart and brain. Also, hypothermia decreases the oxygen needs of tissues, possibly prolonging survival and delaying the onset of hypoxic tissue damage (1). The diving reflex is most prominent in young children.
Fluid aspiration
Laryngospasm may transiently limit the volume of fluid aspirated, but is terminated by the onset of brain hypoxia after which aspiration of water continues. Distinction between freshwater and seawater drowning was once considered important due to the potential electrolyte shifts, hemolysis, and fluid compartment shifting that possibly could occur. However, in most patients, salt and fresh water drowning are physiologically similar, with differences in outcomes related to drowning circumstances rather than water type (2). In one large multicenter cohort study, freshwater downing was associated with higher mortality, but freshwater victims had a significantly greater proportion of psychiatric comorbidity and suicide attempts (3).
Aspiration can lead to pneumonia, sometimes with anaerobic or fungal pathogens, and pulmonary edema.
Dangerous underwater breath-holding behaviors (DUBBs)
Dangerous underwater breath-holding behaviors are practiced mostly by healthy young men (often good swimmers) trying to prolong their capacity to remain submerged (4). There are 3 described types of DUBB:
Intentional hyperventilation—blowing off carbon dioxide before submerged swimming, thereby delaying central hypercarbic ventilatory responses
Hypoxic training—extending capacity for underwater distance swimming or breath-holding
Static apnea—breath-holding for as long as possible while submerged and motionless, including as a game
In DUBBs, while submerged, hypoxia occurs first, followed by loss of consciousness (hypoxic blackout, breath-hold blackout) and then drowning.
Associated injuries
Skeletal, soft-tissue, head, and internal injuries may occur, particularly among surfers, water skiers, boaters, flood victims, and occupants of submerged vehicles. People who dive into shallow water may sustain cervical and other spine injuries (which may be the cause of drowning).
Pathophysiology references
1. Szpilman D, Bierens JJ, Handley AJ, et al. Drowning. N Engl J Med. 2012;366(22):2102-2110. doi:10.1056/NEJMra1013317
2. Orlowski JP, Abulleil MM, Phillips JM. The hemodynamic and cardiovascular effects of near-drowning in hypotonic, isotonic, or hypertonic solutions. Ann Emerg Med. 1989;18(10):1044-1049. doi:10.1016/s0196-0644(89)80927-8
3. Reizine F, Delbove A, Dos Santos A, et al. Clinical spectrum and risk factors for mortality among seawater and freshwater critically ill drowning patients: a French multicenter study. Crit Care. 2021;25(1):372. Published 2021 Oct 24. doi:10.1186/s13054-021-03792-2
4.Boyd C, Levy A, McProud T, et al. Fatal and nonfatal drowning outcomes related to dangerous underwater breath-holding behaviors - New York State, 1988-2011. MMWR Morb Mortal Wkly Rep. 2015;64(19):518-521.
Symptoms and Signs of Drowning
During drowning, panic and air hunger occur. Children who are unable to swim may become submerged in less than a minute, more rapidly than adults. People who are drowning may be unable to signal or call for help because they are struggling to breathe and remain afloat (1). As a result, they may not appear to be in distress by bystanders who are not watching closely. Young children, in particular, may fall into the water silently and can submerge without attracting attention (2).
After rescue, anxiety, vomiting, wheezing, and altered consciousness are common. Patients may have respiratory failure with tachypnea, intercostal retractions, or cyanosis. Patients may have symptoms due to injuries or exacerbations of underlying disorders.
This photo shows a child gasping for air, with only the face above water and without obvious signs of struggle.
Victor/stock.adobe.com
Symptoms and signs references
1. McCallin TE, Dezfulian C, Bierens J, et al. 2024 American Heart Association and American Academy of Pediatrics Focused Update on Special Circumstances: Resuscitation Following Drowning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Pediatrics. 2024;154(6):e2024068444. doi:10.1542/peds.2024-068444
2. Denny SA, Quan L, Gilchrist J, et al. Prevention of Drowning. Pediatrics. 2021;148(2):e2021052227. doi:10.1542/peds.2021-052227
Diagnosis of Drowning
History and physical examination
Imaging studies as indicated for concomitant injuries
Pulse oximetry and sometimes arterial blood gases (ABG) and chest radiograph
Core temperature measurement
Evaluation for causative or contributing disorders (eg, seizure, hypoglycemia, myocardial infarction, intoxication, injury)
Ongoing monitoring as indicated for delayed respiratory complications
Most people are found in or near water, making the diagnosis obvious clinically. Resuscitation, if indicated, should take precedence over the full diagnostic assessment. Cervical spine injury should be considered, and spinal motion restricted in patients whose mechanism of injury potentially involves diving or trauma. Secondary head injury and conditions that may have contributed to drowning (eg, hypoglycemia, myocardial infarction, stroke, intoxication, arrhythmia) are considered.
All patients undergo assessment of oxygenation by oximetry or, if results are abnormal or if there are respiratory symptoms or signs, arterial blood gas (ABG) and chest radiograph. Because respiratory symptoms may be subtle or delayed, even asymptomatic patients should be watched for 4 to 6 hours, either in the emergency department or hospital setting, or if asymptomatic with a normal examination at the scene, by an individual who can observe for symptoms or deterioration (1).
In patients with symptoms or a history of prolonged submersion, core body temperature is measured to evaluate for hypothermia, electrocardiography and serum electrolytes are obtained, and continuous oximetry and cardiac monitoring are performed. Patients with possible cervical spine injury undergo cervical spine imaging.
Patients with altered consciousness undergo head CT. Any other suspected predisposing or secondary conditions are evaluated with appropriate testing (eg, fingerstick glucose for hypoglycemia, electrocardiography for myocardial infarction, cardiac monitoring for arrhythmia, evaluation for intoxication, electroencephalography for suspected seizure). Patients who drown without apparent risk factors are evaluated for long QT syndrome, other inherited arrhythmia syndromes, and any suspected arrhythmogenic cardiac disorders. In patients with pulmonary infiltrates, bacterial or fungal pneumonia is differentiated from chemical pneumonitis and pulmonary edema using blood cultures and sputum Gram stain and culture. If indicated (eg, bacterial or fungal pneumonia is suspected but the pathogen cannot be otherwise identified), bronchial washings are obtained for testing, including culture.
Diagnosis reference
1. Davis CA, Schmidt AC, Sempsrott JR, et al. Wilderness Medical Society Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2024 Update. Wilderness Environ Med. 2024;35(1_suppl):94S-111S. doi:10.1177/10806032241227460
Treatment of Drowning
Resuscitation
Correction of oxygen and carbon dioxide levels and other physiologic abnormalities
Intensive respiratory support
Treatment aims to correct cardiac arrest, hypoxia, hypoventilation, hypothermia, and other physiologic insults (1).
Resuscitation after drowning
In apneic patients, rescue breathing is started immediately—in the water, if necessary. If spinal motion restriction is necessary, it is performed in a neutral position, and the airway is positioned using a jaw thrust without head tilt or chin lift. Emergency medical services are called. Although the 2020 American Heart Association Guidelines for Cardiopulmonary Resuscitation (CPR) recommend chest compressions as the first step in resuscitation of patients in cardiac arrest, drowning is an exception to this recommendation and rescue breathing is started first (2). Similarly, in children, airway management and ventilation are of particular importance (3). Attempts to remove water from the lungs are avoided because they delay ventilation and increase the risk of vomiting. If the patient does not respond to rescue breathing, cardiac compressions are started, followed by advanced cardiac life support (4). Oxygenation, advanced airway endotracheal intubation, or both should proceed as soon as possible. Hypothermic patients are warmed as soon as possible. Immediate treatment measures may include removing clothing, drying, and insulation. Prolonged resuscitation efforts should be considered especially in young patients involved in cold water drownings.
Pearls & Pitfalls
|
Hospital care for drowning patients
All hypoxic or moderately symptomatic patients are hospitalized (5). In the hospital, supportive treatment continues, aimed primarily at achieving acceptable arterial oxygen and carbon dioxide levels. Mechanical ventilation or noninvasive positive pressure ventilation may be necessary. Patients are initially given 100% oxygen; the concentration is titrated lower based on arterial blood gas (ABG) results. Positive end-expiratory pressure ventilation is sometimes necessary to help expand or maintain patency of alveoli to maintain adequate oxygenation. Pulmonary support may be necessary for hours or days. If adequate oxygenation is impossible despite maximizing ventilator settings, extracorporeal membrane oxygenation may be considered. Nebulized beta-2 agonists may help reduce bronchospasm and wheezing. Surfactant administration may be helpful in critically ill patients with significant lung compliance issues after drowning, although no large clinical trials have addressed this.
Core body temperature is monitored, and hypothermia is treated (5). Fluids or electrolytes are rarely required to correct significant volume or electrolyte imbalances (6). Fluid restriction is rarely indicated unless pulmonary or cerebral edema occurs. Concomitant injuries and disorders (eg, head or cervical injury, seizure, arrhythmia) may also require treatment. Patients who have persistent altered mental status despite correction of respiratory compromise should be evaluated for other injuries (eg, occult seizures, intracranial injury). Patients with pneumonia, confirmed by results of sputum testing and/or blood cultures, are treated with antibiotics that target identified or suspected organisms. Empiric antibiotics are indicated only for drowning that has occurred in grossly contaminated fluids; when used, therapy should provide coverage for Gram-negative bacteria (7). Glucocorticoids are not recommended.
Discharge of drowning patients
Patients with mild symptoms, clear lungs, and normal mentation and oxygenation should be observed in the emergency department for 4 to 6 hours (6, 8, 9). If symptoms resolve and the examination and oxygenation remain normal, patients can be discharged with instructions to return if symptoms recur. In children, the presence of any of the following during the emergency department evaluation was found to be associated with developing clinically significant lung injury and should prompt longer observation (10):
Age > 5 years
Any resuscitation at the scene
Hypotension
Abnormal mentation, heart rate, respiratory rate, or lung auscultation
Treatment references
1. Szpilman D, Morgan PJ. Management for the Drowning Patient. Chest. 2021;159(4):1473-1483. doi:10.1016/j.chest.2020.10.007
2. Kleinman ME, Buick JE, Huber N, et al. Part 7: Adult Basic Life Support: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025 Oct 21;152(16_suppl_2):S448-S478. doi: 10.1161/CIR.0000000000001369
3. Dezfulian C, McCallin TE, Bierens J, et al: 2024 American Heart Association and American Academy of Pediatrics Focused Update on Special Circumstances: Resuscitation Following Drowning: An Update to the American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation 150(23):e501-e516, 2024. doi:10.1161/CIR.0000000000001274
4. Wigginton JG, Agarwal S, Bartos JA, et al. Part 9: Adult Advanced Life Support: 2025 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2025;152(16_suppl_2):S538-S577. doi:10.1161/CIR.0000000000001376
5. Berg KM, Bray JE, Ng KC, et al: 2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, Implementation, and Teams; and First Aid Task Forces [published correction appears in Resuscitation. 2024 Aug;201:110262. doi: 10.1016/j.resuscitation.2024.110262]. Resuscitation. 2024;195:109992. doi:10.1016/j.resuscitation.2023.109992
6. Davis CA, Schmidt AC, Sempsrott JR, et al. Wilderness Medical Society Clinical Practice Guidelines for the Treatment and Prevention of Drowning: 2024 Update. Wilderness Environ Med. 2024;35(1_suppl):94S-111S. doi:10.1177/10806032241227460
7. Cousin VL, Pittet LF. Microbiological features of drowning-associated pneumonia: a systematic review and meta-analysis. Ann Intensive Care. 2024;14(1):61. Published 2024 Apr 20. doi:10.1186/s13613-024-01287-1
8. Girasek DC, Hargarten S. Prevention of and Emergency Response to Drowning. N Engl J Med. 2022;387(14):1303-1308. doi:10.1056/NEJMra2202392
9. Bierens J, Abelairas-Gomez C, Barcala Furelos R, et al. Resuscitation and emergency care in drowning: A scoping review. Resuscitation. 2021;162:205-217. doi:10.1016/j.resuscitation.2021.01.033
10. Shenoi RP, Crowe JE, Dorfman SR, et al. Factors Associated with Pediatric Drowning-Associated Lung Injury. J Pediatr. 2025;279:114459. doi:10.1016/j.jpeds.2024.114459
Prognosis for Drowning
Outcome after drowning is determined primarily by the severity and duration of hypoxia and the promptness of rescue and resuscitation. In a study of almost 1000 patients < 18 years of age who received prehospital CPR after a drowning event, only 3.5% experienced favorable neurologic outcomes at 1 month (1). Favorable neurologic outcomes were particularly uncommon after prolonged resuscitation; only 0.3% of patients who received ≥ 33 minutes of CPR after a drowning event had a favorable neurologic outcome (1). Factors that increase the chance of surviving submersion without permanent injury include the following (2):
Rapid institution of resuscitation (most important)
Brief duration of submersion
Colder temperatures
Young age
Absence of underlying medical conditions, secondary trauma, and aspiration of particulate matter or chemicals
Survival may be possible in cold water submersion that lasts >1 hour (2, 3, 4), especially among children, although it does not have a clearly demonstrated protective effect beyond individual case reports. Thus, patients with prolonged cold-water submersion should be vigorously resuscitated, particularly if advanced therapies such as extracorporeal membrane oxygenation are available.
Prognosis references
1. Komori A, Iriyama H, Abe T. Relationship between cardiopulmonary resuscitation duration and outcomes in children with drowning-induced cardiac arrest. Am J Emerg Med. 2025;87:82-87. doi:10.1016/j.ajem.2024.11.004
2. Denny SA, Quan L, Gilchrist J, et al. Prevention of Drowning. Pediatrics. 2021;148(2):e2021052227. doi:10.1542/peds.2021-052227
3. Bitzer K, Breindahl N, Kelly B, et al. The role of accidental hypothermia in drowning patients with out-of-hospital cardiac arrest: A nationwide registry-based cohort study. Resuscitation. 2025;207:110486. doi:10.1016/j.resuscitation.2024.110486
4. Romlin BS, Winberg H, Janson M, et al. Excellent Outcome With Extracorporeal Membrane Oxygenation After Accidental Profound Hypothermia (13.8°C) and Drowning. Crit Care Med. 2015;43(11):e521-e525. doi:10.1097/CCM.0000000000001283
Prevention of Drowning
Illicit Drugs, alcohol, and drowning
Swimming safety
Swimmers should use common sense and be aware of weather and water conditions. Swimmers should be accompanied by an experienced swimmer or swim only in guarded areas (1, 2). Swimming should stop if the swimmer looks or feels very cold, because hypothermia may impair judgment. Ocean swimmers should learn to escape rip currents by swimming parallel to the beach rather than directly toward the beach. Swimmers should be discouraged from dangerous underwater breath-holding behaviors (DUBBs). If they practice them, they should be supervised and should know their dangers. Swimmers should avoid swimming near a boat exhaust port, which can cause carbon monoxide poisoning.
Public swimming areas should be supervised by lifeguards trained in water safety and resuscitation as well as rescue techniques (1, 2). Life preservers, life jackets, and a shepherd's crook should be available close to poolside. Emergency airway equipment, automated external defibrillators (AEDs), and immediate telephone access to emergency medical services should be available. Comprehensive community prevention programs should target high-risk groups, teach children to swim as early as possible, and teach cardiopulmonary resuscitation (CPR) to as many adolescents and adults as possible. Owners of private pools should comply with local laws regarding pool safety, have immediate telephone access to emergency medical services, and know about resuscitation after drowning.
Water safety for children
Children should wear flotation devices that have been approved by the United States Coast Guard or other equivalent authority when in or around water (1, 2). Air-filled swimming aids and foam toys (water wings, noodles, etc) are not designed to keep swimmers from drowning and should not be used as a substitute for approved safety equipment.
Children must be constantly supervised by an adult when around water, including beaches, pools, and ponds (1, 2). Infants and toddlers should also be supervised, ideally within arm’s length, when near toilets, bathtubs, or any collection of water.
Studies in the United States and China have shown that formal swimming lessons reduce the risk of fatal drowning among children ages 1 to 4 (4, 5); however, even children who have been taught how to swim require constant supervision when in or around water.
Adults should remove water from containers such as pails and buckets immediately after use. Swimming pools should be surrounded with a locked fence ≥ 1.5 m in height.
Boating safety
Before embarking, boaters should wear life jackets approved by the United States Coast Guard or other equivalent authority and they should check weather and water conditions. Nonswimmers and small children in a boat should wear appropriately approved life jackets at all times. Because consuming any quantity of alcohol increases the risk of drowning, operators and passengers on recreational boats should generally avoid consuming alcohol.
Special populations at risk for drowning
People who are debilitated or older or have seizure disorders or other medical conditions that can alter consciousness require constant supervision when they are boating or swimming and when in bathtubs.
People with a personal or family history of unexplained drowning not attributable to alcohol use, illicit drug use, or a seizure disorder merit evaluation for arrhythmogenic cardiac disorders.
Prevention references
1. Denny SA, Quan L, Gilchrist J, et al. Prevention of Drowning. Pediatrics. 2021;148(2):e2021052227. doi:10.1542/peds.2021-052227
2. Girasek DC, Hargarten S. Prevention of and Emergency Response to Drowning. N Engl J Med. 2022;387(14):1303-1308. doi:10.1056/NEJMra2202392
3. Pajunen T, Vuori E, Vincenzi FF, et al. Unintentional drowning: Role of medicinal drugs and alcohol. BMC Public Health. 2017;17(1):388. Published 2017 May 19. doi:10.1186/s12889-017-4306-8
4. Brenner RA, Taneja GS, Haynie DL, et al. Association between swimming lessons and drowning in childhood: a case-control study. Arch Pediatr Adolesc Med. 2009;163(3):203-210. doi:10.1001/archpediatrics.2008.563
5. Yang L, Nong QQ, Li CL, et al. Risk factors for childhood drowning in rural regions of a developing country: a case-control study. Inj Prev. 2007;13(3):178-182. doi:10.1136/ip.2006.013409
Key Points
Take preventive measures (eg, provide or take swimming lessons, closely supervise children around water, use flotation devices or life jackets that have been approved by the United States Coast Guard or other equivalent authority, avoid alcohol, and ensure access to trained lifeguards and emergency medical services) to decrease the risk of drowning.
Begin resuscitation of patients in cardiac arrest from drowning with rescue breathing, not chest compressions.
Vigorously resuscitate cold water drowning victims even if submersion was prolonged.
Evaluate patients for suspected causes of drowning (eg, cervical spine injury, head injury, seizure, arrhythmias, hypoglycemia) as well as injuries or consequences of drowning (eg, head or cervical spine injury, aspiration).
