Pulled from a river after 5 minutes; now breathing, GCS 12, SpO₂ 86%, crackles; core temperature 32 °C (or found cold outdoors with bradycardia and Osborn J waves)
Red flags
Core <30 °C
Arrhythmia
Hypoxaemia after drowning
GCS falling
Differential diagnosis
Hypoglycaemia
Sepsis
Hypothyroidism / adrenal insufficiency
Drug or alcohol intoxication
Head/cervical spine injury
When to admit, call ICU or discharge
Admit: All symptomatic drowning, any hypothermia <35 °C, abnormal CXR or gas
ICU: Core <32 °C, arrhythmia, ARDS, intubated, post-arrest
Intubate: GCS ≤8, refractory hypoxaemia, arrest
Key points
"Not dead until warm and dead."
India: drowning is a leading cause of death in children and young adults, especially in monsoon floods and ponds.
In drowning, rescue breaths matter more than chest compressions alone.
Never
Give cold IV fluids
Declare death in hypothermic arrest before rewarming (unless K⁺ >12 mmol/L / HOPE <10%)
Do the Heimlich manoeuvre to drain water
Handle a severely hypothermic patient roughly (VF)
Common mistakes
Iced fluids
Stopping CPR too early
Missing delayed pulmonary oedema
Missing the underlying cause
Disposition and follow-up
ICU/ECLS centre for severe; ward observation for mild; drowning observed ≥6–8 h.
ICU Decoded — original critical-care and internal-medicine pathways by
Dr Javed Akhtar, each cited to a current guideline. For education and quick
reference; verify every dose against local protocols before prescribing.