Anticipate respiratory complications. Since only a small amount of water is usually aspirated during a drowning event, the salinity of the aspirate is unlikely to cause significant disruption in hemodynamic or electrolyte balance.17,20 However, even a small amount of aspirated water, particularly fresh water, can disrupt gas exchange by washing out surfactant. This can rapidly precipitate ARDS. Not surprisingly, the use of exogenous surfactant has been studied in limited case reports and has had positive results.41-43 However, large trials have not yet been conducted, mostly because of the significant cost associated with surfactant therapy.
Antibiotics are rarely indicated prophylactically. Pneumonia after a drowning event is potentially fatal. It is more common in patients who have been intubated, and is therefore thought to be a hospital-acquired infection rather than a direct result of the drowning event.
The best predictor of a good outcome is consciousness at the time of arrival at the emergency department.Frequently, pneumonia after drowning is caused by pathogens native to the upper airway, when a victim is unable to protect his or her upper airway.44 In these cases, start broad spectrum antibiotics, with particular concern for organisms of the upper oropharynx. Also take into consideration species native to the body of water in which the victim was immersed.44
Routine prophylaxis with antibiotics, although common, is not recommended. Exceptions may be victims of drowning in known contaminated water or victims with high volumes of water aspiration.25 Some experts recommend blood cultures for victims who have aspirated, regardless of the presence or absence of infection.24 However, this recommendation seems to be based on opinion.
CORRESPONDENCE Sean C. Engel, MD, 6600 Excelsior Boulevard Suite 100, St. Louis Park, MN 55426; enge0289@umn.edu
