Some factsDrowning is important: 1,000 people drown every day, 2 every 3 minutes, 41 per hour. It is the world’s 3rd leading cause of accidental death: 3.6 million people over 10 years.Disease of youth64% < 30 years old43% < 15 years old25% < 5 years oldMale: female ratio In 40%, alcohol is on board4 stages of Immersion associated with particular risk in drowningInitial Responses/Sudden Death (first 3-5 min)Skin coolingShort-Term Responses (5-30 min)Superficial Nerve and Muscle CoolingLong-Term Responses (30 min +)Cooling of deep tissuesPost-immersion (during rescue)Collapse of arterial pressureContinued coolingFresh versus salt water drowningLethal aspiration of salt water 22ml/kg (approx 1.5 litre), fresh water 44ml/kgBe aware that drowning can take up to 4 hours – observe and watch for 6!PrognosticationBetter outcomes:Rescued and BLS commenced < 5-10 minChildrenThose who have not aspiratedWater temperature < 10 oC, core body temperature 33-35 oCNeurologically intact on arrival at hospitalMinimum blood pH > 7.1, blood glucose < 11.2mmol/LROSC on sceneSpontaneous ventilation in EDWorse prognosisRisk of death or severe neurological impairment after hospital discharge is reported to be nearly 100% when the duration of submersion exceeds 25 minFollowing 30 mins resuscitation, if no signs of life, resuscitation is futile -> stopIt is important to remember that casualties who have entered water sometimes have access to a “bubble” of air – particularly if they had entered the water following a boating incident or were in a car at the point they entered the water. In these circumstances it is impossible to judge the point at which submersion has occurred. What about cold water???This is a regular point of discussion and concern. Water temperature is a key determinant: icy versus not. In the UK sea water is very unlikely to be icy or cold enough – however, small areas of water may well be, particularly in the winter months. ReferencesSzpilman D, Bierens JJ, Handley AJ, Orlowski JP (2012) Drowning. New Engl J Med. 366: 2102–10. Tipton & Golden (2011). Decision making guide for immersion incidents involving total (head under) submersion. Resuscitation. 82: 819-824. Golden & Hervey, 1981 Oakley & Pethybridge, 1997Tipton 2016Bierens 2014. Handbook of Drowning.