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What's the Diagnosis?

March 2022

Visual Diagnosis           


Angela Myers, MD

Column Editor: Joe Julian, MD, MPHTM, FAAP | Hospitalist, Internal Medicine - Pediatrics | Clinical Associate Professor, Internal Medicine and Pediatrics, UMKC School of Medicine


A 6-year-old male is evaluated in the emergency department approximately two hours after a drowning event. Patient was chasing after a loose family pet and was found by his family submerged just under the surface of an above-ground residential pool for an unknown period of time. The patient was unresponsive but had a pulse and was breathing spontaneously. After a short time, he regained consciousness and started coughing, followed by emesis of water. No rescue breaths or chest compressions were required. After evaluation by first responders, the patient was transferred via Children’s Mercy Critical Care Transport to the Emergency Department at Children’s Mercy.

Vital signs are notable for a respiratory rate of 24 and an oxygen saturation of 98% without need for oxygen supplementation. Respirations are non-labored with adequate aeration and bibasilar crackles are present. Neurologic examination does not show any deficits and the patient is able to converse appropriately. Capillary refill is two seconds and the patient appears to be well-perfused.

A two-view chest X-ray and a basic metabolic panel are obtained and shown below.

Which of the following is the most appropriate plan of care for this patient?

A. Admit to medical unit for overnight observation

B. Discharge home with outpatient follow-up

C. Administer intravenous hypertonic saline

D. Initiate continuous positive airway pressure





Answer: A. Admit to medical unit for overnight observation

The literature on drowning is inconsistent due to lack of standardization of terminology. Terms such as “wet drowning,” “dry drowning,” “near drowning,” etc., have contributed to the lack of clarity and difficulty in standardizing evidence-based treatments.

This patient has an abnormal pulmonary examination and an abnormal chest X-ray (bilateral infiltrates consistent with aspiration of water). He did have loss of consciousness but regained it at the scene of the drowning. This puts him at a Grade 2 submersion injury (Szpilman 1997). He does not require supplemental oxygen or other delivery methods such as high-flow nasal cannula or noninvasive ventilation (which would be appropriate if he had persistent hypoxemia or findings of worsening pulmonary edema). While the ultimate timing is unclear, a six- to eight-hour observation period is warranted to ensure no complications from his drowning are present.

The mild hyponatremia should resolve on its own. While both freshwater and saltwater can both cause surfactant dysfunction and disrupt the alveolar-capillary membrane, there is generally no clinically significant impact on the sodium level. If the patient is volume depleted, isotonic fluid should be used for volume expansion. The administration of hypertonic saline would only be appropriate if the patient was obtunded or seizing with hyponatremia as the suspected etiology.

Case Resolution

This patient was observed overnight in the hospital without any need for supplemental oxygen. His pulmonary examination improved, and he was discharged the following morning.

Click here to read more about Drowning Prevention from the American Academy of Pediatrics (AAP).



  1. 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
  2. Szpilman D. Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1,831 cases. Chest. 1997;112(3):660-665. doi:10.1378/chest.112.3.660
  3. Szpilman D, Bierens JJ, Handley AJ, Orlowski JP. Drowning. N Engl J Med. 2012;366(22):2102-2110. doi:10.1056/NEJMra1013317