ED physicians consider a child having undergone a drowning or submersion injury as one who has respiratory impairment which includes but is not limited to difficulty breathing, sustained/prolonged cough, grunting or color change in association with a submersion or aspiration.  This does not include a child who had a brief coughing episode associated with swim lessons, for example. 

After a review of studies discussing safe discharges after drowning, CHOA Quality Improvement team developed pediatric submersion guidelines. If a child is asymptomatic, they are observed for 6 hours after the event. If their respiratory exam remains normal for 6 hours post submersion (no rales, rhonchi or crackles, easy work of breathing, saturations > 94%), they do not need any blood work or a chest x-ray. If at any point that the patients develops signs of hypoxia or respiratory distress, it is recommended to obtain a chest x-ray and a blood gas. Of course, in the case a patient arrives after a submersion with respiratory distress, hypoxia, or altered mental status, labs and imaging should be done immediately. 

Some factors that have been associated with abnormal chest x-rays include abnormal mentation, respiratory distress, > 1 minute of submersion and EMS resuscitation.  In conclusion, minimal laboratory and radiographic evaluations are needed for drowning victims who are alert, beathing and have no respiratory symptoms. 

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