ECAT protocol – Adult – 16 years and over

Immersion or submersion episode

A12.2 Published: December 2023 Printed on 19 May 2024

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Any person, 16 years and over, who has been partly or completely submerged.

This protocol is intended to be used by registered and enrolled nurses within their scope of practice and as outlined in The Use of Emergency Care Assessment and Treatment Protocols (PD2024_011). Sections marked triangle or diamond indicate the need for additional prerequisite education prior to use. Check the medication table for dose adjustments and links to relevant reference texts.

If in respiratory or cardiac arrest, escalate as per local CERS protocol and switch to cardiorespiratory arrest protocol.

History prompts, signs and symptoms

These are not exhaustive lists. Maintain an open mind and be aware of cognitive bias.

History prompts

  • Presenting complaint
  • Immersion or submersion time and duration
  • Time to, and type of, basic life support delivered
  • Time to first respiratory effort
  • Type of liquid and estimated temperature
  • Preceding events, consider:
    • trauma
    • cardiac event, arrhythmia or long QT syndrome
    • hypoglycaemia
    • seizure
    • alcohol or drug use
    • self-harm
  • Pain assessment – PQRST
  • Pre-hospital treatment
  • Past admissions
  • Medical and surgical history
  • Known allergies

Signs and symptoms

  • Altered level of consciousness
  • Respiratory distress
  • Cough
  • Tachycardia
  • Hypothermia
  • Associated injuries

Red flags

Recognise: identify indicators of actual or potential clinical severity and risk of deterioration.

Respond: carefully consider alternative ECAT protocol. Escalate as per clinical reasoning and local CERS protocol, and continue treatment.

Historical

  • Trauma-related injury
  • Suspected drug and/or alcohol use

Clinical

  • Cardiac or respiratory arrest
  • Altered level of consciousness, confusion or agitation
  • Arrhythmia
  • Respiratory compromise
  • Cyanosis
  • Hypoxia
  • Poor perfusion
  • Hypothermia
  • Hypoglycaemia
  • Pink, frothy sputum

Remember adult at risk: patient or carer concern, frailty, multiple comorbidities or unplanned return.

Clinical assessment and specified intervention (A to G)

If the patient has any Yellow or Red Zone observations or additional criteria (as per the relevant NSW Standard Emergency Observation Chart), refer and escalate as per local CERS protocol and continue treatment.

Position

AssessmentIntervention

General appearance/first impressions

 Position of comfort with head elevated to 30°

Suspected cervical spine injury or unconscious

Stabilise the C-spine with in-line immobilisation and/or foam collar (appendix)

Airway

AssessmentIntervention

Patency of airway

Maintain airway patency

Consider airway opening manoeuvres and positioning

Breathing

AssessmentIntervention

Respiratory rate and effort

Auscultate chest (breath sounds)

Oxygen saturations (SpO2)

If no respiratory distress, provide close observation and continue A to G

Signs of inadequate respirations and/or dyspnoea:

  • increased respiratory effort
  • inadequate spontaneous ventilation
  • hypoxia despite increased oxygen
  • abnormal conscious state
  • abnormal breath sounds or crepitations
  • SpO2 less than 95%

Escalate as per local CERS protocol

Continuous SpO2 and cardiorespiratory monitoring

Apply oxygen to maintain SpO2 over 95%

Patients at risk of hypercapnia, maintain SpO2 at 88–92%

Commence high flow nasal cannula if supported by care facility

If ineffective respiratory effort, assess need for non-invasive ventilation (if no contraindications)

Circulation

AssessmentIntervention

Perfusion (capillary refill, skin warmth and colour)

Pulse

Blood pressure

Cardiac rhythm

Assess circulation

Attach cardiac monitor and complete 12 lead ECG if BP/HR are within the Yellow or Red Zones, or where clinically relevant, e.g. irregular pulse, palpitations, syncope, shock, respiratory compromise, cardiac history or clinical concern

IVC and/or pathology

Insert IV cannula, if trained and clinically indicated

If unable to obtain IV access, consider intraosseous, if trained

See pathology section

Signs of shock:

tachycardia and CRT 3 seconds and over

and/or abnormal skin perfusion

and/or hypotension

If signs of shock present and/or SBP less than 90 mmHg, give 250 mL of sodium chloride 0.9% IV/intraosseous bolus

Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Disability

AssessmentIntervention

GCS, pupillary response and limb strength

Obtain baseline and repeat assessment, as clinically indicated

Pain

Assess pain. If indicated, give early analgesia as per analgesia section then resume A to G assessment

Exposure

AssessmentIntervention
Temperature

Avoid hypothermia

Remove wet clothing, towels and blankets

If hypothermic, initiate slow re-warming using blankets, air warming device and warmed room

If temperature less than 33°C escalate as per local CERS protocol

Measure core temperature if actively warming

Skin inspection, including posterior surfaces

Check and document any abnormalities

Fluids

AssessmentIntervention
Hydration status: last ate, drank, bowels opened, passed urine or vomited Commence fluid balance chart, as required
NBM Consider clear fluids or NBM based on red flags and clinical severity
Nausea and/or vomiting If present, see nausea and/or vomiting section

Glucose

Assessment Intervention
BGL

Measure BGL

If BGL less than 4 mmol/L with NO decrease in level of consciousness (Yellow Zone criteria):

  • give quick-acting carbohydrate: sugary soft drink, fruit juice or 40% glucose gel, up to 15 g, buccal
  • reassess BGL in 15–30 minutes and repeat treatment until BGL over 4 mmol/L

If BGL less than 4 mmol/L WITH a decrease in level of consciousness (Red Zone criteria) OR the patient is unable to tolerate oral intake:

  • give 40% glucose gel, up to 15 g, buccally in incremental doses, as tolerated, while establishing IV access
  • give 10% glucose 200 mL by IV infusion over 15 minutes, once only
  • if delay in IV access, give glucagon 1 mg IM, once only
  • reassess BGL in 15 minutes

If the patient is unconscious or peri-arrest:

  • give 50% glucose 50 mL by slow IV injection, once only. Use with caution as extravasation can cause necrosis
  • if delay in IV access, give glucagon 1 mg IM, once only
  • reassess BGL in 15 minutes

Once stabilised, give patient long-acting carbohydrate and continue to check BGL hourly, or as clinically indicated

Repeat and document assessment and observations to monitor responses to interventions, identify developing trends and clinical deterioration. Escalate care as required according to the local CERS protocol.

Focused assessment

Complete secondary survey.

Complete respiratory focused assessment.

Precautions and notes

  • Cervical spine injury should be considered if there is a history of trauma, e.g. diving accident.
  • Consider the cause of drowning, such as cardiac arrhythmia, intoxication, collapse or trauma.
  • Resuscitation guidelines recommend CPR continues until successful rewarming is provided.
  • Hypothermia is more likely in long submersion times.
  • 98% of victims who experience an immersion or submersion episode have some level of increased fluid in their lungs, suggesting that aspiration occurs in almost all cases.
  • Most deaths in hospital are due to hypoxic brain injury, rather than from pulmonary oedema or lung injury from the initial drowning incident.
  • Be alert for signs of pneumothorax, especially if rapid ascent from significant depths.

Interventions and diagnostics

Specific treatment

  • Key principles of management are maintaining adequate oxygenation, preventing aspiration and stabilising body temperature.
  • If ineffective respiratory effort, consider non-invasive ventilation (NIV) where available and escalate as per local CERS protocol if required.

Analgesia

If pain score 1–6 (mild–moderate), give:

  • paracetamol 1000 mg orally once only
  • and/or ibuprofen 400 mg orally once only.

If severe pain present, give analgesia and escalate as per local CERS protocol.

Nausea and/or vomiting

If nausea and/or vomiting is present, give:

  • metoclopramide 10 mg orally or IV/IM once only (over 20 years only)
  • or ondansetron 4 mg orally or IV/IM. If symptoms persist after 60 minutes, repeat once, maximum dose 8 mg
  • or prochlorperazine 5 mg orally once only or 12.5 mg IV/IM once only

Choice of antiemetic should be determined by cause of symptoms.

Radiology

CXR

Pathology

  • FBC, UEC, VBG if available
  • If suspected preceding cardiac event: troponin

Medications

The shaded sections in this protocol are only to be used by registered nurses who have completed the required education.

Drag the table right to view more columns or turn your phone to landscape

Drug Dose Route Frequency

Glucagon

1 mg

IM

Once only

Glucose 10%

200 mL

IV infusion over 15 minutes

Once only

Glucose 40% gel
(0.4 g/mL)

15 g

Buccal

Repeat after 15 minutes if required

Glucose 50%

50 mL

Slow IV injection

Once only

Ibuprofen H, R

400 mg

Oral

Pain score 1–10

Once only

Metoclopramide R

Over 20 years:
10 mg

Oral/IV/IM

Once only

Ondansetron

4 mg

Maximum dose 8 mg

Oral/IV/IM

Repeat once if required after 60 minutes

Oxygen

2–15 L/min, device dependent

Inhalation

Continuous

Paracetamol H

1000 mg

Oral

Pain score 1–10

Once only

Prochlorperazine

5 mg

Oral

Once only

OR

12.5 mg

IV/IM

Once only

Sodium chloride 0.9%

250 mL

Maximum dose 1000 mL

IV/intraosseous

Bolus

Repeat every 10 minutes (up to 1000 mL) until SBP over 90 mmHg or signs of shock have resolved

Medications with contraindications or requiring dose adjustment are marked:

  • H for patients with known hepatic impairment
  • R for patients with known renal impairment.

Escalate to medical or nurse practitioner.

References

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Evidence informed

Information was drawn from evidence-based guidelines and a review of latest available research. For more information, see the development process.

Collaboration

This protocol was developed by the ECAT Working Group, led by the Agency for Clinical Innovation. The group involved expert medical, nursing and allied health representatives from local health districts across NSW. Consensus was reached on all recommendations included within this protocol.

Currency Due for review: Jan 2026. Based on a regular review cycle.
Feedback Email ACI-ECIs@health.nsw.gov.au

ECAT home pageGlossary

Accessed from the Emergency Care Institute website at https://aci.health.nsw.gov.au/ecat/adult/immersion-or-submersion

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