Immersion or submersion episode

Any person, 4 weeks to 15 years, who has been partly or completely immersed or submerged.

History prompts, signs and symptoms

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

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.

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

Assessment	Intervention
General appearance/first impressions	Position supine or position of comfort
Suspected cervical spine injury and/or unconscious	Stabilise the C-spine with in-line immobilisation or foam collar (appendix) If respiratory distress, elevate head to 30°

Airway

Assessment	Intervention
Patency of airway	Maintain airway patency Consider airway opening manoeuvres and positioning

Breathing

Assessment	Intervention
Respiratory rate and work of breathing Auscultate chest (breath sounds) Oxygen saturation (SpO2)	If no respiratory distress, provide close observation and continue A to G assessment
Signs of inadequate breathing: increased respiratory effort difficulty breathing 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% Assist ventilation, as clinically indicated

Circulation

Assessment	Intervention
Perfusion (capillary refill, skin warmth and colour) Heart rate Blood pressure Cardiac rhythm	Assess circulation Attach cardiac monitor 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 Consider 12 lead ECG
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, give sodium chloride 0.9% at 20 mL/kg IV/intraosseous bolus once only, maximum dose 1000 mL

Disability

Assessment	Intervention
AVPU	If AVPU shows reduced level of consciousness, continue to assess GCS, pupillary response and limb strength
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

Assessment	Intervention
Temperature	Measure core temperature Remove wet clothing and maintain normothermia using blankets and/or warmed room If the temperature is less than 34°C, the patient requires simultaneous external and internal rewarming including warmed IV fluids and humidified oxygen Forced air-warming devices should be considered Avoid unnecessary handling of patient
Head-to-toe inspection, including posterior surfaces	Check and document any abnormalities

Fluids

Assessment	Intervention
Hydration status	Assess fluids, in and out. Document on fluid balance chart. Include gastrointestinal losses
NBM	Consider clear fluids or NBM based on red flags and clinical severity

Glucose

Assessment

Intervention

BGL

Measure BGL, where clinically relevant or of concern. See medication table for 40% glucose gel dosing If BGL between 2 mmol/L and 3 mmol/L and NOT symptomatic (Yellow Zone criteria): give quick-acting carbohydrate: Up to 12 months: milk feed and/or 40% glucose gel, buccal 12 months and over: sugary soft drink or fruit juice or 40% glucose gel, buccal reassess BGL in 15–30 minutes and repeat treatment until BGL over 3 mmol/L If BGL less than 2 mmol/L OR symptomatic (Red Zone criteria) OR unable to tolerate oral glucose: give 40% glucose gel buccally in incremental doses, as tolerated, while establishing IV access escalate as per local CERS protocol

Focused assessment

Complete secondary survey.

Complete a respiratory focused assessment.

Precautions and notes

• Most cases of drowning result in minimal or no respiratory impairment and require a period of observation only.
• Any signs of respiratory distress should be managed with supplemental oxygen and continuous observation.
• Cervical spine injury is uncommon but should considered if there is a history of trauma, e.g. diving accident.
• The cause of drowning should be considered, including issues around supervision, safety and medical concerns, e.g. cardiac arrhythmia.
• Resuscitation guidelines recommend CPR continues until successful rewarming is provided.
• Hypothermia is more likely with long submersion time and in winter.
• 98% of patients 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 pulmonary oedema or lung injury from the initial drowning incident.
• Consider the possibility of non-accidental injury.

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.

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Analgesia

If pain score 1–6 (mild–moderate):

Give paracetamol 15 mg/kg orally once only, maximum dose 1000 mg

and/or ibuprofen, if 3 months and over, 10 mg/kg orally once only, maximum dose 400 mg

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

Consider non-pharmacological pain relief (appendix).

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Radiology

• CXR

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Pathology

• FBC, UEC, VBG

Medications

The patient’s weight is mandatory for calculating fluid and medication doses.

The Broselow Tape or APLS weight table (appendix) can be used only in circumstances where the patient cannot be weighed.

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

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.

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