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Drowning

Emergency numbers differ by country. This page uses 911, the number for the United States and Canada. Many other countries use 112, 999, or another number. Find the number for your country.

Drowning is the process of experiencing respiratory impairment from submersion or immersion in liquid. Contrary to popular portrayals in media, drowning is almost always a silent, deceptively calm event: victims rarely splash violently, wave their arms, or shout for help because their physiological reflexes dedicate all energy to gasping for air. When an individual is pulled from the water in cardiac arrest, the root physiological cause is profound lack of oxygen (hypoxemia), making ventilations and rescue breaths the central pillar of resuscitation.

This guide provides clinically validated emergency procedures based on directives from the World Health Organization (WHO), the International Life Saving Federation (ILS), the American Heart Association (AHA), and the European Resuscitation Council (ERC) to execute land-based water rescues, recognize the instinctive drowning response, provide immediate positive-pressure ventilations, and prevent fatal pulmonary deterioration.

Do this now

If someone is submerged, struggling in water, or pulled from the water:

  1. Call your local emergency number immediately or direct a specific bystander to call (911 in the United States and Canada, 112 in the European Union, 999 in the United Kingdom).
  2. Follow the rescue hierarchy: Reach or Throw, do not go into the water. Lie flat on solid ground and extend a pole, paddle, branch, or towel, or throw a buoyant object (such as a life ring, buoy, or sealed empty cooler).
  3. Do not jump into the water unless you are an expert swimmer trained in lifesaving techniques and equipped with a flotation device. Panicked drowning victims instinctively climb on rescuers, pushing them under.
  4. Once the victim is on dry land, check for responsiveness and breathing for up to 10 seconds.
  5. If the person is unresponsive and not breathing normally, begin CPR immediately starting with 2 to 5 initial rescue breaths before delivering 30 chest compressions. Drowning causes hypoxic arrest; rescue breaths are mandatory.
  6. If an automated external defibrillator (AED) is available, wipe the victim chest dry with a towel before applying the adhesive pads, then follow the voice prompts.
  7. Any person rescued from submersion who exhibited coughing, breathing difficulty, or unconsciousness must be evaluated at an emergency hospital, even if they appear to fully recover within minutes.

Water rescue and resuscitation flowchart

                   PERSON STRUGGLING OR SUBMERGED IN WATER
                                     │
                     Is the victim currently in the water?
                                     │
                    ┌────────────────┴────────────────┐
                   YES                                NO
                    │                                 │
           ┌────────┴────────┐               ┌────────┴────────┐
           │ IN-WATER RESCUE │               │ POST-EXTRICATION│
           └────────┬────────┘               └────────┬────────┘
                    │                                 │
        1. Call emergency services           1. Place flat on firm ground
        2. REACH with pole / clothing        2. Check response & breathing
        3. THROW buoyant object              3. Clear visible vomit/foam
        4. ROW with boat / board             4. DO NOT do abdominal thrusts
        5. DO NOT swim out without                     │
           training and flotation            Is the victim breathing normally?
                    │                                 │
        Extricate victim to shore            ┌────────┴────────┐
                    │                       YES                NO
                    └────────────────┬──────┘                  │
                                     │                ┌────────┴────────┐
                                     │                │  HYPOXIC ARREST │
                                     │                └────────┬────────┘
                                     │                         │
                            ┌────────┴────────┐       1. Give 2 to 5 initial
                            │ RECOVERY STABLE │          rescue breaths
                            └────────┬────────┘       2. 30 chest pushes
                                     │                3. Continue 30:2 cycle
                            1. Recovery position      4. Dry chest for AED
                            2. Remove wet clothing    5. Continue until EMS
                            3. Rewarm gently
                            4. MANDATORY hospital ER

Recognizing the instinctive drowning response

For decades, public understanding of drowning has been shaped by dramatic cinematic depictions featuring loud screams, thrashing limbs, and waving arms. In real life, drowning is governed by the Instinctive Drowning Response, identified by marine safety researcher Dr. Frank Pia.

       AQUATIC DISTRESS VERSUS INSTINCTIVE DROWNING RESPONSE
┌──────────────────────────────┬─────────────────────────────────────┐
│ Aquatic Distress (Can Assist)│ Instinctive Drowning Response       │
├──────────────────────────────┼─────────────────────────────────────┤
│ Can shout, call, or wave     │ Physiologically unable to speak     │
│ Can grab reaching poles      │ Cannot grasp rescue equipment       │
│ Active kicking and splashing │ Vertical in water; no kick support  │
│ Head above water surface     │ Mouth sinks and bobs at water level │
│ Conscious effort to stay up  │ Involuntary arm pressing downward   │
│ Can support self for minutes │ Submerges completely in 20-60 sec   │
└──────────────────────────────┴─────────────────────────────────────┘

The physiological reality of drowning

  1. The respiratory priority: The human respiratory system is designed for breathing. Speech is a secondary function. When an individual airway is submerged and alternately bobs above the surface, their body dedicates every millisecond to gasping for air. There is insufficient time or tidal volume to yell for help.
  2. Involuntary arm movements: Drowning individuals cannot wave their hands or signal for assistance. The nervous system involuntarily drives the arms to extend laterally and press down against the water surface in an attempt to leverage the mouth above the waterline.
  3. Lack of supporting kick: The person body remains entirely vertical in the water without visible kicking or tread movements.
  4. Glassy or closed eyes: The victim facial expression is vacant, wide-eyed, unfocused, or eyes are completely closed with hair plastered across the forehead and face.
  5. Hyperventilation or gasping: The head tilts back with the mouth open, bobbing up and down.
  6. The window of opportunity: An adult in the instinctive drowning response can struggle on the surface for only 20 to 60 seconds before sinking beneath the water. A toddler or young child can submerge in under 20 seconds.

The water rescue hierarchy: Reach, Throw, Row, Go

To prevent rescuer drownings, emergency services teach the strict water rescue hierarchy. Rescuers must always choose the lowest-risk operational tactic possible:

                      THE RESCUE SAFETY HIERARCHY
      [ REACH ] ───► Extend pole, branch, paddle, or clothing
          │
      [ THROW ] ───► Toss life ring, buoyant cushion, or throw bag
          │
      [  ROW  ] ───► Approach using boat, kayak, canoe, or paddleboard
          │
      [  GO   ] ───► Swim with flotation aid (TRAINED RESCUERS ONLY)

1. Reach (safest)

If the victim is within 3 to 4 meters (10 to 13 feet) of a pool edge, dock, shoreline, or boat: - Lie completely prone (flat on your stomach) on the dock or ground, spreading your legs wide to lower your center of gravity and prevent being pulled into the water. - Extend a rigid object: an aluminum pool skimmer pole, oar, tree branch, or fishing rod. If rigid items are absent, swing a heavy towel, garden hose, or jacket. - Instruct the person to grab the object, then pull them steadily to safety.

2. Throw

If the victim is beyond physical reaching distance: - Throw a buoyant object: a life ring (ring buoy), personal flotation device (PFD), water ski jacket, sealed empty cooler, or inflatable sports ball. - If using a throw bag with rope, anchor the tail end of the rope around your non-dominant wrist or stand firmly on it with your foot before throwing the bag past the victim shoulders, allowing the trailing line to cross their torso.

3. Row

If watercraft are available: - Use a rowboat, kayak, canoe, or stand-up paddleboard to paddle to the victim. - Approaching the victim in a small craft maintains a solid physical barrier between you and the struggling individual, preventing them from grabbing your neck or shoulders. Have them hold the stern (rear) of the craft.

4. Go (extreme hazard)

Entering the water to perform a contact swimming rescue is an extreme measure reserved exclusively for trained lifeguards and rescue swimmers: - Why untrained swimming rescues fail: A person fighting for their life experiences primal panic and will treat anything solid, including another human, as a ladder. They will climb on top of the rescuer, pushing them underwater. Thousands of bystanders drown each year attempting swimming rescues. - Golden rule if you must enter: Never swim out without a buoyant object (such as a life vest, rescue tube, kickboard, or surfboard) to place between yourself and the victim.

Extrication and cervical spine considerations

Once the victim is reached at the water edge: - Two-person haul: Grasp the victim under the armpits and haul them smoothly out of the water onto the pool deck or dry bank. - Cervical spine dogma revised: Historical protocols dictated rigid cervical spine immobilization for all drowning victims. Modern clinical guidelines from the American Heart Association and Wilderness Medical Society explicitly state that routine spinal immobilization should not be performed unless there is a verified history of high-velocity trauma (such as diving into shallow water, surfing accidents, motorized watercraft collisions, or falling from height). Rigid collars impede airway opening and delay life-saving rescue breaths.

Resuscitation protocols: why rescue breaths are mandatory

Cardiac arrest from drowning is fundamentally different from cardiac arrest caused by medical heart attacks. In a sudden heart attack, the blood remains saturated with oxygen for several minutes, making Hands-Only (compression-only) CPR effective. In drowning, the heart stops because of asphyxial cardiac arrest (extreme systemic hypoxia). The circulating blood is completely stripped of oxygen.

       PHYSIOLOGICAL COMPARISON: CARDIAC ARREST MECHANISMS
┌──────────────────────────────┬─────────────────────────────────────┐
│ Primary Cardiac Event        │ Asphyxial Drowning Event            │
├──────────────────────────────┼─────────────────────────────────────┤
│ Caused by ventricular rhythm │ Caused by prolonged oxygen          │
│ disturbance (arrhythmia)     │ deprivation (hypoxemia)             │
├──────────────────────────────┼─────────────────────────────────────┤
│ Blood retains oxygen reserve │ Blood oxygen completely exhausted   │
│ for several minutes          │ before heart stops                  │
├──────────────────────────────┼─────────────────────────────────────┤
│ Hands-Only CPR acceptable    │ Hands-Only CPR INEFFECTIVE;         │
│ for untrained bystanders     │ rescue breaths are MANDATORY        │
├──────────────────────────────┼─────────────────────────────────────┤
│ Primary action: early shock  │ Primary action: immediate oxygen    │
│ with AED defibrillator       │ delivery via rescue ventilations    │
└──────────────────────────────┴─────────────────────────────────────┘

The resuscitation sequence for drowning

  1. Position on firm ground: Lay the victim supine (flat on their back) on firm, dry terrain.
  2. Open the airway: Use the head-tilt/chin-lift maneuver. Look inside the mouth; if weed, mud, or loose debris is visible, sweep it out with a finger. Do not waste time attempting to clear swallowed water.
  3. Deliver initial rescue breaths: Give 2 to 5 slow, steady rescue breaths, each lasting approximately 1 second, with enough volume to cause visible chest rise. Because lung compliance is reduced by water and surfactant dilution, higher airway pressure may be required.
  4. Begin chest compressions: Immediately transition to 30 chest compressions delivered at a rate of 100 to 120 compressions per minute at a depth of 5 to 6 centimeters (2 to 2.4 inches).
  5. Maintain the 30:2 cycle: Continue cycles of 30 chest compressions followed by 2 rescue breaths.
  6. AED application: As soon as an automated external defibrillator arrives, quickly wipe the victim chest dry with a cloth or shirt. Apply the adhesive pads and follow the voice instructions. If the victim is lying in a shallow puddle, drag them to dry ground before delivering a defibrillation shock.

The dangerous Heimlich maneuver myth

Rescuers must never perform abdominal thrusts (the Heimlich maneuver) on a drowning victim: - The myth: The erroneous belief that rescuers must pump swallowed water out of the stomach or lungs before performing CPR. - The danger: Performing abdominal thrusts forces acidic stomach contents into the pharynx, leading to massive pulmonary aspiration of vomit into the lungs, worsening asphyxiation and causing severe aspiration pneumonitis. Only provide rescue breaths and chest compressions.

Management of regurgitation and foam

During resuscitation, large amounts of frothy white or pink foam frequently emerge from the mouth and nose: - Foam origin: This foam is a mixture of water, alveolar surfactant, and airway secretions whipped together by chest compressions and ventilations. - Protocol: Do not stop CPR to suction or wipe away foam endlessly. If active vomiting occurs, turn the victim onto their side as a single unit, wipe out the oral cavity, return them to their back, and immediately resume chest compressions and ventilations through the foam.

Cold water submersion: the mammalian dive reflex

In cold water submersion (water temperatures below 15°C / 59°F), human physiology exhibits unique survival adaptations:

  • The mammalian dive reflex: Cold water striking the facial trigeminal nerve distribution triggers profound bradycardia (slowing of the heart rate), peripheral vasoconstriction, and shunting of oxygenated blood exclusively to the brain and coronary circulation.
  • Hypothermic neuroprotection: Rapid cooling of the brain dramatically lowers cerebral metabolic oxygen consumption. For every 1°C drop in brain temperature, cellular oxygen consumption falls by approximately 7 percent.
  • Resuscitation rule for cold water: Prolonged submersion in freezing water does not automatically imply non-viability. Complete neurological recoveries have been documented in children submerged in icy water for over 45 to 60 minutes. Rescuers must always initiate full resuscitation for cold-water drowning victims unless there are irreversible traumatic injuries.

Post-rescue complications: the reality of delayed deterioration

The historical terms "dry drowning" and "secondary drowning" have been officially rejected and abandoned by major medical bodies including the World Health Organization, the CDC, and the American College of Emergency Physicians. These outdated terms create dangerous public confusion.

Instead, emergency medicine recognizes that water entering the alveoli washes away pulmonary surfactant (the chemical that keeps lung air sacs open), triggering progressive inflammation, fluid leakage, and ventilation-perfusion mismatch over hours.

       PROGRESSION OF POST-DROWNING PULMONARY INJURY
       Water aspirated into lungs during submersion
                            │
                            ▼
       Alveolar surfactant washed out and diluted
                            │
                            ▼
       Microscopic alveolar collapse (atelectasis)
                            │
                            ▼
       Inflammatory exudate fills air sacs over 2 to 8 hours
                            │
                            ▼
       ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) AND HYPOXEMIA

Warning signs of post-immersion deterioration

Anyone pulled from the water who required resuscitation, struggled for air, coughed persistently, or swallowed large volumes of water must be admitted to an emergency department for a minimum 4 to 6 hour observation period. Watch for: - Persistent coughing or wheezing - Rapid, shallow, or labored breathing - Chest tightness or pain during deep inspiration - Extreme fatigue, lethargy, or unexplained sleepiness - Pale, gray, or bluish discoloration of the lips or fingernail beds - Low blood oxygen saturation on pulse oximetry

Water safety and prevention checklist

  • Provide continuous, undivided touch supervision: When children or non-swimmers are near water, designate an adult "Water Watcher" who is within arm reach, avoiding phones, reading, or alcohol.
  • Install four-sided isolation fencing: Enclose residential swimming pools with four-sided fencing at least 1.2 meters (4 feet) tall with self-closing, self-latching gates.
  • Wear Coast Guard-approved life jackets: Every passenger on motorboats, personal watercraft, kayaks, or navigating open ocean waters must wear an approved life jacket.
  • Swim parallel to escape rip currents: If caught in an ocean rip current, never swim against the current toward shore; swim parallel to the beach until free of the narrow current channel, then angle toward land.
  • Learn high-quality CPR with ventilations: Ensure family members and caregivers complete accredited cardiopulmonary resuscitation courses.

First aid certification

Hands-on certification through the American Red Cross, Royal Life Saving Society, or national equivalents provides practical training on pool extrication, ventilation barrier masks, and pediatric CPR.

Frequently asked questions

Why are rescue breaths so important during drowning CPR?

In a typical cardiac arrest from a heart attack, the blood contains enough oxygen to keep tissues alive for several minutes with chest compressions alone. In drowning, the person heart stops because their body ran out of oxygen while underwater. Delivering air directly into their lungs via rescue breaths is essential to replenish oxygen levels in the blood so compressions can circulate it to the brain and heart.

What is the "instinctive drowning response" and why is it silent?

The instinctive drowning response is the body involuntary neurological reaction to suffocation in water. Because the respiratory system must breathe before it can speak, a drowning person cannot vocalize or yell for help. Their arms automatically press down against the water surface to keep their mouth above water, and their body remains vertical without kicking. Drowning looks deceptively calm and occurs in silence.

Should I try to pump water out of a drowning victim stomach using abdominal thrusts?

No. Never perform abdominal thrusts or the Heimlich maneuver on a drowning victim. Doing so does not remove water from the lungs; instead, it forces swallowed water and stomach acid up into the throat, causing the victim to vomit and inhale acidic fluids directly into their lungs. This worsens lung injury and delays life-saving rescue breaths and chest compressions.

Are the terms "dry drowning" and "secondary drowning" medically accurate?

No. The World Health Organization, the CDC, and the American College of Emergency Physicians have rejected the terms "dry drowning" and "secondary drowning." Drowning is a single continuous process. If water enters the lungs, it can cause alveolar inflammation, pulmonary edema, and breathing difficulty that gradually worsens over several hours. Any individual who experiences respiratory distress after water submersion must be evaluated at a hospital.

Can someone survive being underwater in freezing water for over 30 minutes?

Yes. Cold water (below 15°C / 59°F) triggers the mammalian dive reflex and rapid cooling of the brain. When the brain cools quickly, its metabolic need for oxygen drops dramatically, protecting brain cells from permanent damage. Remarkable full neurological recoveries have occurred in children and adults submerged in icy water for 30 to 60 minutes or longer. Always begin CPR and active warming in cold water submersion cases.