First Aid Steps After Removing Someone from the Water
The fifth and final link in the Drowning Chain of Survival covers medical care after a person has been removed from the water. Although this step comes at the end of the chain, it plays a major role in determining the person's long-term neurological outcome and chance of survival.
Medical care begins the moment the person is stabilized in the water. Before any structured assessment takes place, it must first be confirmed that there's no ongoing danger to the rescuer or the patient. After that comes assessment using the internationally established ABCDE approach:
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Airway: Clear the mouth and throat of water
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Breathing: Give high-concentration oxygen as early as possible; check breathing and breathing rate, and begin rescue breaths immediately if breathing has stopped or is only gasping
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Circulation: Check pulse and heart rhythm; if cardiac arrest is present, start immediately with 5 initial rescue breaths – only after that, continue at the standard ratio of 30 compressions to 2 breaths
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Disability: Check consciousness, pupils, and blood sugar, since other causes such as stroke or low blood sugar can also trigger a drowning incident; check for head and spinal injuries
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Exposure/Environment: Remove wet clothing and check core body temperature – water conducts heat away from the body far faster than air does, which is why hypothermia accompanies almost every drowning incident
Throughout all of this, one thing matters most: even a few minutes of severe hypoxia (oxygen deprivation) can cause permanent neurological damage. The priority isn't searching for other injuries, it's restoring adequate oxygen supply as quickly as possible.
What Happens in the Body When Oxygen Runs Low?
Physiology explains why oxygen has to be restored so quickly: during drowning, blood oxygen levels keep falling because breathing isn't working properly. At the same time, carbon dioxide builds up in the blood instead of being exhaled as normal. This combination – too little oxygen, too much carbon dioxide – makes the blood increasingly acidic. If the oxygen deficit continues, this gets worse still, because the body starts producing energy without oxygen, a process that generates lactic acid as a byproduct, acidifying the blood even further.
The brain is the most sensitive organ to this. Unlike muscles, it has almost no energy reserves of its own and depends on a constant supply of oxygen. After just a few minutes of severe oxygen deprivation, brain cells enter a kind of energy crisis. In the worst case, this causes the brain to swell (known as cerebral edema).
This is exactly why the duration of oxygen deprivation is the single most important factor in how well someone recovers after a drowning incident.
Pulmonary Edema and Respiratory Failure: What Water in the Lungs Really Does
Contrary to earlier assumptions, the amount of water inhaled matters less than the damage it causes to the lungs. The lungs contain tiny air sacs called alveoli, lined with a thin layer called surfactant that keeps them from collapsing like wet balloons. Even small amounts of water can thin out or deactivate this layer. Once surfactant fails, the alveoli collapse – leaving less surface area available to absorb oxygen. At the same time, the lungs' blood vessel walls become more permeable, allowing fluid to leak from the blood into the alveoli. This creates a form of pulmonary edema that can resemble acute respiratory failure. The lungs can no longer supply the body with enough oxygen. How severe this lung damage becomes depends far more on the duration of hypoxia than on whether fresh or salt water was inhaled, which is why the old distinction between freshwater and saltwater drowning no longer has any real treatment relevance today.
Resuscitation in Drowning: Why Rescue Breathing Comes Before Chest Compressions
Airway & Breathing
As the ABCDE approach already suggests, the first step after rescue is to check whether the person is breathing adequately on their own. If they're conscious and breathing normally, high-concentration oxygen should be given as early as possible to correct hypoxemia (low blood oxygen) quickly – with continuous monitoring of breathing, consciousness, and circulation, since lung damage can also develop with a delay. Even patients who initially seem stable can deteriorate hours later. International guidelines therefore recommend a medical evaluation even when the person initially seems fine, as long as a meaningful drowning process took place.
Circulation
If normal breathing is absent or the person is unconscious, resuscitation begins immediately and here, the approach differs clearly from a primary cardiac arrest, where the heart fails first and the oxygen deficit follows afterward. In drowning, it's the reverse: cardiac arrest is almost always the result of progressive respiratory failure. That's why rescue breaths carry more weight in a drowning rescue than in other types of resuscitation. ERC guidelines therefore explicitly recommend five initial rescue breaths before starting chest compressions. This alone is often enough to restore spontaneous circulation. If there are still no signs of life afterward, resuscitation continues at the standard ratio of 30 chest compressions to 2 breaths.
The reason for this is clear: in a primary cardiac arrest, there's still enough oxygen in the blood, the issue is just getting it circulated. In drowning, oxygen is already lacking from the start – chest compressions alone can't fix that. Only rescue breaths bring oxygen back into the alveoli, which can then reach the blood once circulation is adequate. According to ILCOR, high-quality rescue breathing is one of the most important factors influencing neurological outcomes after a drowning incident.
An automated external defibrillator (AED) should be connected as early as possible in drowning cases too. However, the heart's condition in drowning usually looks different than in a typical cardiac arrest caused by a heart attack: there, the heart is often still beating, but chaotically and too fast — a state a defibrillator shock can correct effectively. In drowning, on the other hand, prolonged oxygen deprivation has usually caused the heart to either stop entirely or show only weak electrical activity without an actual pulse. In these cases, a shock alone does little to help. The AED remains important and should still be connected, but the top priority remains restoring oxygen supply as quickly as possible.
Disability (Neurological Status)
Even during resuscitation, rescuers keep an eye on neurological status: How alert is the person? Are the pupils reacting normally? Is there any sign of another underlying cause, such as stroke, head injury, or low blood sugar? Seizures can also occur after severe oxygen deprivation, making assessment even harder. At this stage, the priority for the brain is simple: no further damage. That means keeping a close eye on normal blood sugar, normal body temperature, and balanced carbon dioxide levels – too much or too little carbon dioxide in the blood can further impair blood flow to the brain.
Exposure/Environment
Body temperature deserves special attention. Many drowning incidents happen in cold water, so hypothermia is often present at the same time. Its effect is a double-edged sword: a lower body temperature reduces the brain's oxygen consumption and can, in some cases, have a protective effect, but it also makes resuscitation harder, encourages irregular heart rhythms, and affects blood clotting. Current guidelines therefore recommend controlled rewarming under continuous intensive care monitoring.
Safety Insight: "Nobody is dead until warm and dead." This principle explains why extended resuscitation efforts can be justified for severely hypothermic drowning victims – good neurological outcomes have been documented even after long rescue times.
After Resuscitation: Post-Resuscitation Care
Once spontaneous circulation returns, post-resuscitation care begins – and it plays a major role in long-term neurological outcomes. The goal is to
- stabilize oxygen supply
- prevent further hypoxia
- optimize blood flow to the brain
while identifying and treating lung complications such as accidental water inhalation, pulmonary edema, or respiratory failure early. Depending on severity, this can involve invasive ventilation, lung-protective ventilation strategies, circulatory stabilization, and continuous neurological monitoring. Consistently preventing further brain damage after resuscitation has an especially strong influence on the long-term outcome.
What Factors Matter Most After a Drowning Incident
Prognosis depends on many factors. The strongest predictor is the duration of oxygen deprivation, or full submersion. Also relevant:
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Time until the first rescue breath
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Quality of on-site resuscitation
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Age of the person affected
- Water temperature
- Whether spontaneous circulation had already returned before arrival at the hospital
Even so, international registry data shows: people can make a full neurological recovery even after prolonged resuscitation, as long as oxygen supply is restored in time. This is exactly why every international guideline emphasizes a consistent, structured approach across the entire Drowning Chain of Survival.
Conclusion: Medical Care Is More Than Just the Final Step
Medical care connects
- pre-hospital emergency medicine
- resuscitation science
- intensive care
into one continuous pathway with a single goal: ending hypoxia as quickly as possible and preventing further organ damage.
While the first four links in the Drowning Chain of Survival aim to interrupt the drowning process as early as possible, this final link determines whether the person doesn't just survive, but keeps their neurological function intact. Only when all five links work together does the Drowning Chain of Survival become one of the most effective concepts in modern water rescue.
