Clinical Commander

All dossiers
cardio.post-arrest.drowning-cardiac.v1

Post-cardiac-arrest care — drowning-induced cardiac arrest

cardiologyacuteadultacuteinpatienttransitionoutpatient
Start encounter →Print handoutPRODUCTION

Phase E variant of cardio.post-arrest.core.v1 — narrowed to drowning-induced cardiac arrest cohort. Hypoxic mechanism with PEA/asystole most common; secondary hypothermia + hyperkalemia + acidosis common. Hypothermia complicates resuscitation: AHA 2020 hypothermia section — withhold further ACLS drugs + limit defib to 1 attempt at core <30 °C; warm to 32-35 °C before declaring death; favorable neuro outcomes possible after prolonged downtime in cold-water cases (Schneider 2014 PMID 25034567). ECMO/ECPR per ELSO drowning protocol: witnessed + low-flow <90 min + core 28-32 °C with VF/asystole + ROSC post-warming. ARDS management per ARDSnet + PROSEVA: lung-protective vent + proning if P/F <150; VV-ECMO if refractory. TTM 33-37.5 °C × 24h once normothermic; HYPERION favors 33 in non-shockable; pregnancy not relevant here. Inherits manifest + design-brief pointer from parent. 5 setting playbooks (ed, icu, inpatient, transition, outpatient). 5 severity triggers: severe hypothermia, ECPR eligibility, severe ARDS, severe hyperkalemia, C-spine / co-trauma. Status INTEGRATED until terminology + RxNav-validated drug codes are reconciled. Authored 2026-05-14 by shard-06-cardio-acute Phase E wave 8.

Entry points (3)

  • symptom
    ROSC after submersion / drowning-induced cardiac arrest (AHA 2020 §drowning)
    rosc_after_drowning_arrest
  • symptom
    Comatose patient post-drowning with core temp <32 °C — extended ACLS warranted; TTM candidate (Schneider 2014 PMID 25034567)
    comatose_post_drowning_with_hypothermia
  • history
    Witnessed drowning + low-flow <90 min + core temp 28-32 °C with VF/asystole — ECMO/ECPR consideration (ELSO drowning protocol)
    witnessed_drowning_for_ecpr_eligibility

Required inputs (19)

  • agerequired
    demographic • used at CONTEXT
    Pediatric drownings have different prognosis (separate engine ideally); adult drownings often have alcohol / drug / cardiac trigger
  • submersion_time_minrequired
    history • used at CONTEXT
    Submersion time + water temperature drive prognosis; <10 min submersion in warm water has favorable outcomes; cold water tolerates longer
  • water_temperaturerequired
    history • used at CONTEXT
    Cold water (<6 °C) preceding arrest = rapid cooling + favorable prognosis even after prolonged downtime (Schneider 2014); warm water = standard prognosis weighting
  • arrest_witnessedrequired
    history • used at CONTEXT
    Witnessed + bystander CPR + low-flow time → favourable neuro prognosis + ECPR eligibility (AHA 2020; ARREST PMID 33308475)
  • initial_rhythmrequired
    history • used at CONTEXT
    Asystole/PEA most common (hypoxic mechanism); VF possible if hypothermia + electrolyte derangement; rhythm does NOT predict prognosis in cold-water drowning
  • low_flow_time_minrequired
    history • used at CONTEXT
    CPR duration → ECPR eligibility (ELSO drowning <90 min low-flow); cold-water cases can survive >60 min downtime per Schneider 2014
  • cervical_spine_concern
    history • used at CONTEXT
    Diving-related drownings have C-spine injury risk — MILS during airway management + CT C-spine
  • toxicology_screen_indication
    history • used at INITIAL_WORKUP
    Adult drownings: alcohol ~50 % + sedative drugs common precipitants; obtain ETOH + comprehensive UDS
  • sbprequired
    vital • used at TREATMENT
    MAP ≥65 target post-ROSC; SCAI staging if shock; hypothermia produces transient bradycardia + hypotension that improves with warming
  • core_temprequired
    vital • used at TREATMENT
    Core temp <30 °C → withhold further ACLS drugs + defib >1 attempt until warmed; 30-34 °C → space drugs to q6-10 min; warm to 32-35 °C before declaring death (AHA 2020 §hypothermia)
  • spo2required
    vital • used at TREATMENT
    Avoid hyperoxia: SpO2 92-98% (AHA 2020 Class IIa); ARDS may require higher FiO2 + PEEP per ARDSnet
  • ecg_12_leadrequired
    imaging • used at INITIAL_WORKUP
    Hypothermia ECG features (Osborn J wave at junction; bradycardia; AF common); rule out underlying ischemic / channelopathy trigger for the drowning event
  • troponinrequired
    lab • used at INITIAL_WORKUP
    Cardiac etiology workup if ischemic precipitant suspected (LQTS, Brugada, ACS triggered the submersion); also rises from prolonged hypoxia + arrest itself
  • lactaterequired
    lab • used at INITIAL_WORKUP
    Tissue hypoperfusion + anaerobic metabolism; clearance trajectory drives prognosis (SCAI 2022 PMID 35718438)
  • creatininerequired
    lab • used at CONTEXT
    AKI common post-arrest; rhabdomyolysis if prolonged immersion / down-time; drug renal-adjustment
  • potassiumrequired
    lab • used at INITIAL_WORKUP
    Hyperkalemia common (hypoxia + cell-membrane damage + acidosis); K >12 mmol/L in drowning → very poor prognosis marker per ELSO drowning consensus; correct to 4-4.5
  • abg_with_pao2_to_fio2required
    lab • used at INITIAL_WORKUP
    ARDS diagnosis (P/F <300 with bilateral infiltrates not fully explained by HF); guides PEEP + proning decision (PROSEVA P/F <150 → prone)
  • cxr_post_drowningrequired
    imaging • used at INITIAL_WORKUP
    Bilateral infiltrates + pulmonary edema common; ARDS diagnosis support; aspiration pneumonia evolution; pneumothorax from CPR
  • echo_post_rosc
    imaging • used at INITIAL_WORKUP
    LV/RV function; rule out cardiac trigger (ACS, channelopathy with arrhythmia → submersion); post-arrest myocardial dysfunction

12-phase flow (12)

  1. 1FRAME
    Drowning-induced cardiac arrest — hypoxic mechanism with PEA/asystole most common; secondary hypothermia + hyperkalemia + acidosis common; cold-water drowning with rapid cooling can have favorable neuro outcomes after prolonged downtime; route to parent cardio.post-arrest.core.v1 for TTM + neuroprog arc
    inputs: submersion_time_min, water_temperature, core_temp
    advance: drowning mechanism + thermal status confirmed
  2. 2ENTRY
    Standard ACLS modified for hypothermia: if core <30 °C, withhold further drug doses + defib >1 attempt until warmed; if 30-34 °C, space drugs q6-10 min; airway management with MILS if C-spine concern; warm IVF + warm humidified ventilation
    inputs: age, arrest_witnessed, core_temp
    advance: modified ACLS + warming initiated
  3. 3CONTEXT
    Submersion time, water temperature, witnessed status, alcohol / drug history, prior cardiac history (LQTS, Brugada, ischemic), cervical-spine concern from diving
    inputs: cervical_spine_concern, toxicology_screen_indication, sbp, spo2, creatinine, potassium
    advance: context complete + GOC documented
  4. 4RED_FLAGS
    Severe hyperkalemia >10-12 mmol/L (very poor prognosis); refractory shock; refractory VF/asystole at warm core temp; ARDS with severe hypoxemia (P/F <100); cervical-spine injury; co-existing trauma
    inputs: potassium, sbp, spo2, core_temp
    actions: cardiogenic_shock
    advance: red flags screened or escalated
  5. 5INITIAL_WORKUP
    ECG + serial troponin + BMP + lactate + ABG + CBC + coags + UDS + ETOH + CXR + bedside echo + CT C-spine if diving accident; consider CT head if down-time prolonged or Mental status not improving with rewarming
    inputs: ecg_12_lead, troponin, lactate, potassium, abg_with_pao2_to_fio2, cxr_post_drowning
    actions: post_arrest_care, panel.cardiac, panel.renal
    advance: workup complete + ARDS / cardiac etiology / co-injuries assessed
  6. 6BRANCHING_WORKUP
    ECPR criteria check (witnessed + low-flow <90 min + core 28-32 °C with VF/asystole); ARDS management per ARDSnet (TV 6 mL/kg PBW + plateau <30) + PROSEVA proning if P/F <150; cardiac etiology workup if ECG/echo suggestive
    actions: acs_pathway, wide_complex_tach
    advance: ECPR / ARDS / cardiac branching decided
  7. 7DIFFERENTIAL
    Primary drowning event (alcohol, fatigue, cold incapacitation) vs secondary drowning trigger (cardiac arrhythmia → unconsciousness → submersion: LQTS, Brugada, CPVT; or ischemic/structural cardiac); also seizure, syncope, head trauma, scuba/diving barotrauma
    advance: primary vs secondary drowning + co-precipitant established
  8. 8RISK_STRATIFICATION
    Submersion time + water temp + arrival K + arrival pH + initial rhythm at 32 °C drive prognosis; CAHP/OHCA scores partial applicability; ELSO drowning K >12 mmol/L = poor prognosis marker
    inputs: submersion_time_min, low_flow_time_min, sbp, lactate, potassium
    actions: calc.map, calc.heart, calc.ckd_epi_2021, calc.cha2ds2vasc
    advance: risk class + ECPR / continuation decision documented
  9. 9TREATMENT
    Active warming (warm IVF + warm humidified vent + bladder/peritoneal/extracorporeal warming); ARDSnet vent settings + proning if severe ARDS; TTM 33-37.5 °C × 24h once normothermic (HYPERION non-shockable favors 33); avoid hyperoxia; cardiac-cause-specific therapy if secondary trigger identified
    inputs: sbp, core_temp, spo2, creatinine
    actions: protocol.cardiogenic_shock
    advance: warming + lung-protective vent + TTM bundle delivered
  10. 10DISPOSITION
    CICU vs medical ICU per local pathway and predominant problem (cardiac etiology → CICU; ARDS-predominant → MICU); pulmonology + cardiology + intensivist + EP if channelopathy
    advance: unit + service-line ownership assigned
  11. 11MONITORING
    Continuous telemetry + arterial line + central line + Foley; lactate q2-4h; BMP q6-12h; serial troponin; ABG q4-6h until P/F stable; multimodal neuroprog ≥72h post-rewarm with caution if hypothermia confounding (Sandroni 2021 PMID 33745427)
    inputs: creatinine, potassium
    actions: panel.renal, panel.cardiac
    advance: monitoring + neuroprog timeline documented
  12. 12FOLLOWUP
    Pulmonology follow-up for ARDS sequelae; cardiology + EP follow-up if cardiac trigger (LQTS, Brugada, structural); rehab for cognitive sequelae; mental health (post-arrest PTSD, family); substance-use referral if alcohol/drug precipitated; aquatic safety education
    advance: pulmonology + cardiology / EP + rehab + mental health + family-counseling plan booked