A 35-year-old man is brought to the emergency department 2 hours after rescue from a river. He is conscious, alert, and breathing spontaneously with an oxygen saturation of 94% on room air. Chest examination is clear. He complains of mild chest discomfort and cough. What is the most appropriate next step in management?

Explanation

## Management of Near-Drowning Survivor with Respiratory Symptoms ### Clinical Scenario Analysis **Key Point:** A near-drowning victim who is conscious but symptomatic (cough, chest discomfort) requires admission for observation and monitoring, even if initial vital signs appear stable. Delayed pulmonary edema (secondary drowning) can develop hours after rescue. ### Why Admission Is Mandatory | Feature | Significance | |---------|-------------| | **Time since rescue** | 2 hours — within the critical window for complications | | **Respiratory symptoms** | Cough suggests aspiration/pulmonary irritation | | **Chest discomfort** | May indicate pulmonary edema, myocardial involvement | | **Initial SpO₂ 94%** | Borderline; may deteriorate with pulmonary edema | | **Clear chest exam** | Does NOT exclude early pulmonary edema | **High-Yield:** Secondary drowning (delayed pulmonary edema) can occur 12–72 hours post-rescue, even in victims who initially appear well. Mortality is significant if unrecognized. ### Pathophysiology of Pulmonary Complications 1. **Aspiration of hypotonic water** → osmotic fluid shift into alveoli → pulmonary edema 2. **Surfactant washout** → increased alveolar surface tension → atelectasis and V/Q mismatch 3. **Inflammatory response** → increased capillary permeability → delayed edema 4. **Myocardial injury** → arrhythmias, reduced contractility (especially in cold-water immersion) ### Recommended Admission Protocol 1. **Continuous cardiopulmonary monitoring** (ECG, SpO₂, HR, BP) 2. **Supplemental oxygen** to maintain SpO₂ ≥ 94–95% 3. **Serial chest X-rays** (baseline, 6–12 hours, 24 hours) to detect evolving pulmonary edema 4. **Arterial or venous blood gas** to assess oxygenation and acid-base status 5. **Troponin, ECG** to rule out myocardial injury (especially in cold-water immersion) 6. **Avoid prophylactic antibiotics** unless aspiration of contaminated water is confirmed 7. **Avoid prophylactic diuretics** — may worsen hypovolemia if present **Clinical Pearl:** A normal chest X-ray at presentation does NOT exclude pulmonary edema; radiographic changes may lag clinical deterioration by 12–24 hours. ### Minimum Observation Period - **Asymptomatic victims with normal initial assessment:** 4–6 hours minimum - **Symptomatic victims (cough, dyspnea, chest pain):** Admission for 24–48 hours - **Victims with loss of consciousness or aspiration:** Admission regardless of initial stability **Warning:** Discharging a symptomatic near-drowning victim after brief observation is a common error and carries high medicolegal risk.