setting of extensive pulmonary damage, pulmonary and cardiovascular components of the disease are intimately entwined Optimum management requires monitoring of blood gases and systemic arterial pressure Patients who have experienced significant hypoxemia are often not able to be aroused Again, reversal of hypoxemia and acidosis is critical, as well as fluid resuscitation and avoidance of hyperglycemia Avoiding hypercapnia and resultant cerebral hyperemia is generally accepted, but hyperventilation, barbiturate coma, and other measures initially believed to provide cerebral protection and prevent or treat elevated intracranial pressure have not been helpful in these patients Hypothermia does appear to have some protective effect Extreme hypothermia should be corrected to at least 32°C (89.6°F) to achieve hemodynamic stability and to minimize the risk of infection The child should then be allowed to rewarm passively Although data in humans are limited, animal studies suggest that maintenance of mild brain hypothermia may minimize reperfusion injury Hyperthermia, a common result of active rewarming, should be avoided Recent studies suggest that early initiation of extracorporeal membrane oxygenation (ECMO) in hypothermic patients with cardiorespiratory insufficiency may prevent cardiopulmonary failure and improve survival in post-drowning cardiac arrest There is no benefit to prophylactic antibiotics, which should be reserved for strongly suspected or proven bacterial infection Exceptions are when grossly contaminated water is aspirated or when maximal ventilatory support is required to provide any margin for survival Bronchoalveolar lavage and steroids have no demonstrated benefit However, there is anecdotal evidence supporting the use of surfactant therapy, which is consistent with the pathophysiology of the disease process Renal function, normal electrolytes, and an adequate hemoglobin level (more than 10 g/100 mL) should be maintained If significant hemoglobinuria exists, diuresis is recommended Indications for Discharge or Admission The patient’s clinical condition in the ED dictates further management and may provide prognostic clues It is advisable that patients should be observed for to 12 hours after presentation Most studies have demonstrated no delayed symptoms in patients with normal initial oxygen saturations on room air at hours after submersion Patients who develop symptoms usually so by 4.5 hours after submersion Even if initially symptomatic, in most cases symptoms resolve by hours after submersion