{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,10,10]],"date-time":"2026-10-10T06:46:26Z","timestamp":1791614786852,"version":"4.3.4"},"reference-count":108,"publisher":"American Physiological Society","issue":"3","content-domain":{"domain":["journals.physiology.org"],"crossmark-restriction":true},"short-container-title":["Journal of Applied Physiology"],"published-print":{"date-parts":[[2026,9,1]]},"abstract":"<jats:p>Cold water immersion (CWI) is a significant cause of open-water drowning mortality. Epidemiological data challenge the prevailing assumption that hypothermia is the primary mechanism of death, pointing instead to acute responses that precede core cooling. The four-stage model (cold shock response, swimming failure, hypothermia, and circum-rescue collapse) provides a framework for understanding the sequential threats faced by an immersion victim. The cold shock response, triggered within seconds of immersion, can cause death through aspiration, hypocapnia-induced cerebral hypoperfusion, and cardiac arrhythmia before core temperature begins to fall; autonomic conflict and underlying channelopathies are candidate mechanisms for sudden arrhythmic death in susceptible individuals. Swimming failure follows as peripheral neuromuscular cooling impairs motor function at near-normal core temperatures. Hypothermia develops only after sustained exposure, and in most cold water drowning deaths it occurs after aspiration-induced hypoxic arrest rather than as the primary cause of death. Circum-rescue collapse, driven primarily by the abrupt loss of hydrostatic pressure on extraction, also carries significant mortality risk. Although fewer than 10% of drowning victims present in a shockable rhythm, when such a rhythm is encountered it should prompt investigation for a primary arrhythmic cause that may have precipitated submersion. This narrative review examines the four-stage model of CWI in light of these developments and addresses the modifying effects of alcohol and psychoactive substances, self-rescue strategies, and implications for prehospital management.<\/jats:p>","DOI":"10.1152\/japplphysiol.00578.2026","type":"journal-article","created":{"date-parts":[[2026,7,30]],"date-time":"2026-07-30T22:15:58Z","timestamp":1785449758000},"page":"760-769","update-policy":"https:\/\/doi.org\/10.1152\/aps-crossmark-policy","source":"Crossref","is-referenced-by-count":1,"title":["Beyond hypothermia: mechanisms of death, rescue, and prevention in cold water immersion"],"prefix":"10.1152","volume":"141","author":[{"given":"Laura","family":"Leuci","sequence":"first","affiliation":[{"name":"Humanitas University","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-3860-3988","authenticated-orcid":false,"given":"J\u00f8rgen","family":"Melau","sequence":"additional","affiliation":[{"name":"Oslo University Hospital","place":["Norway"]},{"name":"Norwegian Armed Forces","place":["Norway"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Antonio","family":"Messina","sequence":"additional","affiliation":[{"name":"Humanitas University","place":["Italy"]},{"name":"IRCCS Humanitas Research Hospital","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7928-8451","authenticated-orcid":false,"given":"Mike","family":"Tipton","sequence":"additional","affiliation":[{"name":"University of Portsmouth","place":["United Kingdom"]}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-4646-2660","authenticated-orcid":false,"given":"Luca","family":"Carenzo","sequence":"additional","affiliation":[{"name":"IRCCS Humanitas Research Hospital","place":["Italy"]}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"24","reference":[{"key":"B1","unstructured":"World Health Organization. Global Report on Drowning: Preventing a Leading Killer (Online). World Health Organization, 2014. https:\/\/iris.who.int\/server\/api\/core\/bitstreams\/af4b8253-32c6-4f43-a833-e73b97bdf5ae\/content [2026 Mar 25]."},{"key":"B2","unstructured":"Brogan R, McAvoy C. Water Incident Database Enhancement Project Report. Royal Society for the Prevention of Accidents (RoSPA) (Online). RoSPA, 2025. https:\/\/nationalwatersafety.org.uk\/media\/1450\/rospa-water-incident-database-enhancement-project-report-v5-july25-for-website.pdf [2026 Mar 25]."},{"key":"B3","doi-asserted-by":"publisher","DOI":"10.1001\/jama.286.23.2974"},{"key":"B4","doi-asserted-by":"publisher","DOI":"10.1042\/cs0770581"},{"key":"B5","doi-asserted-by":"publisher","DOI":"10.1016\/0034-5687(75)90080-8"},{"key":"B6","doi-asserted-by":"publisher","DOI":"10.1016\/j.resuscitation.2011.02.021"},{"key":"B7","doi-asserted-by":"publisher","DOI":"10.1136\/jrnms-77-139"},{"key":"B8","volume":"378","author":"Tipton M","year":"1986","journal-title":"J Physiol"},{"key":"B9","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(99)07273-6"},{"key":"B10","doi-asserted-by":"publisher","DOI":"10.1136\/jrnms-59-5"},{"key":"B11","first-page":"4","volume-title":"Handbook of Offshore Helicopter Transport Safety: Essentials of Underwater Egress and Survival","author":"Tipton MJ","year":"2015"},{"key":"B12","doi-asserted-by":"publisher","DOI":"10.1016\/j.autneu.2016.02.009"},{"key":"B13","doi-asserted-by":"publisher","DOI":"10.1113\/EP086283"},{"key":"B14","doi-asserted-by":"publisher","DOI":"10.1002\/cphy.c140081"},{"key":"B15","doi-asserted-by":"publisher","DOI":"10.1113\/jphysiol.2012.229864"},{"key":"B16","doi-asserted-by":"publisher","DOI":"10.1136\/bjsports-2015-094722"},{"key":"B17","doi-asserted-by":"publisher","DOI":"10.1580\/pr01-05.1"},{"key":"B18","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.115.019464"},{"key":"B19","doi-asserted-by":"publisher","DOI":"10.1186\/s41073-019-0064-8"},{"key":"B20","doi-asserted-by":"publisher","DOI":"10.1002\/14651858.MR000026.pub2"},{"key":"B21","doi-asserted-by":"publisher","DOI":"10.1136\/bmj.38636.593461.68"},{"key":"B22","first-page":"444","volume":"75","author":"Stocks JM","year":"2004","journal-title":"Aviat Space Environ Med"},{"key":"B23","doi-asserted-by":"publisher","DOI":"10.1016\/j.jtherbio.2022.103349"},{"key":"B24","doi-asserted-by":"publisher","DOI":"10.1016\/s0140-6736(03)15057-x"},{"key":"B25","doi-asserted-by":"publisher","DOI":"10.1152\/japplphysiol.01201.2005"},{"key":"B26","doi-asserted-by":"publisher","DOI":"10.1152\/jappl.1991.70.1.317"},{"key":"B27","doi-asserted-by":"publisher","DOI":"10.1007\/BF00625061"},{"key":"B28","first-page":"374","volume":"78","author":"Mantoni T","year":"2007","journal-title":"Aviat Space Environ Med"},{"key":"B29","doi-asserted-by":"publisher","DOI":"10.1136\/bcr-2022-253125"},{"key":"B30","doi-asserted-by":"publisher","DOI":"10.12890\/2025_005200"},{"key":"B31","doi-asserted-by":"publisher","DOI":"10.1007\/s004210000255"},{"key":"B32","doi-asserted-by":"publisher","DOI":"10.1007\/s00421-012-2473-y"},{"key":"B33","unstructured":"Royal National Lifeboat Institution (RNLI). Float to Live: Pocket Guide (Online). RNLI, 2025. https:\/\/rnli.org\/safety\/float\/float-resources?type=guides [2026 Mar 25]."},{"key":"B34","unstructured":"Royal National Lifeboat Institution. Lifejackets and Buoyancy Aids: Choose and Maintain Yours (Online). https:\/\/rnli.org\/water-safety\/lifejackets [2026 Jul 17]."},{"key":"B35","doi-asserted-by":"publisher","DOI":"10.1080\/23328940.2017.1414014"},{"key":"B36","first-page":"305","volume":"21","author":"Tipton MJ","year":"1994","journal-title":"Undersea Hyperb Med"},{"key":"B37","doi-asserted-by":"publisher","DOI":"10.14814\/phy2.70430"},{"key":"B38","doi-asserted-by":"publisher","DOI":"10.3357\/asem.2700.2010"},{"key":"B39","doi-asserted-by":"publisher","DOI":"10.1016\/j.yjmcc.2018.02.001"},{"key":"B40","doi-asserted-by":"publisher","DOI":"10.1186\/2046-7648-4-S1-A39"},{"key":"B41","doi-asserted-by":"publisher","DOI":"10.3389\/fcvm.2024.1443214"},{"key":"B42","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.109.863209"},{"key":"B43","doi-asserted-by":"publisher","DOI":"10.1038\/nm0504-463"},{"key":"B44","doi-asserted-by":"publisher","DOI":"10.1056\/NEJM199910073411504"},{"key":"B45","doi-asserted-by":"publisher","DOI":"10.4065\/mcp.2011.0373"},{"key":"B46","doi-asserted-by":"publisher","DOI":"10.1161\/01.CIR.0000144471.98080.CA"},{"key":"B47","doi-asserted-by":"publisher","DOI":"10.1113\/jphysiol.1958.sp006071"},{"key":"B48","doi-asserted-by":"publisher","DOI":"10.1152\/jappl.1979.46.5.885"},{"key":"B49","doi-asserted-by":"publisher","DOI":"10.1152\/jappl.1960.15.1.155"},{"key":"B50","doi-asserted-by":"publisher","DOI":"10.1016\/j.ajem.2009.08.004"},{"key":"B51","doi-asserted-by":"publisher","DOI":"10.3389\/fphys.2017.00652"},{"key":"B52","doi-asserted-by":"publisher","DOI":"10.7326\/M17-0847"},{"key":"B53","doi-asserted-by":"publisher","DOI":"10.1136\/bjsports-2012-092021"},{"key":"B54","doi-asserted-by":"publisher","DOI":"10.3390\/ijerph19010501"},{"key":"B55","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMra1114208"},{"key":"B56","doi-asserted-by":"publisher","DOI":"10.1152\/ajplegacy.1953.175.3.389"},{"key":"B57","doi-asserted-by":"publisher","DOI":"10.1161\/01.cir.101.25.e233"},{"key":"B58","doi-asserted-by":"publisher","DOI":"10.1089\/ther.2013.0003"},{"key":"B59","doi-asserted-by":"publisher","DOI":"10.1016\/S0733-8627(20)30715-X"},{"key":"B60","doi-asserted-by":"publisher","DOI":"10.1111\/j.1553-2712.1999.tb00114.x"},{"key":"B61","doi-asserted-by":"publisher","DOI":"10.1016\/S0140-6736(00)01021-7"},{"key":"B62","doi-asserted-by":"publisher","DOI":"10.1152\/physiol.00002.2015"},{"key":"B63","doi-asserted-by":"publisher","DOI":"10.1016\/j.resuscitation.2014.04.029"},{"key":"B64","doi-asserted-by":"publisher","DOI":"10.1093\/ejcts\/ezaa159"},{"key":"B65","doi-asserted-by":"publisher","DOI":"10.1097\/00075198-200212000-00016"},{"key":"B66","doi-asserted-by":"publisher","DOI":"10.1161\/CIR.0000000000001380"},{"key":"B67","volume-title":"Hypothermia Ashore and Afloat","author":"Golden F","year":"1981"},{"key":"B68","doi-asserted-by":"publisher","DOI":"10.1201\/b19650"},{"key":"B69","doi-asserted-by":"publisher","DOI":"10.1152\/jappl.1988.65.6.2709"},{"key":"B70","doi-asserted-by":"publisher","DOI":"10.1152\/jappl.1992.73.4.1253"},{"key":"B71","doi-asserted-by":"publisher","DOI":"10.1016\/j.wem.2019.10.002"},{"key":"B72","doi-asserted-by":"publisher","DOI":"10.1152\/japplphysiol.90984.2008"},{"key":"B73","doi-asserted-by":"publisher","DOI":"10.1007\/BF00581289"},{"key":"B74","doi-asserted-by":"publisher","DOI":"10.1152\/physrev.1992.72.3.563"},{"key":"B75","doi-asserted-by":"publisher","DOI":"10.1111\/j.1365-2044.1975.tb00871.x"},{"key":"B76","doi-asserted-by":"publisher","DOI":"10.1111\/dar.12817"},{"key":"B77","doi-asserted-by":"publisher","DOI":"10.1093\/ije\/27.6.1038"},{"key":"B78","doi-asserted-by":"publisher","DOI":"10.1016\/j.amepre.2022.03.025"},{"key":"B79","doi-asserted-by":"publisher","DOI":"10.1007\/s004210050161"},{"key":"B80","doi-asserted-by":"publisher","DOI":"10.1111\/j.1469-7793.1998.621be.x"},{"key":"B81","doi-asserted-by":"publisher","DOI":"10.1016\/j.physbeh.2017.02.026"},{"key":"B82","doi-asserted-by":"publisher","DOI":"10.1042\/cs0660733"},{"key":"B83","doi-asserted-by":"publisher","DOI":"10.1139\/y79-131"},{"key":"B84","doi-asserted-by":"publisher","DOI":"10.1016\/j.mehy.2015.12.015"},{"key":"B85","doi-asserted-by":"publisher","DOI":"10.15288\/jsa.2005.66.555"},{"key":"B86","doi-asserted-by":"publisher","DOI":"10.1136\/injuryprev-2016-042156.271"},{"key":"B87","doi-asserted-by":"publisher","DOI":"10.1186\/s12889-017-4306-8"},{"key":"B88","doi-asserted-by":"publisher","DOI":"10.2174\/1570159X20666220830110758"},{"key":"B89","doi-asserted-by":"publisher","DOI":"10.1016\/j.aap.2016.10.009"},{"key":"B90","doi-asserted-by":"publisher","DOI":"10.1002\/wfs2.1510"},{"key":"B91","unstructured":"CredibleMeds. Drugs To Be Avoided By Congenital Long QT Patients (Online). AZCERT, Inc. 2025. https:\/\/crediblemeds.org\/index.php\/tools\/pdfdownload?f=dta_en [2026 Mar 25]."},{"key":"B92","doi-asserted-by":"publisher","DOI":"10.1016\/j.forsciint.2004.02.013"},{"key":"B93","doi-asserted-by":"publisher","DOI":"10.1186\/s13052-023-01464-1"},{"key":"B94","doi-asserted-by":"publisher","DOI":"10.1136\/ip-2025-045970"},{"key":"B95","doi-asserted-by":"publisher","DOI":"10.1016\/j.physbeh.2015.11.017"},{"key":"B96","doi-asserted-by":"publisher","DOI":"10.25035\/ijare.05.02.03"},{"key":"B97","doi-asserted-by":"publisher","DOI":"10.1186\/s12889-024-19409-6"},{"key":"B98","doi-asserted-by":"publisher","DOI":"10.1007\/s00421-015-3306-6"},{"key":"B99","doi-asserted-by":"publisher","DOI":"10.1113\/jphysiol.1987.sp016744"},{"key":"B100","doi-asserted-by":"publisher","DOI":"10.1152\/jappl.1975.38.6.1073"},{"key":"B101","doi-asserted-by":"publisher","DOI":"10.1186\/s13049-025-01474-4"},{"key":"B102","doi-asserted-by":"publisher","DOI":"10.1378\/chest.112.3.660"},{"key":"B103","doi-asserted-by":"publisher","DOI":"10.1056\/NEJMra1013317"},{"key":"B104","doi-asserted-by":"publisher","DOI":"10.1177\/10806032241227460"},{"key":"B105","doi-asserted-by":"publisher","DOI":"10.1097\/00005373-200110000-00006"},{"key":"B106","doi-asserted-by":"publisher","DOI":"10.1161\/CIR.0000000000001274"},{"key":"B107","doi-asserted-by":"publisher","DOI":"10.1186\/s13049-025-01469-1"},{"key":"B108","doi-asserted-by":"publisher","DOI":"10.1016\/j.resuscitation.2025.110753"}],"container-title":["Journal of Applied Physiology"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/journals.physiology.org\/doi\/pdf\/10.1152\/japplphysiol.00578.2026","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,8,24]],"date-time":"2026-08-24T23:30:09Z","timestamp":1787614209000},"score":1,"resource":{"primary":{"URL":"https:\/\/journals.physiology.org\/doi\/10.1152\/japplphysiol.00578.2026"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,9,1]]},"references-count":108,"journal-issue":{"issue":"3","published-print":{"date-parts":[[2026,9,1]]}},"alternative-id":["10.1152\/japplphysiol.00578.2026"],"URL":"https:\/\/doi.org\/10.1152\/japplphysiol.00578.2026","relation":{},"ISSN":["8750-7587","1522-1601"],"issn-type":[{"value":"8750-7587","type":"print"},{"value":"1522-1601","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,9,1]]},"assertion":[{"value":"2026-06-16","order":0,"name":"received","label":"Received","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-07-21","order":1,"name":"revised","label":"Revised","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-07-21","order":2,"name":"accepted","label":"Accepted","group":{"name":"publication_history","label":"Publication History"}},{"value":"2026-08-24","order":3,"name":"published","label":"Published","group":{"name":"publication_history","label":"Publication History"}}]}}