You are called to assist with a 12-year-old child, brought in to the Emergency Department unconscious, following near drowning at a local beach.
Outline your immediate management.
Assess for signs of life and if absent commence CPR, check underlying rhythm and treat appropriately following APLS guidelines
Airway and breathing Administer 100% oxygen
Intubation for airway protection and suction with ETT cuffed size 7 (ILCOR guidelines – cuffed ETT’s acceptable in children) (age/4 +4) (half size bigger and smaller available) with C spine precautions
Ventilate with appropriate settings (Vt 6-8ml/kg, RR 15-20, PEEP > 5cm H2O) SpO2 and ETCO2 monitoring, ABG and CXR
May get some discussion re management of ARDS
Assess pulse rate and volume, blood pressure and capillary return, Doppler may be helpful if hypothermic
Secure IV access
If inadequate circulation fluid bolus of 20 ml/kg 0.9% Saline – avoid hypotonic intravenous fluids
Consider inotrope support early Blood glucose, FBE, U & E
Avoid any further episodes of hypoxia and hypercarbia
Actively rewarm to core temperature of 34oC Passively rewarm over 34oC
If post cardiac arrest – maintain hypothermia 32.5 – 33.5oC for > 24 hours
Primary and secondary survey for associated trauma
Look for precipitating cause (hypoglycaemia, epilepsy, drug/alcohol ingestion, marine envenomation)
Antibiotics not indicated routinely
Collateral history – immersion time, resuscitation at scene, medical history Admit to ICU with appropriate paediatric expertise
Counsel family regarding likely outcomes
This question would benefit from a systematic answer. The college answer is already quite systematic; there is little that can be added to it without this turning into an unmanageably long discussion.
First step: assess for signs of life/confirm cardiac arrest.
If cardiac arrest is confirmed, follow the pediatric ALS algorithm.
Next step: Primary survey;
Important pre-hospital issues
Emergency management issues
ICU management issues
The ARC ALS2 manual (2011) has a section on drowning (pp. 127). This was my main source of information.
Pearn, John. "The management of near drowning." British medical journal (Clinical research ed.) 291.6507 (1985): 1447.