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.
Difficult to give exact template, as style may vary, but should include:
Initial Assessment/Primary Survey
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 ETTs 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 and arterial access
If inadequate circulation fluid bolus of 20 ml/kg 0.9% Saline – avoid hypotonic intravenous fluids Consider vasopressor support early
Blood glucose, FBE, U & E
Avoid any further episodes of hypoxia and hypercarbia. Avoid hyperoxia
Actively rewarm to core temperature of 34oC
Passively rewarm over 34oC
If post cardiac arrest – maintain hypothermia 32.5 – 33.5oC for > 24 hours
Could allow a normothermia strategy, but fever must be controlled
Primary and secondary survey for associated trauma
Look for precipitating cause (hypoglycaemia, epilepsy, toxin 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.
Generic issues in the resuscitation of drowning, from the chapter on immersion submersion and drowning:
Emergency management issues
ICU management issues
Uniquely paediatric issues in the resuscitation of drowning, from the chapter on resuscitation of the drowned child
Need to search for predisposing conditions and risk factors:
Unique paediatric issues:
Non-accidental drowning needs to be considered as the cause
Features which favour non-survival or severe disability:
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