Question 14

College answer

Not available.

Discussion

a)

A "resuscitative management plan" would surely have an ABCDE structure, one might think - that is fairly standard. What is contentious is whether the examiners would have accepted "non-resuscitative" elements, such as the investigations for potential primary reasons behind the drowning (eg. head injury from diving into the shallow end). A reasonable person would argue that finding an extradural haematoma would contribute positively to the overall success of the resuscitation. 

• Airway:
  • Intubate the patient, taking care not to cause arrhythmias with induction agents (as the patient is very hypothermic)
• Breathing:
  • Ventilation with high FiO₂ (as the child appears to be rather hypoxic)
  • High PEEP, 12-15; lung protective ventilation (lung compliance will be poor due to decreased surfactant)
  • Respiratory rate to maintain a high minute volume, expecting a metabolic acidosis
  • Investigation of possible aspiration with CXR and ABG
• Circulation:
  • Establishment of IV access and correction of hypovolemia (the most likely cause of the tachycardia and hypotension)
  • Vasoactive substances once hypovolemia is corrected
  • Investigate cardiac cause of drowning (12-lead ECG, TTE)
• Neurology:
  • CT brain to investigate an intracranial cause of the drowning (eg. ICH, or trauma resulting from a fall into submerged obstacles)
  • Appropriate sedation to tolerate ETT
  • C-spine immobilisation (never forget the possibility of trauma)
• Exposure:
  • Rewarm the patient to normothermia using a combination of warm IV fluids and external warming devices
• Bloods and biochemistry
  • Look for electrolyte derangement (eg. sodium and chloride abnormalities) that might result from inhalation and ingestion of salt water or chlorinated pool water
  • Look for haemolysis which might occur with the ingestion of a large amount of hypotonic water
• In case of cardiac arrest on arrival
  • Resuscitation should continue until the patient is rewarmed, as case report experience suggests good outcomes from cardiac arrest in hypothermic drowning victims

b)

Factors which influence the outcome of the immersion injury could be any four of the following:

  Factors at the site of submersion:

•  Immersion for more than 5 minutes
• Delay in CPR of more than 10 minutes
• Warm water drowning
• Submersion time > 10 minutes (a good independent predictor of neurological outcome)

    Factors on presentation to the ED

• Fixed dilated pupils
• GCS of 3

    Factors after admission to the ICU:

• GCS less than 6
• Arterial pH less than 7.00 upon arrival to ICU
• No spontaneous purposeful movement and the abnormal brainstem function after 48 hours
• Abnormal CT within 36 hours

But more importantly, how shallow was this pool? As an attentive reader has pointed out (thank you James Doherty), immersion is defined as being incompletely covered in water, whereas submersion is where you are completely covered, as one might be in the bottom of the pool. This failure of nomenclature is only forgivable when one considers that during the later stages of 2021, while trying to prepare this paper, the CICM court of examiners were completely overrun with COVID and in fact many reflect that it is remarkable that any exam happened at all, i.e. other colleges just said "tough, you're holding the registrar pager for another couple of years".