Environmental

Immersion with aspiration and hypothermia — elderly male

Advanced

Elderly · 75yr · male

Patient Information

Dispatch	You are called to the lake edge at the Swan River Festival. A 75YO male (Harold Sutton) has been pulled from the water by bystanders. Witnesses say he was submerged for approximately 4–5 minutes before being retrieved.
Patient	Harold Sutton — 75yr (75kg)
Incident History	Pt was observed to lose his footing on a wet jetty pontoon and fall into the Swan River. Bystanders pulled him from the water after approximately 4–5 minutes of submersion. Pt was found unresponsive on retrieval. Bystanders initiated CPR for approximately 2 minutes prior to EHS arrival. Pt has regained some responsiveness but remains confused and distressed.
Emergency Contact	Margaret Sutton (Wife) — 0412 883 047

Initial Rapid Assessment

Response	Voice
Airway	Partially patent. Audible gurgling. Secretions and water visible in oropharynx. No foreign body obstruction. Moderate aspiration risk.
Breathing	Laboured. Shallow and fast. Accessory muscle use present. Audible wet crackles bilaterally on auscultation. RR 26. SpO2 82% on room air. DETECT & CORRECT.
Circulation	Weak and irregular radial pulse. Skin cold, wet and pale peripherally. Central pallor. CRT 4s. No external haemorrhage.
Disability	GCS 10 (E3V3M4). Confused and disoriented. Not orientated to time, place or person. Pupils equal and reactive. BGL 5.8 mmol/L.
Exposure	Fully clothed and saturated. Core body temperature 33.1°C (tympanic). No visible trauma. Lips cyanotic. Skin mottled across lower limbs.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	82% (RA)	Severe	26	48	94/60	4s	10	3 3 ++	33.1	5.8 mmol/L	–
10 mins	93% (O2 NRB 15L)	Moderate	22	54	100/64	3s	12	3 3 ++	33.4	5.8 mmol/L	–

History Taking

Treatment Response

Diagnosis

This patient is suffering from immersion (near-drowning) with aspiration of contaminated river water and secondary hypothermia following prolonged submersion. The patient has achieved spontaneous circulation following bystander CPR but remains at high risk of delayed respiratory deterioration, aspiration pneumonitis, and re-arrest due to hypothermia and underlying cardiac history.

Facilitator Triggers — if trainees miss a critical step

! (If suction is not performed within the first 2 minutes: patient produces a large volume of water-tinged sputum, GCS drops to 8, and gurgling becomes louder — prompt trainee to suction and reassess airway immediately.)
! (If high-flow oxygen via non-rebreather mask is not applied promptly: SpO2 remains at 82% and patient becomes increasingly agitated and cyanotic — facilitator states 'the patient is reaching for their face and becoming combative'.)
! (If wet clothing is not removed and passive rewarming not initiated within 5 minutes: temperature drops to 32.8°C at 10 minutes and pulse becomes more irregular — facilitator states 'patient's shivering has now ceased and his skin is becoming more mottled'.)
! (If the trainee attempts to induce vomiting or applies abdominal pressure to 'drain' the lungs: facilitator states 'the patient immediately vomits a large volume — what is your next priority?' — redirect to lateral position and airway management.)
! (If hypothermia is identified but BGL is not checked: facilitator prompts 'what other assessment might be relevant in a hypothermic patient with altered conscious state?')
! (If trainee does not consider aspiration of contaminated water as an ongoing risk factor for respiratory deterioration: facilitator prompts 'the patient begins coughing up dark-tinged frothy sputum — does this change anything about your assessment or handover to ambulance?')

Treatment Objectives

1. Ensure personal safety — don gloves and appropriate PPE given contaminated river water exposure risk.
2. Perform Primary Survey — open and clear airway using lateral position to facilitate drainage of secretions.
3. Suction oropharynx using Yankauer catheter to clear water and secretions — maximum 5 seconds per pass, reassess between passes.
4. Insert Oropharyngeal Airway (OPA) — size measured from centre of lips to angle of mandible — if patient tolerates and GCS permits.
5. Apply high-flow oxygen via Non-Rebreather Mask at 10–15 litres per minute — target SpO2 94–98%.
6. Assist ventilations with BVM if respiratory effort deteriorates or becomes inadequate — ventilate gently, avoid high pressures.
7. Remove all wet clothing immediately to halt ongoing heat loss — use scissors/trauma shears as required.
8. Perform passive rewarming — cover patient with Ready-Heat blanket (sticker side down, over a sheet) then standard blanket — do NOT place directly on skin.
9. Treat hypothermia as per CPG: remove from cold environment, dry and cover, warm surroundings.
10. Perform Vital Sign Survey — GCS, SpO2, RR, BP, HR, CRT, temperature (tympanic), BGL.
11. Perform Secondary/CNS Survey — assess for concealed trauma from fall onto jetty, check all limbs for injury.
12. Monitor closely for signs of re-arrest — hypothermia significantly increases risk; have defibrillator immediately available.
13. Do NOT attempt to empty stomach by external abdominal pressure — aspiration risk is high.
14. Position patient in lateral position if unresponsive or vomiting — left lateral if GCS deteriorates further.
15. Record full observations every 5 minutes given time-critical status.
16. Note contaminated river water aspiration in handover — risk of delayed aspiration pneumonitis and water-borne organism exposure.
17. Notify ambulance and receiving ED of prolonged submersion, hypothermia, aspiration of contaminated water, current GCS, SpO2 trend, and known cardiac history including anticoagulation with warfarin.
18. Scenario ends on arrival of ambulance and IMISTAMBO handover.
19. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Immersion · Hypothermia · Unconsciousness · Cardiac Arrest - Adult · Oxygen Delivery · Suction · Lateral Position · Oropharyngeal Airway · Bag Valve Mask Ventilation · Ready Heat Blanket · Tympanic Thermometer · Blood Glucose Monitor · Primary Survey · Secondary & CNS Survey

How did you go?

← Prev ← → navigate · Space reveal

Print Next →

Signs/Symptoms	Pt reports feeling very cold, short of breath and confused. Persistent cough productive of frothy, discoloured sputum since retrieval from river water.
Allergies	Penicillin — rash.
Medications	Metoprolol 50mg daily (beta blocker — note: may blunt tachycardic response to hypothermia and hypoxia). Warfarin 3mg daily. Atorvastatin 40mg daily.
Pertinent History	Known ischaemic heart disease. Hypertension. Atrial fibrillation (on warfarin). No known respiratory conditions. Lives with wife. Independent ADLs.
Last Oral Intake	Lunch approximately 2 hours prior — sandwich and water.
Events Leading	Pt was walking along the jetty pontoon at the Swan River Festival precinct when he slipped on wet decking and fell approximately 1.5 metres into the river. Was submerged and unable to self-rescue. Bystanders dived in to retrieve him after approximately 4–5 minutes.
Treatment Prior	Bystander CPR performed for approximately 2 minutes prior to EHS arrival. No medications administered. Pt removed from water and placed supine on jetty decking.

Onset	Acute. Fell from jetty pontoon approximately 10 minutes prior to EHS arrival.
Pain	Pt reports mild chest discomfort 3/10 associated with coughing. No cardiac-sounding chest pain.
Quality	Chest discomfort described as a tight, burning sensation with each cough.
Radiates	Nil radiation.
Severity	Dyspnoea 8/10. Chest discomfort 3/10.