Paediatric near-drowning with hypothermia and contaminated water aspiration

Facilitator Triggers — if trainees miss a critical step

• ! (If airway is not suctioned within the first 60 seconds and patient repositioned laterally — patient vomits again and SpO2 drops to 78%. Prompt trainees: 'What is your immediate airway priority?')
• ! (If high-flow oxygen via NRB mask is not applied within 2 minutes — SpO2 remains at 84% and RR increases to 34. Prompt trainees: 'What does this child need urgently?')
• ! (If wet clothing is not removed and passive warming not commenced within 5 minutes — temperature drops to 33.8°C and HR increases to 130. Prompt trainees: 'What environmental factors are contributing to this child's deterioration?')
• ! (If BGL is not checked — facilitator prompts: 'The child has a history of limited oral intake. What baseline assessment are you missing?' — BGL is 3.8 mmol/L, borderline for an active child, monitor trend.)
• ! (If hypothermia is not recognised and warm measures not applied — at 10 minutes temp remains 34.2°C, GCS does not improve beyond 9 and HR remains elevated at 118. Facilitator states: 'Despite oxygen, the child is not improving as expected. What else could be contributing?')
• ! (If trainee attempts to administer Glucose Oral Gel with BGL of 3.8 mmol/L — redirect: 'The CPG threshold for glucose gel is below 4 mmol/L — is this patient symptomatic and is the BGL below threshold? What does your CPG state?')
• ! (If spinal precautions are not considered given the mechanism — facilitator prompts: 'The patient fell from a height into water. What does your immersion CPG say about spinal injury consideration?')
• ! (If patient's conscious state improves to GCS 14 and trainee considers removing oxygen — redirect: 'Consciousness is not synonymous with recovery in immersion patients. What does your CPG note about delayed deterioration?')

Treatment Objectives

1. 1. Ensure scene safety — confirm patient is away from water's edge and on a flat dry surface.
2. 2. Don appropriate PPE including gloves — high risk of body fluid exposure and potential contaminated water contact.
3. 3. Perform Primary Survey — simultaneously direct bystanders to clear area and summon ambulance via 000.
4. 4. Airway: Place patient in lateral position (left lateral) immediately to facilitate drainage of vomitus and water from oropharynx.
5. 5. Airway: Suction oropharynx using Yankauer/Ducanto catheter — maximum 5 seconds per pass — until airway is visibly clear.
6. 6. Airway: Insert appropriately sized OPA (measure centre of lips to angle of mandible) — given GCS 9, patient is unlikely to tolerate but assess tolerance; if intolerant, insert NPA instead (measure corner of nose to earlobe, lubricate, advance along right nostril with bevel toward septum).
7. 7. Breathing: Apply oxygen via Non-Rebreather Mask at 10–15 L/min — titrate to target SpO2 ≥94% in paediatric patient.
8. 8. Breathing: Assist ventilations with BVM if respiratory effort becomes inadequate (rate <10 or SpO2 not responding to high-flow O2) — ventilate at age-appropriate rate of 20–25 breaths per minute, gentle tidal volume to visible chest rise only.
9. 9. Circulation: Assess central pulse (carotid or brachial) — if absent at any time, commence CPR as per Paediatric Cardiac Arrest CPG (15:2 ratio, 100–120/min, depth ~5cm, use CPR feedback device if available, defibrillate shockable rhythms at 4 J/kg via paediatric pads).
10. 10. Disability: Perform GCS — document E2V2M5 = GCS 9. Assess pupils: 3mm bilaterally, reactive to light.
11. 11. Exposure: Remove ALL wet clothing immediately to arrest heat loss — this is a critical step in hypothermia management.
12. 12. Hypothermia management: Dry the patient thoroughly with towels or blankets. Passively re-warm using dry blankets and ambulance heater if available. Do NOT apply Ready-Heat blanket directly to skin — place sheet between blanket and patient. Keep patient off cold ground — use stretcher or improvised insulation.
13. 13. BGL assessment: Perform blood glucose test — result 3.8 mmol/L. This is borderline; monitor trend. Do not administer Glucose Oral Gel as BGL is above 4 mmol/L treatment threshold and patient has reduced conscious state (GCS 9) — risk of airway obstruction.
14. 14. Temperature: Obtain tympanic temperature — 34.2°C. Recognise mild hypothermia (32–35°C). Note tympanic readings may be unreliable in hypothermia extremes — use as a guide only.
15. 15. Spinal precautions: Consider spinal immobilisation given mechanism (fall from height into water with submersion). If spinal injury cannot be excluded — apply Lateral Trauma Position maintaining spinal alignment rather than standard lateral position. Apply C-spine collar if clinically indicated and tolerated.
16. 16. Contaminated water consideration: Document that aspiration of lake water of unknown microbiological quality has occurred. Advise receiving ED at handover — this is clinically relevant for downstream antibiotic and infection monitoring decisions. Do not delay transport for this.
17. 17. Monitoring: Record full observations every 5 minutes given time-critical status. Monitor SpO2 persistently. Reassess GCS, temperature, and BGL at 10-minute mark.
18. 18. Transport: This is a Priority 1 paediatric immersion patient — do not delay transport. Active resuscitation and monitoring must continue en route. Pre-notify receiving ED with patient age, weight, submersion duration, water source, current GCS and temperature.
19. 19. Scenario ends on arrival of ambulance and IMISTAMBO handover.
20. 20. Attention to hand hygiene will be given throughout the scenario.