CICM SAQ 2015.2 Q25

Question

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.

Answer

Answer and interpretation

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

Circulation

  • 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

Cerebral support

  • Avoid any further episodes of hypoxia and hypercarbia. Avoid hyperoxia Optimise circulation
  • BSL control

Temperature

  • Actively rewarm to core temperature of 34C
  • Passively rewarm above 34C
  • If post cardiac arrest – maintain hypothermia 32.5 – 33.5C for > 24 hours
  • Could allow a normothermia strategy (T36C), but fever must be controlled

Other

  • 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.
  • Pass rate: 63%
  • Highest mark: 9.0

Additional Examiners’ Comments:

  • Most candidates answered this question well although knowledge relating to the evidence for tranexamic acid was overall limited. Some gave a reasonable discussion of the medical management of bleeding but omitted surgical strategies.
Exams LITFL ACEM 700

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Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the  Clinician Educator Incubator programme, and a CICM First Part Examiner.

He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.

His one great achievement is being the father of three amazing children.

On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.

| INTENSIVE | RAGE | Resuscitology | SMACC

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