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 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
- 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 Optimise circulation
- BSL control
- 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
- 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.
Chris is an Intensivist and ECMO specialist at the Alfred ICU in Melbourne. He is also a Clinical Adjunct Associate Professor at Monash University. He is a co-founder of the Australia and New Zealand Clinician Educator Network (ANZCEN) and is the Lead for the ANZCEN Clinician Educator Incubator programme. He is on the Board of Directors for the Intensive Care Foundation and is a First Part Examiner for the College of Intensive Care Medicine. He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives.
After finishing his medical degree at the University of Auckland, he continued post-graduate training in New Zealand as well as Australia’s Northern Territory, Perth and Melbourne. He has completed fellowship training in both intensive care medicine and emergency medicine, as well as post-graduate training in biochemistry, clinical toxicology, clinical epidemiology, and health professional education.
He is actively involved in in using translational simulation to improve patient care and the design of processes and systems at Alfred Health. He coordinates the Alfred ICU’s education and simulation programmes and runs the unit’s education website, INTENSIVE. He created the ‘Critically Ill Airway’ course and teaches on numerous courses around the world. He is one of the founders of the FOAM movement (Free Open-Access Medical education) and is co-creator of litfl.com, the RAGE podcast, the Resuscitology course, and the SMACC conference.
His one great achievement is being the father of three amazing children.
On Twitter, he is @precordialthump.