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.