ICU and trauma07 / 13
Child drowning with possible neck injury9-year-old boy, 30 kg, pulled from a shallow pool after diving in
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Know this first
- Hypoxia is the main injury in drowning.
- Diving: assume spinal injury.
- After paediatric arrest: SpO2 94–99%, PaCO2 35–45 mmHg.
- Avoid central temperature above 37.5 °C after arrest.
- Treat clinical seizures after arrest; many are only seen on EEG.
The patient
9-year-old boy, 30 kg, pulled from a shallow pool after diving in; 4 minutes of CPR at the scene, then return of circulation.
GCS 9, cold, frothy pink secretions, weak arm movements. Needs intubation and transfer for CT and PICU.
No regular drugs.
Vitals: HR 128, BP 96/58, SpO2 86% on a 15 L mask, RR 36, temperature 34.8 °C; glucose 2.4 mmol/L.
The examiner asks
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Consider
What are your priorities?
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- A 9-year-old after drowning and a brief arrest, possible neck injury, needing intubation and transfer. Patient
- A child and a trauma patient: a dive means spinal injury until proven otherwise.
- Hypoxia is the core injury in drowning, so oxygen and ventilation come first. Disease
- Pink froth and SpO2 86%: aspiration and lung oedema, behaving like ARDS.
- Core temperature monitored, controlled rewarming to a TTM target, never above 37.5; glucose 2.4 corrected now.
Plan
How do you intubate and transfer him?
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- Rapid sequence with manual in-line stabilisation; collar front off. Airway
- Ketamine 1–2 mg/kg and rocuronium 1–1.2 mg/kg.
- Videolaryngoscope to reduce neck movement.
- Orogastric tube to empty swallowed water and air. Disease
- Glucose now: 2–4 mL/kg of 25% dextrose.
- PEEP and small tidal volumes, as for ARDS.
- Transfer checklist: tube secured, drugs and oxygen for the trip, senior escort. After surgery
Crisis
After intubation, SpO2 is 82% on FiO2 1.0 and PEEP 8, with pink froth in the tube; BP 92/54. What do you do?
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- Tube checked and patent: refractory hypoxaemia from drowning lung injury. Crisis
- PEEP up in steps; open lung levels run from 12 upwards.
- No permissive hypercapnia: his brain is injured, so CO2 stays 35–45.
- Closed suction for the froth; bronchoscopy if there are plugs.
- Still hypoxic: discuss ECMO with the receiving PICU. After surgery
Crisis
In the CT scanner he has a generalised seizure; HR 160, BP 128/80. What do you do?
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- Seizure from hypoxic brain injury after arrest; clinical seizures must be treated. Crisis
- Lorazepam 0.1 mg/kg IV.
- Continuing: levetiracetam 20 mg/kg.
- Keep him normal: SpO2 94–99%, CO2 35–45, temperature no higher than 37.5.
- Glucose and sodium rechecked and corrected.
- Continuous EEG in PICU; once paralysed, his seizures are invisible. After surgery
Fatal mistakes
- Ignoring a possible neck injury after a dive.
- Low PEEP for drowning lung injury.
- Letting him become hyperthermic or hypoglycaemic.
Checked against: AHA guidelines: special circumstances of resuscitation (2025) · AHA and AAP guidelines: pediatric advanced life support (2025) · Miller 10e
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