Simulated Patient Scenario

Paediatric Drowning

Scenario Details

Scenario: Paediatric Drowning - Cardiac Arrest

Simulated Patient: 4-year-old Child Mannequin

Actor/Actress: Parent (highly distressed)

MDT Information

Urgent Response - Drowning / Cardiac Arrest
4-year-old child pulled from backyard swimming pool
Unresponsive, not breathing
Bystander CPR reportedly in progress (quality unknown)
Location: Residential address
Police responding

On Arrival

You arrive at a suburban house. A highly distressed parent meets you, pointing towards the backyard pool area. You see a small child lying supine on the poolside paving. Another adult (neighbour/bystander) is performing chest compressions, appearing panicked and possibly ineffective. The child is cyanotic, wet, and appears lifeless. The pool area is fenced but the gate is open.

Scene Safety Note: Ensure pool area is safe, be mindful of wet surfaces. Manage distressed bystanders calmly.

Initial Impression and Primary Survey (Assume bystander CPR stops on your arrival)

Category	Finding
Initial Impression	Lifeless child, cyanotic, wet, likely cardiac arrest post-drowning.
Response	Unresponsive to all stimuli. (AVPU = U)
Airway	May be obstructed by water, vomit, or laryngospasm. Froth may be present. Requires immediate opening and clearing.
Breathing	Apneic. No respiratory effort observed.
Circulation	No palpable central pulse (e.g., carotid/femoral). Skin cyanotic, cool, mottled.
Disability	Unresponsive (GCS 3). Pupils may be fixed and dilated.
Exposure/Environment	Poolside, wet environment. Child is wet and likely hypothermic. Remove wet clothing quickly.

Secondary Survey and Simulation Progression (Performed concurrently with resuscitation)

History (obtained rapidly from parent/bystander)

Allergies	NKDA (Parent confirms)
Medications	None.
Past Medical History	Previously well child. No history of seizures or cardiac issues.
Last Oral Intake	Breakfast ~ 2 hours ago.
Events Preceding	Child was playing in backyard near the pool. Parent lost sight of them for a brief period (estimated 3-5 minutes). Found floating unresponsive in the pool. Pulled out immediately. Neighbour started CPR. Total submersion time unknown but likely < 5-10 minutes. Water temperature cool (ambient temperature day). No witnessed trauma/fall prior to entering water.

Vital Signs/Assessment (During Resuscitation)

Parameter	Value
Resp. Rate (/min.)	Apneic - requiring BVM ventilation.
Lung Sounds (L/R)	Difficult to assess during CPR. May hear gurgling initially. Aim for chest rise with ventilation.
SpO2 (%)	Unrecordable initially. Aim for >94% with effective oxygenation/ventilation.
EtCO2 (mmHg)	Low or absent initially. Monitor trend with CPR/ventilation (aim >10-15 mmHg during CPR).
Pulse Rate (/min.)	Absent central pulse initially.
CRT (sec.)	Not reliable in arrest/hypothermia.
ECG rhythm	Asystole or PEA (Pulseless Electrical Activity) most likely initially. Possible VF/VT (less common in paediatric drowning).
12-lead ECG	Not a priority during initial CPR. Rhythm strip analysis is key.
BP (mmHg)	Unrecordable (in cardiac arrest).
Skin	Cyanotic, cool/cold, wet, mottled.
Pain (/10)	Unresponsive.
GCS (/15: E,V,M)	3/15 (E1, V1, M1)
BGL (mmol/L)	Check early - may be low.
Pupils (mmL/mmR)	Likely fixed and dilated.
Temp. (°C)	< 35°C (Hypothermic) - Rectal temp if feasible/protocol.

Physical Examination (During Resuscitation)

General Appearance: Unresponsive, apneic, pulseless, cyanotic, wet, cold.
Airway: Check for foreign material, water, vomit. Froth may be present at mouth/nose.
Breathing: No spontaneous effort. Assess chest rise/fall with BVM ventilation.
Circulation: Confirm absence of central pulse. Assess skin signs.
Neurological: GCS 3. Fixed, dilated pupils common.
Exposure: Remove wet clothing rapidly. Check for signs of trauma (especially head/neck if fall suspected).

Assessment and Treatment (Paediatric ALS for Drowning)

Appropriate Management Focus

Safety & Scene Management: Ensure rescuer safety. Remove patient from water. Manage bystanders/family supportively.
Immediate Resuscitation (DRSABCD): Confirm unresponsiveness, check for breathing/pulse. Commence high-quality CPR immediately (Rate 100-120/min, Depth 1/3 chest diameter ~5cm, full recoil, minimise interruptions). 15:2 compression:ventilation ratio (two rescuers).
Airway Management: Open airway (head-tilt/chin-lift or jaw thrust if trauma suspected). Suction airway clear of water/vomit/froth. Insert oropharyngeal airway (OPA) or nasopharyngeal airway (NPA) if tolerated/needed.
Breathing/Ventilation: Provide positive pressure ventilation with Bag-Valve-Mask (BVM) using 100% oxygen. Focus on effective chest rise. Consider advanced airway (LMA/ETT) early if BVM ineffective or prolonged resuscitation anticipated, performed by appropriately skilled provider.
Circulation/CPR: Continue high-quality CPR. Apply defibrillator pads/monitor ASAP. Analyse rhythm. Follow Paediatric ALS algorithm:
- Non-Shockable (Asystole/PEA): Continue CPR, gain IV/IO access, administer Adrenaline (10mcg/kg IV/IO) every 3-5 minutes. Identify and treat reversible causes (Hypoxia, Hypothermia, Hypo/Hyperkalaemia, Hypoglycaemia, Hypovolemia, Tamponade, Tension pneumo, Toxins, Thrombosis).
- Shockable (VF/Pulseless VT): Defibrillate immediately (4 J/kg), resume CPR immediately for 2 mins, analyse rhythm. If still shockable, defibrillate again, resume CPR, administer Adrenaline (10mcg/kg IV/IO) after 2nd shock (then every 3-5 mins). Consider Amiodarone (5mg/kg IV/IO) after 3rd shock.
Hypothermia Management: Remove wet clothing. Dry patient thoroughly. Cover with warm blankets. Use active warming measures if available (e.g., forced air warmer, warmed IV fluids - use caution).
Glucose Management: Check BGL. Treat hypoglycaemia (<3.0-3.5 mmol/L depending on protocol) with IV Dextrose (e.g., 2-5mL/kg Dextrose 10%) or IM Glucagon if no IV/IO access.
Cervical Spine: Maintain manual in-line stabilisation only if significant trauma is suspected based on mechanism (e.g., dive into shallow water, fall from height into water). Routine C-spine immobilisation not recommended in simple drowning.
Gastric Decompression: Consider nasogastric/orogastric tube insertion by skilled provider to decompress stomach (improves ventilation), especially if prolonged BVM used.
Transport: Rapid transport to the nearest appropriate Emergency Department (preferably with paediatric critical care capabilities) once initial resuscitation is underway or if ROSC achieved. Continue full resuscitation during transport. Pre-notify hospital early (Paediatric drowning arrest, rhythm, interventions, ETA).
Family Support: Communicate updates calmly and compassionately to parent/family. Assign a team member for family liaison if possible.
Teamwork & Communication: Clear roles, closed-loop communication, adherence to ALS algorithms.

Debrief Focus Points

Recognizing drowning and initiating resuscitation promptly.
Key differences in drowning resuscitation (emphasis on oxygenation/ventilation).
High-quality paediatric CPR techniques (rate, depth, ratio).
Airway management in drowning (clearing airway, BVM technique, advanced airway considerations).
Paediatric ALS algorithm application (rhythm analysis, drug doses - Adrenaline, Amiodarone, defibrillation energy - 4J/kg).
Management of hypothermia in drowning.
Importance of checking and correcting hypoglycaemia.
Considerations for C-spine immobilisation in drowning.
Teamwork, communication, and family support during paediatric resuscitation.
Importance of rapid transport and pre-notification.