A 4-year-old boy is brought to the emergency department after drowning in a pool. The mother reports she was outside with her son in the back yard when she left him to go inside. She returned a few minutes later to find the boy submerged in the deep end of the pool. She removed him from the water and called 911. The patient was unresponsive but breathing when paramedics arrived. They placed him on oxygen and transported him to the hospital. Temperature is 33.9 C (93 F), blood pressure is 100/58 mm Hg, pulse is 120/min, and respirations are 44/min. Pulse oximetry is 89% on high-flow oxygen. On examination, the patient is somnolent. The pupils are equal and reactive to light. Nasal flaring and intercostal retractions are noted. Wheezing is present on auscultation of the lungs. He moves all extremities but does not follow commands. Which of the following is the first step in management of this patient?

Question

A 4-year-old boy is brought to the emergency department after drowning in a pool.  The mother reports she was outside with her son in the back yard when she left him to go inside.  She returned a few minutes later to find the boy submerged in the deep end of the pool.  She removed him from the water and called 911.  The patient was unresponsive but breathing when paramedics arrived.  They placed him on oxygen and transported him to the hospital.  Temperature is 33.9 C (93 F), blood pressure is 100/58 mm Hg, pulse is 120/min, and respirations are 44/min.  Pulse oximetry is 89% on high-flow oxygen.  On examination, the patient is somnolent.  The pupils are equal and reactive to light.  Nasal flaring and intercostal retractions are noted.  Wheezing is present on auscultation of the lungs.  He moves all extremities but does not follow commands.  Which of the following is the first step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient who drowned is now hypoxic, in respiratory distress (eg, respirations of 44/min with nasal flaring and intercostal retractions), and unable to protect his airway (eg, somnolence). Endotracheal intubation should be performed, and mechanical ventilation should be initiated. Drowning often results in aspiration of a large amount of fluid, which may cause alveolar-capillary membrane damage, surfactant washout, and ventilation/perfusion mismatch, resulting in hypoxia. Correction of hypoxia is the primary goal in management of drowning victims. Respiratory support is tailored to maintaining oxygenation and ventilation and may include: Supplemental oxygen (eg, high-flow oxygen) Noninvasive positive pressure ventilation (eg, continuous positive airway pressure): This helps reduce atelectasis and ventilation/perfusion mismatch; however, because it does not protect against aspiration, it should not be used in somnolent patients (such as this one) who cannot protect their airway (Choice D). Endotracheal intubation with mechanical ventilation: This is performed if airway protection is required (as in this patient) or if adequate oxygenation cannot be achieved with less invasive strategies. Following intubation, this patient will also benefit from the administration of bronchodilators (eg, albuterol) to treat bronchospasm (eg, wheezing), another common respiratory complication of drowning. (Choice A) Cervical spine injury is uncommon in drowning victims who have no signs of trauma (eg, head contusion/laceration) and no concerning mechanism (eg, diving into shallow water); therefore, immobilization is not routinely performed, particularly because it can interfere with airway management. In this patient who was found in deep water with no evidence of head/neck trauma, the risk of cervical spine injury is very low. (Choice B) CT scan of the head in patients with an abnormal neurologic examination (eg, somnolent, not following commands) due to hypoxic/ischemic injury is often appropriate. However, this patient has ongoing hypoxia, respiratory distress (eg, tachypnea, intercostal retractions), and the need for airway protection; he should be intubated prior to going to the CT scanner, where his condition may decompensate. (Choice E) Warm intravenous fluids can be used to treat hypothermia, and although they may be appropriate in this mildly hypothermic (ie, 32-35 C [89.6-95 F]) patient, along with other rewarming measures (eg, removal of wet clothing, warm blankets), management of the airway and breathing (ie, ABCs or resuscitation) takes precedence. Educational objective: Drowned patients often require respiratory support to correct hypoxia. In patients who are unable to protect their airway or who are hypoxic despite supplemental oxygen, intubation with mechanical ventilation should be performed. References: Drowning. (http://www.ncbi.nlm.nih.gov/pubmed/22646632) Physiology of drowning: a review. (http://www.ncbi.nlm.nih.gov/pubmed/26889019)

A 4-Year-Old Boy Is Brought to the Emergency Department After