By Brandon Kappy, MD, Children’s National Hospital

You receive an EMS notification about a 5-year-old M being brought in following a near-drowning event that occurred in the last 30 minutes. Per EMS report, patient climbed over a fence and jumped in a pool, despite not knowing how to swim. His mother does not know how long he was down in the pool but stated that it could not have been more than “1 minute.” Bystanders reportedly did 3-4 chest compressions and patient immediately became conscious. When EMS arrived, patient was reportedly alert although scared and tired appearing; breathing normally and not requiring oxygen. No known past medical history. ETA 10 minutes.

As you are preparing for EMS arrival in the trauma bay, a curious first-year resident asks what tests you would obtain on presentation. As an aspiring clinician-educator, you are thrilled with the question!

EMS arrives and you see that the patient is on an Oxy-Mask.  EMS and Mom confirm the story. Bystanders saw him jump in and struggle to swim and thrash before sinking underwater. He did not dive in or hit his head. EMS stated that patient has been responsive to them since arrival, answering questions and moving all extremities. However, he has also kept trying to sleep since the event, so they placed him on an OxyMask to provide additional O2. Oxygen saturations have been 99% both before and after the OxyMask.

PMH: None; no recent illnesses.

PFH: No known family history of any diseases, sudden deaths, or near-drownings.

Allergies: None.

Physical Exam:

Vital Signs: T 36.1 C, HR 99-105, BP 102/57, RR 36, O2 100% 5L OxyMask. Weight: 17kg

General: Well-appearing male, hair and clothing damp

HEENT: Normocephalic, atraumatic. EOMI, no conjunctival erythema/injection. TMs clear.  Oral mucosa moist.  No pharyngeal erythema or exudate.   Facial bones intact without tenderness to palpation.

CV: Regular rate and rhythm.  Normal peripheral perfusion. Brisk cap refill.  

Pulmonary: Lungs clear to auscultation without any crackles or wheezing; breath sounds equal bilaterally. Prominent belly-breathing noted with minor subcostal retractions. No suprasternal retractions or tugging.

Abdomen: Soft, nontender, non-distended, normal bowel sounds.

Neuro: GCS 14 initially (intermittently falling asleep so 3 for eye-opening); when asked questions or touched, GCS 15. Follows all commands normally. Moving all extremities normally.

Skin: 2 second capillary refill. Scattered petechiae on L cheek, otherwise no marks or bruises.

As you are preparing to summarize the case, the respiratory therapist notes that the patient is not in a C-collar and stabilizes the patient’s head/neck.

Now that you have assessed the patient:

As you are working on obtaining an IV, the patient finds the mask uncomfortable and takes it off. Oxygen saturation remains 99% and respiratory status is unchanged from above. Nursing obtains an IV and you obtain the following labs/images:

VBG: 7.29 / 37.5 / 17.3

Electrolytes from VBG: Na 140, Potassium 3.9, Hb 12.6

POC glucose: 159

CBC, BMP pending

CXR: Unremarkable image; clear lungs bilaterally without pneumothorax, pulmonary edema, or effusions.

Patient’s respiratory exam remains relatively similar to prior, with RR 38-44, belly breathing; intermittent subcostal retractions.  SpO2 100% on RA. Patient is tired and continues to fall asleep, but with light stimulation will open eyes and answers questions appropriately. Can argue that GCS between 12-15 depending on alertness. Speaking in full sentences.

As it is unclear if patient is simply exhausted from near-drowning or displaying waxing/waning mental status, you elect to send patient to Head CT. CT shows ‘mild diffuse cerebral swelling, given the reported history.’ After Head CT, you place the patient on BiPap 12/6, FiO2 30% due to continued tachypnea (RR 40-50) with subcostal retractions.

Over the next 2 hours, patient continues to have RR ~40 with no worsening in work of breathing. His intercostal retractions might be slightly improved. CBC and BMP return normal. Nursing is concerned because patient continues to fall asleep on the BiPap machine. GCS ~12, though he does require more stimulation to wake and is falling asleep more frequently. You obtain a repeat blood gas and CXR.

VBG: 7.32 / 39.8 / 23.1

CXR: Unchanged from prior.

45 minutes pass; neuro and pulmonary exams unchanged.