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  1. Lawes, Rhonda RN, CNE, MS

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THE PARAMEDICS ARRIVE at your hospital with Nathan Charles, 4, who was found unresponsive and floating face-down in the lake near his grandparents' summer home. He's endotracheally intubated and on a backboard. The paramedics report that after initial resuscitation at the scene, Nathan was in normal sinus rhythm at 62 beats/minute with a pulse and a BP of 74/58 mm Hg. He's awake now, but is lethargic.

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What's the situation?

Nathan was fishing on the pier with his older brother. When the brother returned from a brief trip to the house to get more bait, Nathan was face-down in the water. The brother called for help. When Nathan was pulled from the water, he was apneic and pulseless. Family members immediately started CPR. Shortly after the paramedics took over resuscitation efforts, they could palpate a weak pulse.


In the ED, you assess Nathan's airway, breathing, and circulation (ABCs), suction his endotracheal tube as needed, continue ventilatory support, cardiac monitoring, and complete a baseline assessment. His vital signs are BP, 88/68 mm Hg (normal pediatric range, 88/47 mm Hg to 122/79 mm Hg); heart rate, 71 and normal sinus rhythm (normal awake range, 60 to 140 beats/minute); and temperature, 97[degrees] F (36.1[degrees] C). His respiratory rate is 24 on a ventilator setting of 20 breaths/minute, so he's taking some breaths on his own-a good sign. His SpO2 is 97% and he's able to follow commands, such as opening his eyes in response to his name, but returns to sleep after interaction. Closely monitor Nathan's vital signs, cardiac rhythm, and oxygen saturation while you and the healthcare team complete a full assessment. Send blood specimens for a stat arterial blood gas (ABG) analysis, comprehensive metabolic panel, coagulation profile, cardiac troponin, and complete blood cell count.


To preserve skin integrity, remove Nathan from the backboard. However, until computed tomography or magnetic resonance imaging rules out spinal or cervical damage, keep Nathan in a cervical collar, log roll him when he needs to be turned, and handle him in a way that protects his spine.


You auscultate pulmonary crackles and wheezing bilaterally. A portable chest X-ray demonstrates diffuse pulmonary edema.


What's your assessment?

Nathan has apparently suffered a near-drowning, defined as survival, even if temporary, beyond 24 hours after a submersion episode. He's at risk for complications, including central nervous system, pulmonary, and cardiovascular complications, secondary to hypoxemia, and inadequate tissue perfusion.


His ABG results were within normal limits except for a pH of 7.29 (normal range, 7.35 to 7.45) and a PaCO2 of 62 mm Hg (normal range, 35 to 45 mm Hg), indicating respiratory acidosis. When you perform a neuro assessment, Nathan opens his eyes to command, his pupils are equal and reactive to light, and he has some spontaneous movement of all four extremities. He has no seizure activity.


What must be done first?

Continue to support Nathan's ABCs while you intervene to decrease his PaCO2 to help return the pH to within normal limits. This can be done by increasing the number of breaths he receives per minute on the ventilator until his ABG values stabilize. Be careful not to reduce the PaCO2 below 35 mm Hg, which could cause cerebral vasoconstriction. Nathan also will have a gastric tube to remove water and debris from his stomach, an indwelling urinary catheter for assessment of urine output, and a central venous access device.


What should be done later?

Nathan will be admitted to the pediatric ICU for close monitoring for continued ventilatory support and monitoring for complications, such as cardiac dysrhythmias, which are common in near-drowning victims. Dysrhythmias can be caused by hypoxemia, electrolyte imbalances, and acid-base disturbances.


In a fresh-water near-drowning, alveolar surfactant can be disrupted, leading to atelectasis and acute respiratory distress syndrome. Assess breath sounds regularly and monitor his ABGs closely. A beta-adrenergic agent such as albuterol may be prescribed to control bronchospasm.


Nathan responded well to treatment and was extubated on his second day in the pediatric ICU. He was transferred to the step-down unit the next day and discharged home after 5 days in the hospital.