Phone Triage for Post-Pool Incident with Respiratory Symptoms
This child requires immediate emergency department evaluation and should be sent to the hospital, not to a GP, because the combination of coughing, difficulty breathing, and altered mental status (sleepiness) after a pool incident represents life-threatening signs consistent with drowning-related respiratory compromise. 1
Critical Red Flags Present
The American Heart Association guidelines explicitly state that sleepiness, difficulty breathing, and coughing after a pool incident are life-threatening conditions requiring immediate EMS activation. 1 The triad of symptoms Philipp is experiencing meets criteria for urgent hospital transport because:
- Altered mental status (sleepiness) indicates potential hypoxemia and is a sign of severe respiratory compromise 1
- Difficulty breathing suggests ongoing respiratory impairment from water aspiration 1
- Coughing may indicate aspiration of water and developing pulmonary edema 2
Essential Triage Questions
Immediate Assessment Questions:
- What exactly happened in the pool? Was there submersion? How long was the child underwater? Did he lose consciousness at any point? 1
- Current level of consciousness: Can you wake him easily? Is he responding normally to you or is he unusually drowsy/confused? 1
- Breathing pattern: How fast is he breathing? Is he struggling to breathe? Can he speak in full sentences? Is he using neck or chest muscles to breathe? 1
- Skin color: Is his skin or lips blue/gray or pale? 2
- Cough characteristics: Is he coughing up water, blood, or pink frothy sputum? 2
- Time since incident: When did this happen? Are symptoms getting worse or staying the same? 1
Secondary Assessment Questions:
- Any chest pain or tightness? 1
- Any vomiting? 1
- Pre-existing conditions: Does he have asthma, seizure disorder, or any heart/lung conditions? 1
Hospital vs GP Decision Algorithm
SEND TO HOSPITAL IMMEDIATELY if ANY of the following:
- Altered mental status (sleepiness, confusion, difficulty waking) - PRESENT IN THIS CASE 1
- Difficulty breathing or respiratory distress - PRESENT IN THIS CASE 1
- Any history of submersion or aspiration - PRESENT IN THIS CASE 1
- Cyanosis (blue/gray skin or lips) 2
- Inability to speak in full sentences 3
- Hemoptysis (coughing blood) 2
- Chest pain 1
- Seizures 1
- Loss of consciousness at any point 1
Consider GP Only if:
None of the above apply - However, the 2020 American Heart Association guidelines state that all victims of drowning who require any form of resuscitation should be transported to hospital for evaluation and monitoring, even if they appear alert with effective cardiorespiratory function. 1 This is because decompensation can occur 4-6 hours after the event. 1
Critical Clinical Reasoning
The duration and severity of hypoxia from drowning is the single most important determinant of outcome. 1 The presence of sleepiness indicates potential ongoing hypoxemia and central nervous system involvement, which can rapidly progress to respiratory failure and cardiac arrest. 1, 2
Common pitfall: Underestimating the severity because the child initially seemed fine after the pool incident. Drowning victims can deteriorate significantly in the first 4-6 hours post-event, developing pulmonary edema and respiratory failure even after appearing stable initially. 1, 2
Immediate Action
Advise the parent to call emergency services (ambulance) immediately rather than driving to hospital themselves if the child shows worsening sleepiness or breathing difficulty, as respiratory arrest can occur rapidly. 1 If symptoms are stable but concerning, direct transport to the emergency department is appropriate, but emphasize the need for immediate evaluation. 1