What are the pre-hospital management considerations for a 3-year-old child who was submerged in water for 30 seconds, is awake and irritable, and did not receive cardiopulmonary resuscitation (CPR) at the scene?

Pre-Hospital Management of Brief Submersion in an Awake, Irritable Child

This 3-year-old child who is awake and irritable after 30 seconds of submersion requires immediate transport to the emergency department with continuous monitoring and oxygen administration, as all drowning victims—even those appearing stable—are at risk for delayed respiratory deterioration and secondary drowning complications. 1

Initial Scene Assessment and Safety

• Verify scene safety before approaching the child 1
• Rapidly remove the child from water if not already done, as outcome is determined by duration of submersion and how promptly resuscitation is provided 1
• Do not perform the Heimlich maneuver, as aspirated water is rapidly absorbed and does not preclude ventilation; this intervention only delays necessary oxygenation 2

Primary Assessment (ABCs)

Airway and Breathing:

• Assess for normal breathing versus gasping or absent respirations 1
• Check for airway obstruction from water, debris, or vomitus 1
• Since this child is awake and irritable, the airway is likely patent, but continuous reassessment is critical 3

Circulation:

• Check pulse simultaneously with breathing assessment (within 10 seconds) 1
• If pulse is present but heart rate <60/min with signs of poor perfusion, initiate CPR 1
• In this awake child, circulation is adequate, but monitor continuously 3

Specific Management for This Clinical Scenario

Since the child is awake and irritable (not requiring CPR):

• Activate emergency response system immediately and arrange transport to an appropriate facility 1
• Place child on 100% oxygen via non-rebreather mask or blow-by oxygen if mask not tolerated 2
• Position child in position of comfort (likely sitting upright in caregiver's arms) to optimize breathing 3
• Keep child warm, as even brief submersion can cause hypothermia 1
• Monitor continuously for deterioration during transport, as respiratory status can worsen rapidly 2, 4

Critical Monitoring During Transport

• Reassess breathing and pulse every 2 minutes 1
• Watch for signs of respiratory distress: increased work of breathing, decreased oxygen saturation, altered mental status 3
• Be prepared to initiate rescue breathing (1 breath every 2-3 seconds) if breathing becomes inadequate 1
• Be prepared to start CPR if child becomes unresponsive or pulseless 1

Transport Destination

• Transport to a facility with pediatric expertise and 24/7 capability to manage potential complications 3
• Prehospital advanced life support should be available during transport, including capability for intubation if needed 2
• The window for medical intervention in submersion victims is in the prehospital setting, making rapid transport with continuous monitoring essential 2

Common Pitfalls to Avoid

• Do not assume stability based on initial appearance—delayed respiratory deterioration and secondary drowning can occur hours after submersion 2, 4
• Do not perform abdominal thrusts or Heimlich maneuver—this delays ventilation and has no proven benefit in drowning victims 2
• Do not delay transport for extensive on-scene interventions in a stable child; continuous monitoring during rapid transport is the priority 2
• Do not underestimate the need for hospital evaluation—even brief submersions in awake children require emergency department assessment for potential pulmonary complications 4

If Clinical Deterioration Occurs During Transport

If child becomes unresponsive or stops breathing:

• Immediately check pulse (within 10 seconds) 1
• If pulse present but no breathing: provide rescue breathing at 20-30 breaths/minute (1 breath every 2-3 seconds) 1
• If no pulse or heart rate <60/min with poor perfusion: initiate CPR with 15 compressions to 2 breaths (two-rescuer ratio) 1
• Compress at least one-third anterior-posterior diameter of chest at rate of 100-120/minute 1

The irritability in this child may indicate hypoxia or anxiety, making oxygen administration and continuous reassessment during rapid transport the cornerstone of prehospital management. 2, 3