Scenario summary
A previously healthy three-year-old wandered into the deep end of a backyard pool and was found submerged. The parents brought her to the surface unconscious and coughing up white frothy material. EMS provided oxygen and transported her to a tertiary emergency department with PICU access.
On ED arrival, the child is obtunded with respiratory distress, persistent hypoxemia, and foam in the airway. The team should apply monitors, obtain pediatric resuscitation resources, begin warming, call for help, and prepare for a difficult airway. After intubation, the case deliberately shifts into post-intubation hypoxemia, then bradycardia with poor perfusion requiring PALS-directed CPR and epinephrine.
Patient chart
| Field | Details |
|---|---|
| Patient | Lyla, 3-year-old female, 16 kg |
| Presenting complaint | Respiratory distress after pool submersion |
| Initial vitals | T 34.0 C, HR 150, BP 85/40, RR 40, SpO2 90% with assisted breaths on 100% FiO2 |
| Neurologic status | GCS 8, eyes closed, groans to pain, localizes, poor tone |
| History | Previously healthy, born at 38 weeks by spontaneous vaginal delivery |
| Exam cues | Frothy foam in the airway, noisy chest, bilateral crackles and wheeze, cool clammy skin, no signs of trauma |
| Initial equipment | Pediatric manikin, monitor, defibrillator pads, pediatric airway cart, capnography, warming equipment, PALS algorithm |
Case progression
| State | Patient status | Expected learner actions | Triggers and modifiers |
|---|---|---|---|
| Baseline post-submersion respiratory distress | Sinus rhythm, HR 150, BP 85/40, RR 38, SpO2 90% with BVM, T 34 C, GCS E1V2M5 | IV access, monitors, glucose, pediatric crash cart, core temperature, active warming, high-flow oxygen or BiPAP, labs, chest X-ray, PICU/ECMO help, bronchodilators if bronchospasm is recognized | Positive pressure improves SpO2 to about 93%. Progress when the team decides to intubate. |
| Definitive airway | HR 150, BP 85/40, RR 38, SpO2 94% with BVM, T 36 C, GCS E1V2M5 | Preoxygenate with good seal and 100% FiO2, recognize difficult airway with foam, communicate airway plan, use weight-based tube and medications, confirm with EtCO2 and chest X-ray, order post-intubation sedation | Inadequate preoxygenation drops SpO2 rapidly. Regardless of first-pass setup, SpO2 falls to 80% after intubation. |
| Post-intubation hypoxemia | HR 150, BP 85/40, RR 25 ventilated, SpO2 80% improving to 85%, sedated | Confirm 100% FiO2, verify ETT position, suction tube, assess obstruction, pneumothorax, bronchospasm, disconnect from ventilator and bag, adjust PEEP, deepen sedation or paralysis, repeat gas and CXR, decompress stomach | Secretions through ETT improve SpO2 to 87%. Manual BVM, bronchodilators, higher PEEP, and deeper sedation improve saturations. |
| Bradycardia with poor perfusion | HR 50, BP 85/40, RR 25 ventilated, SpO2 88% on 100% FiO2, sedated | Recognize pediatric bradycardia with poor perfusion, start CPR for HR less than 60, give PALS epinephrine 0.01 mg/kg IV, consider atropine 0.02 mg/kg, call PICU and code ECMO | At the first pulse check after CPR, HR increases to 100 and the consulting team arrives. |
Design choices
The airway foam is a deliberate cue. It signals drowning physiology, but the facilitator should not let learners spend the case suctioning indefinitely. Positive pressure ventilation improves the airway view, while persistent suctioning produces more foam and delays the real work.
The progression also creates a post-intubation fixation trap. The debrief can explore whether the team used a shared approach such as DOTTSS: disconnect, oxygen, tube, tweak the ventilator, sonography, squeeze, and sedation/paralysis.
Debrief focus
Use the debrief to connect clinical management with crisis resource management:
- How did the leader assign roles and build a shared mental model around a sick child?
- What made the team decide to intubate, and how did it prepare for pediatric airway risk?
- How did the team approach post-intubation hypoxemia?
- Did the team recognize pediatric bradycardia with poor perfusion as an arrest-adjacent emergency?
- When did the team call PICU, ECMO, or other consultants, and what information did they communicate?
Shared mental model language is central. Ask what the leader summarized, what the team heard, and how the plan changed as hypoxemia persisted.
Facilitator notes
The complete DOCX includes laboratory results, references, room setup, medication and airway sizing reminders, and expanded facilitator debriefing prompts. The source case also includes focused teaching material on drowning physiology, surfactant washout, laryngospasm, negative pressure pulmonary edema, lung-protective ventilation, post-intubation hypoxemia troubleshooting, and ECLS referral.
Source materials
- Original case: EM Sim Cases - Pediatric Drowning
- The provided case packet cites pediatric submersion literature, PALS guidance, BC Children’s ECLS guidance, ELSO resources, and hypoxemia troubleshooting references.