Environmental

Near-drowning with aspiration and hypothermia

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Adult · 35yr · male

Patient Information

Dispatch	You are called to the lake foreshore at the Whiteman Park Summer Splash Festival. A 35YO male (Callum Reid) has been pulled from the lake by bystanders after failing to resurface during a swim race. Bystanders report he was in the water for approximately 8–10 minutes.
Patient	Callum Reid — 35yr (80kg)
Incident History	Pt was participating in an open-water swim race in the park lake when he failed to resurface. Bystanders pulled him from the water unresponsive. One bystander commenced CPR. Unknown time of initial submersion. Lake water is known to be used for recreational activities — untreated, potentially contaminated.
Emergency Contact	Sarah Reid (Wife) — 0412 384 971

Initial Rapid Assessment

Response	Pain
Airway	Partially compromised. Frothy, discoloured water and secretions visible in oropharynx. Gurgling audible on inspiration. No foreign body. Jaw relaxed — OPA insertion appropriate.
Breathing	Present but inadequate. Shallow, irregular, laboured. Accessory muscle use. Audible coarse crackles. RR approximately 8 in 30 seconds. SpO2 82% on room air.
Circulation	Weak, rapid central pulse palpable. Radial pulse faint. Skin cold, pale, mottled peripherally. CRT 4 seconds. No external haemorrhage.
Disability	GCS 9 (E2V2M5). Not orientated to time, place, or person. Eyes open only to pain. Confused moaning. Localises to pain.
Exposure	Shivering absent despite cool ambient temperature — concerning for moderate-to-severe hypothermia. Skin cold to touch across torso and limbs. No external trauma identified. Wearing swim shorts only. Lips cyanosed.

Vitals

Time	SpO2	Resp Dist	RR	Pulse	BP	CRT	GCS	PERL	Temp	BGL	Pain
Initial	82% (RA)	Severe	8	52	88/60	4s	9	3 3 SL	32.1	4.8 mmol/L	–
10 mins	94% (O2 NRB 15L)	Moderate	14	60	98/64	3s	12	3 3 ++	32.4	4.8 mmol/L	–

History Taking

Treatment Response

Diagnosis

This patient is suffering from near-drowning (immersion injury) with aspiration of contaminated lake water causing severe hypoxia and respiratory compromise, complicated by moderate hypothermia secondary to prolonged submersion in cool water.

Facilitator Triggers — if trainees miss a critical step

! (If suction is not performed within 2 minutes of arrival, the patient begins to vomit — facilitator describes gurgling worsening and SpO2 dropping to 78% — trainee must immediately laterally position patient and suction oropharynx.)
! (If oxygen is not applied within 3 minutes, SpO2 remains at 82% and GCS drops to 7 — trainee must apply NRB mask at 15L/min and consider BVM-assisted ventilation.)
! (If hypothermia is not identified and active warming not initiated by 5 minutes, facilitator reports patient develops muscle rigidity and heart rate drops to 44 bpm — trainee must remove wet clothing, wrap in Ready-Heat blanket over sheet, and raise concern for moderate hypothermia and associated arrhythmia risk.)
! (If the contaminated water aspiration risk is not noted in handover or documented, facilitator prompts: 'The receiving facility asks — what type of water did the patient aspirate?' — trainee should be able to state open lake, potentially contaminated, untreated water, relevant to delayed pulmonary and infectious complications.)
! (If BVM ventilation is not commenced despite RR of 8 and SpO2 remaining below 90% on high-flow oxygen, facilitator states patient becomes increasingly cyanosed — trainee must initiate assisted ventilations via BVM at appropriate rate, not exceeding 10 breaths per minute, ensuring minimal chest rise only.)

Treatment Objectives

1. Ensure scene safety — confirm patient has been removed from water and is on a dry, firm surface away from lake edge.
2. Don appropriate PPE — note potential exposure to contaminated water (blood/body fluid and waterborne pathogen risk).
3. Perform Primary Survey — C-spine consideration low given witnessed atraumatic submersion with no mechanism for spinal injury, but use clinical judgement.
4. Open airway — use jaw thrust or triple airway manoeuvre; insert appropriately sized OPA to maintain patent airway.
5. Suction oropharynx using Yankauer/Ducanto catheter — clear frothy secretions and water visible in oropharynx, suction for maximum 5 seconds at a time.
6. Laterally position patient to facilitate drainage of secretions if airway management allows — or maintain supine with head turned if spinal concern.
7. Apply high-flow oxygen via Non-Rebreather Mask at 10–15 L/min — target SpO2 94–98%.
8. Assess adequacy of breathing — RR 8, shallow and irregular with SpO2 82% indicates inadequate spontaneous ventilation; commence BVM-assisted ventilations to supplement respiratory effort, timed with spontaneous breaths, at no more than 10 breaths/min.
9. Obtain full Vital Sign Survey — GCS, SpO2, RR, BP, HR, CRT, BGL, temperature (tympanic — note may underestimate core temperature in hypothermia).
10. Identify hypothermia — tympanic temperature 32.1°C indicates moderate hypothermia; note absence of shivering is an ominous sign at this temperature.
11. Remove all wet clothing immediately to stop ongoing heat loss.
12. Apply Ready-Heat blanket over dry sheet to begin passive and active rewarming — do NOT apply directly to skin.
13. Handle patient gently — avoid sudden movement or jarring which may precipitate ventricular arrhythmia in moderate hypothermia.
14. Reassess GCS and SpO2 every 5 minutes — record full observations every 5 minutes given time-critical status.
15. Monitor for cardiac arrest — defibrillator and CPR equipment to be at hand given hypothermia and hypoxia arrhythmia risk.
16. Note contaminated water aspiration for IMISTAMBO handover — open lake water, untreated, potentially contaminated, risk of delayed pneumonia and waterborne infection.
17. Reassure wife (Sarah Reid) on scene and obtain further history including allergies and medications.
18. Prepare for Priority 1 transport — pre-notify receiving ED with IMISTAMBO including: near-drowning, approximately 8–10 minutes submersion, aspiration of contaminated lake water, moderate hypothermia 32.1°C, GCS 9, SpO2 82% on RA improving to 94% on NRB, assisted ventilations commenced.
19. Scenario ends on arrival of ambulance and IMISTAMBO handover.
20. Attention to hand hygiene will be given throughout the scenario.

Clinical references: Immersion · Hypothermia · Bag Valve Mask Ventilation · Suction · Oropharyngeal Airway · Oxygen Delivery · Lateral Position · Ready Heat Blanket · Primary Survey

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Signs/Symptoms	Unresponsive on retrieval from water. Gurgling respirations. Cold to touch across entire body. Shivering absent. Cyanosed lips. Frothy secretions from mouth.
Allergies	NKDA — confirmed by wife on scene.
Medications	Nil regular medications — confirmed by wife.
Pertinent History	Fit and healthy. Recreational swimmer. No known cardiac or respiratory conditions. No prior submersion events. Non-smoker. No alcohol consumed today per wife.
Last Oral Intake	Sandwich and water approximately 2 hours prior to event.
Events Leading	Pt was competing in a 400m open-water swim race in Whiteman Park lake. Witnessed by other competitors to go under approximately halfway through the race and fail to resurface. Bystanders and race marshals entered water to retrieve him.
Treatment Prior	Bystander CPR commenced approximately 2 minutes after retrieval from water and ceased when patient began breathing. No airway adjuncts or oxygen applied prior to EHS arrival.

Onset	Acute. Approximately 8–10 minutes of submersion in open lake water prior to bystander retrieval.
Pain	Unable to fully assess due to altered GCS. No withdrawal to limb palpation.
Quality	N/A — patient unable to verbalise.
Radiates	Nil
Severity	Unable to assess — GCS 9.