((If airway is not suctioned within the first 60 seconds and patient repositioned laterally — patient vomits again and SpO2 drops to 78%. Prompt trainees: 'What is your immediate airway priority?'))

((If high-flow oxygen via NRB mask is not applied within 2 minutes — SpO2 remains at 84% and RR increases to 34. Prompt trainees: 'What does this child need urgently?'))

((If wet clothing is not removed and passive warming not commenced within 5 minutes — temperature drops to 33.8°C and HR increases to 130. Prompt trainees: 'What environmental factors are contributing to this child's deterioration?'))

((If BGL is not checked — facilitator prompts: 'The child has a history of limited oral intake. What baseline assessment are you missing?' — BGL is 3.8 mmol/L, borderline for an active child, monitor trend.))

((If hypothermia is not recognised and warm measures not applied — at 10 minutes temp remains 34.2°C, GCS does not improve beyond 9 and HR remains elevated at 118. Facilitator states: 'Despite oxygen, the child is not improving as expected. What else could be contributing?'))

((If trainee attempts to administer Glucose Oral Gel with BGL of 3.8 mmol/L — redirect: 'The CPG threshold for glucose gel is below 4 mmol/L — is this patient symptomatic and is the BGL below threshold? What does your CPG state?'))

((If spinal precautions are not considered given the mechanism — facilitator prompts: 'The patient fell from a height into water. What does your immersion CPG say about spinal injury consideration?'))

((If patient's conscious state improves to GCS 14 and trainee considers removing oxygen — redirect: 'Consciousness is not synonymous with recovery in immersion patients. What does your CPG note about delayed deterioration?'))

This patient is suffering from near-drowning (immersion injury) complicated by mild to moderate hypothermia (core temp 34.2°C) and risk of waterborne illness from aspiration of contaminated lake water.

• Ensure scene safety — confirm patient is away from water's edge and on a flat dry surface.
• Don appropriate PPE including gloves — high risk of body fluid exposure and potential contaminated water contact.
• Perform Primary Survey — simultaneously direct bystanders to clear area and summon ambulance via 000.
• Airway: Place patient in lateral position (left lateral) immediately to facilitate drainage of vomitus and water from oropharynx.
• Airway: Suction oropharynx using Yankauer/Ducanto catheter — maximum 5 seconds per pass — until airway is visibly clear.
• Airway: Insert appropriately sized OPA (measure centre of lips to angle of mandible) — given GCS 9, patient is unlikely to tolerate but assess tolerance; if intolerant, insert NPA instead (measure corner of nose to earlobe, lubricate, advance along right nostril with bevel toward septum).
• Breathing: Apply oxygen via Non-Rebreather Mask at 10–15 L/min — titrate to target SpO2 ≥94% in paediatric patient.
• Breathing: Assist ventilations with BVM if respiratory effort becomes inadequate (rate <10 or SpO2 not responding to high-flow O2) — ventilate at age-appropriate rate of 20–25 breaths per minute, gentle tidal volume to visible chest rise only.
• Circulation: Assess central pulse (carotid or brachial) — if absent at any time, commence CPR as per Paediatric Cardiac Arrest CPG (15:2 ratio, 100–120/min, depth ~5cm, use CPR feedback device if available, defibrillate shockable rhythms at 4 J/kg via paediatric pads).
• Disability: Perform GCS — document E2V2M5 = GCS 9. Assess pupils: 3mm bilaterally, reactive to light.
• Exposure: Remove ALL wet clothing immediately to arrest heat loss — this is a critical step in hypothermia management.
• Hypothermia management: Dry the patient thoroughly with towels or blankets. Passively re-warm using dry blankets and ambulance heater if available. Do NOT apply Ready-Heat blanket directly to skin — place sheet between blanket and patient. Keep patient off cold ground — use stretcher or improvised insulation.
• BGL assessment: Perform blood glucose test — result 3.8 mmol/L. This is borderline; monitor trend. Do not administer Glucose Oral Gel as BGL is above 4 mmol/L treatment threshold and patient has reduced conscious state (GCS 9) — risk of airway obstruction.
• Temperature: Obtain tympanic temperature — 34.2°C. Recognise mild hypothermia (32–35°C). Note tympanic readings may be unreliable in hypothermia extremes — use as a guide only.
• Spinal precautions: Consider spinal immobilisation given mechanism (fall from height into water with submersion). If spinal injury cannot be excluded — apply Lateral Trauma Position maintaining spinal alignment rather than standard lateral position. Apply C-spine collar if clinically indicated and tolerated.
• Contaminated water consideration: Document that aspiration of lake water of unknown microbiological quality has occurred. Advise receiving ED at handover — this is clinically relevant for downstream antibiotic and infection monitoring decisions. Do not delay transport for this.
• Monitoring: Record full observations every 5 minutes given time-critical status. Monitor SpO2 persistently. Reassess GCS, temperature, and BGL at 10-minute mark.
• Transport: This is a Priority 1 paediatric immersion patient — do not delay transport. Active resuscitation and monitoring must continue en route. Pre-notify receiving ED with patient age, weight, submersion duration, water source, current GCS and temperature.
• Scenario ends on arrival of ambulance and IMISTAMBO handover.
• Attention to hand hygiene will be given throughout the scenario.

Clinical references: Immersion · Hypothermia · Cardiac Arrest - Paediatric · Oxygen · Oropharyngeal Airway · Nasopharyngeal Airway · Suction · Lateral Position · Lateral Trauma Position · Bag Valve Mask Ventilation · Blood Glucose Monitor · Tympanic Thermometer · C-Spine Collar · Spinal Immobilisation · Ready Heat Blanket