# A 6-year-old child is brought to the emergency department after being found unresponsive in a bathtub. The child was submerged for approximately 2 minutes before being rescued. Upon arrival, the child is conscious but lethargic, with shallow respirations and oxygen saturation of 88% on room air. What is the priority nursing intervention?

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> subject: Child Health

## 문제

A 6-year-old child is brought to the emergency department after being found unresponsive in a bathtub. The child was submerged for approximately 2 minutes before being rescued. Upon arrival, the child is conscious but lethargic, with shallow respirations and oxygen saturation of 88% on room air. What is the priority nursing intervention?

Emergency management of pediatric submersion injury with respiratory compromise

## 보기

1. Administer high-flow oxygen via non-rebreather mask at 15 L/min
2. Prepare for endotracheal intubation and mechanical ventilation **✔ 정답**
3. Position the child in Trendelenburg position to promote drainage
4. Initiate continuous cardiac monitoring and obtain arterial blood gases

**정답: 2**

## 해설

Endotracheal intubation is priority for severe hypoxemia (SpO2 88%) and altered mental status to secure airway and provide mechanical ventilation. Other interventions are important but less immediate.

## 심화 해설

Clinical Reasoning and Priority Setting

The child presents with a classic submersion injury pattern: respiratory impairment following liquid aspiration. The primary pathophysiological event in drowning is asphyxia, leading to hypoxemia and subsequent organ dysfunction. The reported oxygen saturation of 88% on room air, coupled with shallow respirations and lethargy, indicates significant hypoxemic respiratory failure. In pediatric cardiac arrest, the etiology is overwhelmingly asphyxial rather than a primary cardiac event, making immediate reversal of hypoxia the single most critical determinant of survival and neurological outcome [1].

While administering high-flow oxygen via a non-rebreather mask (Option 1) is an initial step, this child's clinical picture—lethargy, shallow respirations, and severe hypoxemia—signals impending or actual ventilatory failure. A non-rebreather mask is a passive oxygen delivery system; it does not support ventilation in a patient with a depressed respiratory drive or inadequate tidal volume. Relying on this modality risks progressive hypercapnia, worsening acidosis, and respiratory arrest. The definitive intervention for a patient who cannot maintain a patent airway or adequate ventilation is definitive airway management. Preparing for endotracheal intubation and mechanical ventilation (Option 2) directly addresses the core problem by securing the airway, enabling delivery of high concentrations of oxygen, and providing positive pressure ventilation to overcome the intrapulmonary shunting and decreased lung compliance caused by drowning-associated lung injury [4].

The Trendelenburg position (Option 3) is contraindicated. This position was historically, and incorrectly, thought to drain water from the lungs. In reality, aspirated water is rapidly absorbed into the pulmonary circulation, and the primary injury is surfactant washout and alveolar-capillary membrane damage, not a volume of free fluid in the airways. Placing a patient with respiratory compromise in Trendelenburg can worsen ventilation by pushing abdominal contents against the diaphragm and may increase intracranial pressure, which is dangerous in a setting of potential hypoxic brain injury.

Initiating continuous cardiac monitoring and obtaining arterial blood gases (Option 4) are important components of ongoing care, but they are diagnostic and monitoring interventions, not the priority therapeutic action. The immediate threat to life is uncorrected hypoxemia. While monitoring for arrhythmias is crucial, as hypothermia and hypoxia can precipitate events like ventricular fibrillation , the most effective way to prevent such arrhythmias is to first correct the underlying hypoxia with a secure airway and effective ventilation. The sequence of care in the primary survey always prioritizes airway and breathing intervention before detailed diagnostics.References (research sources)

- [1]2025 Korean Guidelines for Cardiopulmonary Resuscitation: Part 7. Pediatric basic life support.GuidelineLee J, Kim DK, Kim JT, Na JY, Park B, Jeong SI, Park JD, Chung SP, Kim TY, Sohn Y, Shim G, Jung YH, Oh Y, Youn CS, Lee MJ, Lee CH, Jang Y, Jang YS, Cho GC, Cha KC, Heo JS, Hwang SO. (2026) · DOI: 10.15441/ceem.26.150

- [4]Early Prone Positioning in Three Pediatric Cases of Post-drowning Acute Respiratory Failure: A Case Series of Short-Term Changes in Oxygenation and Respiratory System Compliance.Case reportGotou T, Hagihara T, Wada Y, Hashimoto K, Nagashima F. (2026) · DOI: 10.7759/cureus.102778

## 임상 시나리오

Pediatric Submersion Injury: Airway PriorityRecognizing Ventilatory Failure in Drowning
The primary insult in drowning is asphyxia, leading to hypoxemia. In a lethargic child with an SpO2 of 88% and shallow respirations, this is not just hypoxemia but ventilatory failure.

A non-rebreather mask delivers oxygen but provides no ventilatory support. For a patient with a depressed respiratory drive, immediate endotracheal intubation and positive pressure ventilation are required to reverse hypoxia and prevent cardiac arrest.

CautionNever place a submersion victim in the Trendelenburg position; it increases intracranial pressure and aspiration risk. Airway and breathing interventions always precede detailed diagnostics like ABGs.

## 핵심 개념

- **Asphyxia** — A condition of severely deficient oxygen supply to the body that arises from abnormal breathing, the primary event in drowning.
- **Hypoxemic Respiratory Failure** — A state where the lungs cannot adequately oxygenate the blood, typically defined as PaO2 < 60 mmHg or SpO2 < 90% on room air.
- **Non-rebreather Mask** — A passive oxygen delivery device that provides high concentrations of oxygen but does not support ventilation or protect the airway.
- **Ventilatory Failure** — The inability to maintain adequate alveolar ventilation, leading to hypercapnia, signaled by lethargy and shallow respirations.

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