After achieving return of spontaneous circulation (ROSC) in a 3-year-old drowning case, with SpO₂ at 90% on BVM 100% O₂, what is the next step?

Upon achieving return of spontaneous circulation (ROSC) in a pediatric patient, particularly following a drowning incident, it is crucial to assess the airway and breathing effectiveness. The oxygen saturation (SpO₂) level being at 90% on bag-valve-mask (BVM) ventilation with 100% oxygen indicates that despite the use of supplemental oxygen, the patient is not maintaining optimal oxygenation. This can be due to several factors, including airway obstruction, secretions in the airway, or lung injury from water aspiration.

Suctioning is an important intervention to clear the airway of any residual fluids, vomitus, or secretions that might be impairing the patient's ability to oxygenate adequately. Following suctioning, proper positioning can help facilitate breathing and improve oxygen saturation. In pediatric patients, positioning also plays a crucial role in enhancing airway patency and reducing the risk of further complications.

The other options, while they have their indications in various scenarios, do not address the immediate need to ensure a clear and patent airway for this specific case. For example, CPAP might be indicated in cases of respiratory distress with ongoing obstructive patterns but would not directly address acute airway clearance needs. Intubation may be warranted if the patient's condition does not improve;