Pediatric Case StudiesPediatric Case Studies

Jana A. Stockwell, MD, FAAPPediatric Critical Care Medicine

Children’s Healthcare of Atlanta @Egleston

Atlanta, Georgiajana.stockwell@CHOA.org

Case #1

• He is sleeping but arouses to stimulation.

• Vital signs: T 39.2ºC, HR 220, RR 55, BP 75/40, SpO2 99% on 2L NC, CR ~4 sec

• You receive a 4 month old male from another ER who is suffering from respiratory distress

• His CXR is read as “no infiltrate”

Case #1

Shortly after arriving on the ward, the child develops difficulty breathing and an elevated heart rate. The rhythm strip is shown below...

Case #1

How fast is the heart beating?

Use the 300-150-75 rule

300 150

Start here and count

boxes

So, a little less than 300 bpm!!!

Case #1

• What should you do next?

• Determine if the child is clinically stable

or unstable

SupraVentricular Tachycardia

You suspect SVT...

HOW?

Case #1

• In SVT, if the child is clinically stable, try: Inducing the Dive Reflex by applying an

ice bag to the face Bearing down (i.e. Valsalva maneuver) Eyeball pressure & carotid massage, may

be harmful and are discouraged

Case #1

• You suspect SVT

& the child is clinically unstable…

Place an IV

Give IV bolus of ADENOSINE

Very short t (10 sec) & must be given rapidly

Continuous rhythm strip during attempted conversion

Potential side effects include hypotension, bronchospasm, and

flushing

Be prepared to see a flat line EKG!

Case #1

• You suspect SVT…

& the child is very clinically

unstable…

If an IV cannot be started quickly OR

If the patient fails to convert with IV adenosine

OR

Patient becomes unconscious or unresponsive

Then, cardiovert using 0.5 - 1 joule/kg

Case #1 Summary

• Things are not always what they are advertised to be

• Be aware that multiple therapies may be available and choice depends upon clinical situation

Case #2

• You are admitting a 6 year old male with no significant past medical history who presented at an outlying physician’s office with a decreased level of consciousness. He has been having massive amounts of emesis and diarrhea.

• VS: T 38.2ºC, HR 150, RR 28, BP 70/30, SpO2 97% on Room Air

• There is good air exchange in all lung fields, peripheral pulses are 1+, central pulses are 1+, the CR is ~4 sec

Case #2

What is wrong with this child?

This child is in uncompensated shock, most likely from hypovolemia

What is the first logical step in management of this child?

Crystalloid (NS, LR) at 20 cc/kg bolus

Case #2

• After giving 20 cc/kg of NS, what should be done? Re-assess the child’s clinical status

Check pulses and heart rateCheck blood pressureEvaluate capillary refill timeEvaluate mental statusAuscultate chest to determine if heart can

handle volume load -- rales, gallop

Case #2

• VS: HR 150, RR 32, BP 70/50, SpO2 97% on RA

• There is good air exchange in all lung fields, peripheral pulses are 1+, central pulses are 1+, the CR is ~ 4 sec

• Now that the BP has improved, is this child still in shock?

Yes, the child is in uncompensated shock!!

Repeat the NS bolus at 20 cc/kg

What should you do now?

Case #2

• VS: HR 140, RR 30, BP 90/60, SpO2 97% on RA. There is good air exchange in all lung fields, peripheral pulses are 2+, central pulses are 2+, the CR is ~3 sec

• Now that the BP has improved, is this child still in shock?

Yes, it is now compensated shock

Repeat the NS bolus at 10-20 cc/kg

What should you do now?

Case #2

• The child’s VS are HR 100, RR 22, BP 98/65, SpO2 94% on RA. There is good air exchange in all lung fields, peripheral pulses are 2+, central pulses are 2+, the CR is < 2 sec

• Now that the VS have improved, is this child still in shock? No. The fluid resuscitation has brought this

child out of hypovolemic shock

Case #2 Summary

• When the tank is low, it may take a lot of fluid to fill it back up!

• Remember, being 10% dehydrated means 10% of the body weight is lost due to fluid ouput/poor intake

Case #3

• You are transporting a 13 year old male who presented to an outlying ER with nausea and bilious vomiting. He has a past history of BMT for CML. He also has a history of recurrent bowel obstructions.

• In the ER, VS are T 35.7ºC, HR 110, RR 32, BP 90/45, SpO2 98% on RA. His extremities are warm and well perfused.

Case #3

• During transport, the child begins to speak in incomprehensible sentences.

• VS: T36.8ºC, P 162, RR 38, BP 70/42, SpO2 95% on RA, he is having rigors.

• What should be done next?

This child is in uncompensated shock. He should receive 20 cc/kg of crystalloid

Case #3

• After receiving a total of three 20 cc/kg boluses of crystalloid, the child remains hypotensive.

• What should be the next course of action?

Pharmacological support of his BP

Case #3

• Dopamine added What dose should you start? You titrate the dose to 12 mcg/kg/min and the

child is still hypotensive...

• What exam findings are important in guiding therapy at this time? Capillary refill time Tactile temperature of the extremities Mental status Peripheral and central pulses

Case #3

• What are the clinical features of “warm” vs. “cold” septic shock?

Warm Cold

CR time Brisk Prolonged

Warm Cool

Nml/activity Nml/activity

Bounding Nml/Thready

Skin temp

Precordiu

mPulses

Case #3

• How do these findings guide the next phase of therapy? In warm septic shock, the underlying

problem is decreased SVR, therefore an agent with mostly vasopressor activity should be started (i.e. norepinephrine)

In cold septic shock, the underlying problem is decreased CO, therefore an agent with inotropic activity and/or afterload reduction should be started (i.e. epinephrine, milrinone, nipride)

Case #3 Summary

• The stage of shock will determine which drugs are most appropriate for resuscitation -- the list of choices is long

dopaminedobutamine

milrinone

epinephrine

nipride

neosynephrine norepinephrine

Case #4

• You are transporting a 4 year old male who fell out of a 4th story window. His head CT reveals small contusions. He is in a C-collar.

• VS: HR 65, RR 20, BP 60/30, SpO2 98% on RA, CR ~4 sec. His neck films are shown.

Case #4

Case #4

• Recognizing the hypotension, a medic has already administered three boluses of NS at 20 cc/kg, but the child remains hypotensive.

• Repeat VS: HR 55, RR 25, BP 65/30, SpO2 98% on RA, CR ~4 sec.

• What is unique about these vital signs? There is no compensatory tachycardia for

the hypotension

• What does this suggest? The child may have neurogenic shock

Case #4

• What is neurogenic shock? It is a condition characterized by loss of

sympathetic tone to the peripheral vascular bed and to the heart

• What is the hallmark of this type of shock? There is marked hypotension without

compensatory tachycardia following a CNS injury

Case #4

How does this occur?

A lesion occurs in the cervical

region of the spinal cord

This cuts off the connection

between the heart and the brain

Now the brain cannot

control the heart and the

heart functions

independently from the

rest of the circulation

Case #4

• How is this treated? The use of pure -agonist (e.g.

neosynepherine) agents is preferred

Case #4 Summary

• Not all shock secondary to trauma is due to blood loss!

Case #5

• You are working on Transport, when a 16 year old male, who was riding a motorcycle when he lost control, flipped, and smashed into a guard rail, is brought in to a referring ED. He was wearing a helmet.

• He was found to have a multiple rib fractures an and underlying hemothorax.

• His chest x-ray is as follows.

Case #5

• Prior to transport, the child has been intubated for respiratory distress and altered mental status.

• A left chest tube has been placed. CT’s of the head, chest, abdomen, and pelvis are negative for additional pathology.

• VS: T 38.2ºC, HR 108, RR 20, BP 90/60, SpO2 98%.

• He is currently intubated, sedated, and paralyzed. He is stable and he is loaded onto the ambulance for transport.

Case #5

• During transport, the child becomes progressively tachycardic. What do you do now? Check all vitals and perform quick, focused

clinical exam accessing airway, breathing, and circulation

You determine that there is no immediately life-threatening cause of the tachycardia and suspect pain and under sedation for which you administer fentanyl and lorazepam.

Case #5

• Now the teenager’s pulse is 185 and he is becoming hypotensive to 50/20. You check the pupils because heart rate and BP changes are part of Cushing’s Triad. What is Cushing’s Triad? Bradycardia Hypertension Altered respirations

Case #5

• This is not Cushing’s Triad what else could it be? Your quick physical examination finds the following: Neck vein distension Tachycardia with decreased heart sounds Hypotension Thready pulses

Case #5

• What is happening?Cardiac tamponade

• How is this treated? 20 cc/kg fluid push Emergent pericardiocentesis

Removal of even a small volume of fluid is the definitive treatment & can rapidly improve BP & cardiac output -- may ultimately prove to be lifesaving

Cardiac

tamponade occurs

when blood or

other fluid

accumulates in

the pericardial

space. This

creates increased

pressure around

the heart and

interferes with

heart function.

Case #5

• What are the signs of cardiac tamponade? Tachycardia Hypotension JVD Decreased cardiac output Pulsus paradoxus - >10 mmHg change

between inspiratory and expiratory systolic BP

Narrow pulse pressure Muffled heart tones

“Blind” Pericardiocentesis - Technique

• Subxiphoid Approach

• Position the patient so the chest is at a 30-degree angle

• Insert an 18-gauge spinal needle attached to a 20-ml syringe into the left xiphocostal angle perpendicular to the skin and 3 to 4 mm below the left costal margin

• While aspirating constantly, advance the needle directly into the inner aspect of the rib cage

“Blind” Pericardiocentesis - Technique

• Depress the needle so the needle points toward the left shoulder

• Using a slow, cautious, turning action of the fingers, advance the needle until fluid is aspirated

• Observe the cardiac monitor for arrhythmias

• Successful removal of fluid confirms the needle's position

“Blind” Pericardiocentesis - Complications

• Laceration of a coronary artery

• Laceration or perforation of either ventricle

• Laceration or perforation of the right atrium

• Perforation of the stomach or colon

• Pneumothorax

• Arrhythmias

• Tamponade

• Hypotension (perhaps reflexogenic)

Case #6

• Your 3 y.o. patient’s mother calls out that something is wrong.

• You find the child lying on the bed with his right arm in extension with his hand twitching & his eyes dancing horizontally. Mom states that she has been trying to arouse the child without success.

• VS: T 39.2ºC, HR 180, BP 110/70, RR 38 and irregular, SpO2 82% on room air.

Case #6

• What is your first impression of this situation? Child with …

Complex focal seizureHypoxic respiratory distressTachycardiaFever

Case #6

• What are the first things you should assess? Airway

Breathing

Circulation

Appears patent

Ineffective, child is cyanotic

Child is tachycardic with good pulses & brisk capillary refill time

Case #6

• Does this child need intubation?

Not at this time. While the child is

hypoxic, repositioning and oxygen by

face mask can improve oxygenation.

Additionally, treatment of the child’s

seizures may restore regular respirations

and improve the oxygenation status.

Case #6

• What medications should be given and by which routes? Diazepam (Valium): onset in 2-10 minutes

Rectal gel (Diastat)– Infants <6 months: Not recommended

– Children <2 years: Not been studied

– Children 2-5 years: 0.5 mg/kg

– Children 6-11 years: 0.3 mg/kg

– Children 12 years and Adults: 0.2 mg/kg

– Round doses to nearest 2.5, 5, 10, 15, and 20 mg/dose

Case #6

• What medications should be given and by which routes? Lorazepam (Ativan): onset in 2-5

minutesNeonates: 0.05 mg/kg IV/IMInfants, Children, and Adolescents: 0.1 mg/kg

(max 4 mg) IV/IMMay repeat up to 3 times before considering

a non-benzodiazepine agent

Case #6

• What medications should you consider if the first line agents fail to control the seizures? Phenobarbital Phenytoin (Dilantin)

Fosphenytoin if peripheral IV questionable

Case #6

• The child stops twitching after lorazepam is given. His respirations are shallow & his SpO2 in 100% on NRB FM at FiO2 1.0

• What reflexes should be evaluated to see if this child requires intubation? Gag to evaluate airway protection.

Case #7

• You are working in the ER when a 13 year old unresponsive female is brought in.

• Her little brother states the girl has been sick all day. She was really thirsty having consumed four 2 liter bottles of Coke in the last 8 hours.

• VS: T 36ºC, HR 165, BP 80/palp RR 25 and very deep, SpO2 99% on room air.

Case #7

• A: abuse or alcohol

• E: encephalopathy or endocrine

• I: insulin/hypoglycemia/ metabolic disorder

• O: opiates

• U: uremia

• T: trauma/ tumor

• I: infection/

intussusception

• P: poisoning

• S: sepsis/ seizure/ shock

What is the differential diagnosis? "AEIOU - TIPS”

Case #7

• D: dehydration

• P: poisoning

• T: trauma

• O: occult trauma

• P: post-ictal or post-anxoia

• V:VP shunt infection

• H: hypoxia/ hyperthermia

• I: intussusception

• B: brain mass

• M: meningitis

• M: metabolic

• R: Reye’s syndrome

What is the differential diagnosis? “DPT - OPV - HIB - MMR”

Case #7

• The sibling states that she takes

injections in her leg. What is the most

likely diagnosis?

Diabetic ketoacidosis

Case #7

• You check a blood gas which demonstrates … pH 6.91, PaCO2 23, PaO2 80, SaO2 98%,

base deficit -27 Na+ 133, K+ 6.5, Glucose ***, iCa++ 4.5

mg/dL

Case #7

• Should you give NaHCO3 to correct

the acidosis?

No. NaHCO3 should only be given in the setting

of cardiovascular dysfunction, i.e. arrhythmias.

Its use has been associated with the

development of cerebral edema in patients wth

DKA.

(N Engl J Med 2001;344:264-9)pH 6.91, PaCO2 23, PaO2 80, SaO2 98%, base deficit -27

Na 133, K 6.5, Glucose ***, iCa 4.5 mg/dL

Case #7

• Why is the K+ elevated? Elevated serum hydrogen ion is counter-

transported across the RBC membrane with potassium in an effort to buffer the acidosis

pH 6.91, PaCO2 23, PaO2 80, SaO2 98%, base deficit -

27

Na 133, K 6.5, Glucose ***, iCa 4.5 mg/dL

Case #7

• Why is Na+ low? The hyperosmolality of diabetes attracts

more water into the intravascular space. This causes a “ficticious hyponatremia”.

pH 6.91, PaCO2 23, PaO2 80, SaO2 98%, base deficit -

27

Na 133, K 6.5, Glucose ***, iCa 4.5 mg/dL

Case #7

• What IVF should be given and how much? 0.9% NaCl at 20 cc/kg unless in

uncompensated shock. Excess IVF has been associated with cerebral edema. (4 liters/M2)

pH 6.91, PaCO2 23, PaO2 80, SaO2 98%, base deficit -

27

Na 133, K 6.5, Glucose ***, iCa 4.5 mg/dL

Case #8

• You are admitting a 6 year old male who is coughing uncontrollably.

• VS: T 37.2ºC, HR 140, RR 40, SpO2 85% on room air.

• He has nasal flaring, supra-sternal, intercostal, and subcostal retractions.

• By auscultation, you hear expiratory wheezes bilaterally with a prolonged expiratory time.

Case #8

• What is this child’s problem?

Asthma is a chronic inflammatory

pulmonary disorder that is

characterized by reversible obstruction

of the airways

Acute exacerbation of asthma

Case #8

• What is the 1st step in treatment? Provide oxygen

• What is the next step? Provide nebulized bronchodilators

Case #8

• How would the diagnosis change if the child had a right-sided, wheeze heard best on inspiration, with decreased air exchange on the right side, and tracheal deviation to the left? This would suggest the presence of a

foreign body. Remember, all that wheezes is not

asthma!

Case #8

• Physical examination of the child reveals a palpable liver edge 5 cm below the right costal margin. Why is this? Hyperinflation related to obstructive

airway disease in asthma has pushed the liver inferiorly into the abdomen.

Case #8

• What agents are used in the treatment of asthma and why? -agonist agents

Increase cAMP which leads to decreased intracellular calcium and smooth muscle relaxation.

Albuterol nebs or MDI, terbutaline nebs or SQ, epinephrine SQ

Case #8

Agents… Anticholinergic agents

Inhibit the acetylcholine receptor thereby decreasing the intracellular cGMP which leads to decreased intracellular calcium and smooth muscle relaxation.

Ipratroprium bromide nebs

Steroids Acutely, they may lead to -receptor

upregulation and sub-acutely/chronically have been shown to decrease the inflammatory response in asthma

Case #8

• Agents… Magnesium sulfate:

Competitively inhibits intracellular calcium and leads to smooth muscle relaxation

Ketamine: Binds sigma opiate receptors to cause

dissociative amnesia and relaxation. Causes secondary release of endogenous

epinephrine which causes smooth muscle relaxation. Can cause excessive secretions.

Case #9

• A 7 week old female infant is being seen for unresponsiveness after being found face down in the bed by her parents.

• VS: T 35.2ºC, HR 68 & thready, RR 13, BP 65/40 with SpO2 unable to trace, and CR ~5 sec. She responsive to painful stimulation.

• The physician seeing the patient is concerned about sepsis and gave the child IM antibiotics because no IV access has been obtained.

Case #9

• What are the first things you should do? Airway & Breathing

Bagging this child with 100% oxygen increased the heart rate to 180 bpm

CirculationThis child is in shock. An attempt at IV access

should be made. If no access is obtained in 90 seconds or after 3 attempts, an IO needle should be placed.

After this, the child should receive 20 cc/kg of crystalloid solution

Case #9

• What should be done next? Disability

This child is hypothermic and should be placed under warming lights or wrapped in a blanket

Case #9

• What components of the history should be obtained? Birth history:

Full term or premature? Discharged right after birth or was there a

prolonged stay?

GI: Has the child been taking good PO?Making good UOP?Diarrhea or vomiting?

Case #9

ID:Any fever? Any rash? Any sick contacts?

Medical: Is the child on any medication? When was the last visit to the doctor?Are the vaccinations up to date?

Case #10

• You arrive at your night shift on a community hospital inpatient floor. One of your patients is a 9 month old, former 25 week male premie who is respiratory distress.

• The nurse signing out to you states that the child has developmental delay and cerebral palsy.

• The child presented to your facility with fever and rhinorrhea for 3 days, with progressively increasing work of breathing. The child has been receiving albuterol nebs Q 2 hours around the clock for the last 2 days without relief.

• VS: 38.3ºC, HR 195, RR 60, BP 100/57, SpO2 89% on 5L FM, and CR <2 sec

Case #10

• Different parts of the respiratory tree may be contributing to this infant’s problems Nasal Passages: obstruction from rhinorrhea, adenoid

hypertrophy Oropharynx: inability to clear secretions, pharyngeal

hypotonia with obstruction, tonsillar hypertrophy Trachea: Stenosis, malacia, vocal cord paralysis, viral

croup Small Conducting Airways: Reactive airway disease,

bronchopulmonary dysplasia Alveoli: pneumonia, bronchopulmonary dysplasia

Case #10

• Name different ways to overcome these airway problems Nasal Passages: suction, -agonists (i.e. Afrin) Oropharynx: suction, BVM to give CPAP with 100%

oxygen, intubation Trachea: racemic epinephrine nebs, Heliox, BVM to give

CPAP with 100% oxygen, intubation Small Conducting Airways: albuterol, ipratroprium, BVM

to give CPAP with 100% oxygen, intubation Alveoli: BVM to give CPAP with 100% oxygen, intubation

Case #11

• You are transporting a 14 year old male with bilateral frontal contusions after a MVC.

• The child has also sustained pulmonary contusions and a liver laceration. He was intubated for a GCS of 6. His pupils are 4mm and sluggish.

• VS: T 37.2ºC, HR 108, BP 90/45 with SpO2 100%.

• Vent settings are VT 400 cc, PEEP 5, IMV 12, FiO2 1.0.

Case #11

• During transport, the child develops a BP of 180/120 & pulse 65. What might be happening? The bradycardia and elevated BP suggest Cushing’s Triad

(altered respirations is the third component) which suggests impending herniation.

• What is the next most appropriate step in management? Hyperventilation: decreases PCO2 causing cerebral

vasoconstriction leading to decreased blood flow decreasing cerebral edema.

Hyperosmotic agents: Mannitol or 3% NaCl: removes water from brain and can

relieve edema

Elevation of head.

Case #11• Now his sats are falling...

• You begin to manually bag him and notice that it is much more difficult to obtain chest rise than previously.

• What should you think of next? “DOPE”

DisplacementObstructionPneumothoraxEquipment Failure

Case #11

• You check for displacement by auscultation bilaterally No air exchange in the right lung fields with

good air exchange in the left lung fields. Could the ETT have slipped and led to left main-

stem intubation? This is unlikely as the right main-stem is straighter and the tube is still taped at the original position.

• You check for obstruction of the ETT by passing a suction catheter into the ETT Suction catheter passes without difficulty

Case #11

• You check for a possible pneumothorax There is no air exchange on the right side There is no chest rise on the right side The trachea is deviated to the left These findings suggest a right sided

pneumothorax

• You quickly access for equipment failure The BVM is connected to 100% oxygen The anesthesia bag inflates correctly

• You suspect a right sided PTX and perform a needle thoracotomy in the 2nd ICS at the mid-clavicular line and hear a whoosh of air

Case #12

• You arrive at an ER to transport a 5 year old male who was intubated for respiratory failure secondary to shock.

• His VS are 39.2ºC, P 140, RR 32, BP 90/30, SpO2 93% on 100% O2.

• The child received 40 cc/kg LR, vancomycin, & ceftriaxone prior to intubation.

• There is an IO in the left tibia (attempt at a right IO failed). There is an a-line in the right radial artery.

Case #12

• En route, the becomes hypotensive to 55/20. While pushing volume, the IO displaces. What should you do next? Place an IO in either femur, just proximal

to the knee. Placement of the IO in either of the tibias may result in extravisation of fluid out of the previous IO attempt sites

Case #12

• The child remains hypotensive despite a 20 cc/kg bolus (60 cc/kg total given since presentation). What should you do next? Begin dopamine at 5 mcg/kg/min

• How do you make a drip using the rule of 6’s? Wt(kg) x 60, 6, or 0.6 = # mg/100 cc to

make a drip that at 1 cc/hr = 10, 1, or 0.1 mcg/kg/min

Case #12

• You obtain a arterial blood gas which demonstrates: pH 7.20, PaCO2 60, PaO2 75. What is happening and what should you do? The patient is suffering from a respiratory

acidosis and you should increase the ventilation rate or tidal volume

• How can you estimate the change in pH from the change in PCO2? For every 10 change in PCO2, a change of

0.08 in pH will be seen

Case #12

• You have attempted to titrate the dopamine to keep the MAP > 65. It is now at 18 mcg/kg/min but the hypotension persists. Which agent should you consider if the child has a

CR < 2, peripheral pulses +3, and a hyperdynamic precordium?This child is in warm septic shock. Norepinephrine should

be started.

Which agent should you consider if the child has a CR ~ 4 and the peripheral pulses are thready?This child is in cold septic shock. Epinephrine should be

started.

Case #13

• You are transporting a 16 year old male from a peripheral ER who is suspected of taking PCP. He was combative and received IM haloperidol which controlled his temperament adequately.

• During transport, he develops muscle spasms, eye dancing, a stiff neck, and an inability to open his jaw. What is happening? Acute dystonic reaction from haloperidol

Case #13

• What other drugs can commonly cause this reaction? Metoclopromide (Reglan) Prochlorperazine (Compazine)

• How is this reaction treated? Diphenhydramine (Benadryl) Benztropine (Cogentin)

Case #13• You arrive at the ER of a rural medical center

to transport a 13 month old child who has respiratory distress for the last 3 days.

• He is now significantly worse. VS T 39.8ºC, HR 198, RR 55, BP 65/30, SpO2 93% on 5L FM.

• The child appears physically exhausted.

• Physical examination demonstrates rales on auscultation bilaterally, distant heart sounds, and increased liver size.

• His pulses are thready and CR ~3 sec.

• The CXR is shown on the next slide.

Note the increased cardiac to

thoracic ratio

Case #13

• The diagnosis of acute myocarditis is made. While transporting the child, he develops the following rhythm:

• What is the diagnosis of this rhythm? Ventricular tachycardia

Case #13

• What should you do next? Check for a pulse

If no pulse present, initiate CPR and PALS pulseless arrest algorithm

If pulse present with poor perfusion:

– STAT defibrillation 2 J/kg.

– Consider alternative medications

»Amiodarone 5 mg/kg IV over 20 minutes or

»Lidocaine 1 mg/kg IV

– Intubation

Case #13

• What should you do next? (Con’t) Check for a pulse

If pulse present with adequate perfusion: – Consider medications

» Amiodarone 5 mg/kg IV over 20 minutes or

» Lidocaine 1 mg/kg IV

» Cardioversion with 0.5 to 1.0 J/kg

Case #14

• You arrive at a physician’s office to transport a 4 year old child with a suspected acute abdomen.

• The child has had bilious emesis for 2 days along with loss of appetite.

• VS: T 40.1ºC, HR 140, RR 45, BP 80/40, SpO2 100% on room air, CR < 2 sec.

• The physician has given the child 4 doses of morphine (2 mg) with minimal pain relief.

Case #14

• While en route, the child falls asleep and appears comfortable.

• The BP cycles and determines that the BP is now 60/20 with the heart rate elevated to 180.

• What should you do now? Consider a crystalloid bolus of 20 cc/kg

Case #14

• The child’s SpO2 is beginning to fall (84%). Examination demonstrates shallow respirations. What should you do next? Place the child on 100% FM

• The SpO2 continues to fall after oxygen. Should you intubate this child? No. This child is probably suffering from a

depressed respiratory drive, try naloxone (Narcan).

CASESCASES