# Need a little help on this one



## marcus2011 (Nov 8, 2010)

Aight pt was a 1 year old male suffering from shortness of breath....skin was moist and a little pale but had some red splotches on him. bp was normal but then dropped into 90/p. pulse was 103 . respirations was 34 with low tidal. no airway obstruction.no allergies. no meds. child was in crib before this happened. was in hospital 3 days before for dehydration and recived fluids via IV route. This is all my instructor gave me and I have to write a essay on treatment. Im thinking a possible catheter shear on the IV's he had but im also leading toward a possible asthma event. Anybody got any other suggestions here? Im thinking some drop a tube, get med control to let me administer narcan and bag him to the hospital.


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## 46Young (Nov 8, 2010)

Whoa, slow down a minute. You're already dropping tubes and pushing meds right away. You need to take things from the top. 

What did PALS teach you about the BP upper and lower limits of a one year old? And what of respirations?

The BP is okay, as is the respiratory rate. What's not okay is the relatively shallow chest rise, unless you're overlooking the fact that peds can be belly breathers. You didn't mention anything about lung sounds, or anything regarding stridor or the absence thereof. Also, asthma isn't diagnosed for a pt of that age.

You made no mention of the pt's mental status. Age appropriate behavior? Irritable? lethargic?  

I'm also concerned about the HR. We know that respiratory issues are typically the cause of cardic issues in peds, barring congenital abnormalities. Try some supplemental O2 and then bagging if things don't improve. If the BVM is effective, then you don't need a tube, unless the airway is swelling shut, which is why I asked about stridor.

Regarding the splotches, I would be thinking about a possible allergic reaction to something. Parents are typically introducing all different types of foods to children in this age group. Again, you made no mention of lung sounds. Wheezing? Silent chest? Stridor? Epi SQ, albuterol, benadryl, solu-medrol would be things I would be getting ready to push. With the pale skin, it may be tough to get a line due to shunting, and the SQ epi may not get into systemic circulation. A good EZ IO will fix that. Epi works great in reversing an allergic reaction. Speaking of the IO, if the BP was in fact dropping, and bagging to increase the HR wasn't working, then a fluid bolus could be beneficial. Udse a buretrol so that you don't over bolus the child.

Where are you getting ideas about catheter shear, and what indication do you have for pushing narcan?

BTW, how far along are you in medic class? I'm assuming medic class since you're talking about dropping a tube, narcan, etc.


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## MrBrown (Nov 9, 2010)

Bro you're spinning faster than the rotor blades on Brown's helicopter!

What the normal respiratory and heart rates for a one year old?
What is the normal range of blood pressure for a one year old?
Paediatric assessment triangle?
Activity, work of breathing, grimace, cry etc?
Recent activity, feedings, possible exposures?
Temperature?

Do you want to try and intubate a one year old? Brown sure as hell doesn't

Could be a million things, could be DIC, could be nothing ....


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## Voodoo1 (Nov 9, 2010)

MrBrown said:


> Bro you're spinning faster than the rotor blades on Brown's helicopter!
> 
> What the normal respiratory and heart rates for a one year old?
> What is the normal range of blood pressure for a one year old?
> ...



Brown.. you rock my socks
OP, Why were you thinking of pushing narcan? Or intubating? I'm a student as well and this is something that I've pounded into my own head *Yes, you need to know what to do, but you also need to know WHY you're doing it*


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## MrBrown (Nov 9, 2010)

but Brown isin't currently wearing any socks!


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## Voodoo1 (Nov 9, 2010)

What was the home environment like? Does the boy go to daycare? What was the prior dehydration due to?


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## FrostbiteMedic (Nov 9, 2010)

MrBrown said:


> but Brown isin't currently wearing any socks!


You can have mine Mr. Brown...I have several pairs of toe socks from back in the day (don't ask folks....loooongg story)


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## marcus2011 (Nov 9, 2010)

46Young said:


> Whoa, slow down a minute. You're already dropping tubes and pushing meds right away. You need to take things from the top.
> 
> What did PALS teach you about the BP upper and lower limits of a one year old? And what of respirations?
> 
> ...



just started medic class...this is all he gave us for this situation


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## marcus2011 (Nov 9, 2010)

Voodoo1 said:


> Brown.. you rock my socks
> OP, Why were you thinking of pushing narcan? Or intubating? I'm a student as well and this is something that I've pounded into my own head *Yes, you need to know what to do, but you also need to know WHY you're doing it*



well. we have no airway here...my thought were going toward et tube or naso tube. And I may be getting my drugs mixed up here so if I am let me know. Narcan is used for narcotic overdose and resp depression so thats why


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## CAOX3 (Nov 9, 2010)

marcus2011 said:


> well. we have no airway here...my thought were going toward et tube or naso tube. And I may be getting my drugs mixed up here so if I am let me know. Narcan is used for narcotic overdose and resp depression so thats why



Trouble breathing and no airway are two entirely different things and should be treated as such. Narcan is used for resp depression in suspected overdose .


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## EMSrush (Nov 9, 2010)

Always think BLS before ALS... and that just may be the point that your instructor is getting ready to get across to you if you've just started medic school.


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## marcus2011 (Nov 9, 2010)

seems like it


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## 46Young (Nov 9, 2010)

marcus2011 said:


> well. we have no airway here...my thought were going toward et tube or naso tube. And I may be getting my drugs mixed up here so if I am let me know. Narcan is used for narcotic overdose and resp depression so thats why



I figured that you were fairly early on in your class. Nothing wrong with that. 

One thing you have to be re-educated on is the fact that we're not just treating signs and symptoms like we were as EMT's. It's not "see A, do B" anymore. You may have seen medics do the same thing for a particular pt presentation, but it doesn't mean that every pt with a certain sign or symptom always gets the same treatment course. That's referred to as "cookbook medicine," which means that you try and fit each pt to a narrow protocol, instead of delving deeper, determining reversible causes, and instead using the protocols as guidelines, since sick pts may have several different issues going on.

We're taught to assess the pt, and form a provisional diagnosis from the differentials that you're considering. As a student paramedic, it's easy to look past the importance of a full assessment and thinking ahead to what skills and meds you want to try out. The trend in this profession has actually been de-emphasizing skills and increasing education. You have to know why you're doing what you're doing. It's obvious that you've had no college level A&P or pharmacology going in. This is highly recommended. Those two classes are the bedrock of a paramedic's education. It's too late now. I recommend taking these courses after you get out. I feel that the in house focused A&P and pharm "for EMS" is too watered down to be truly useful. 

A pearl of wisdom for you - all medications have the potential to kill! Respect them as such, and don't empty your drug box at every opportunity just because you can. Also, it would benefit you to do some ALS IFT work after graduating from medic school, so you can see how pts are affected by field EMS treatments, such as being on a ventilator when they could have been treated in a different matter, sparing them the need for one, for example.


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## Veneficus (Nov 9, 2010)

Was the kid borne at term?

Pre or post natal complications/risks?

Parents/relatives genetic history?

Suspicion the kid swallowed something and has partial obstruction?

Maybe he has an infection?

Respiratory and GI complications are fairly common before 2 years and world over, are the leading cause of mortality. (granted most of it is in third world countries, but still.)


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## abckidsmom (Nov 9, 2010)

How many wet diapers has he had?  You can tell if he's been having diarrhea from the diaper rash, if any.


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## MrBrown (Nov 9, 2010)

marcus2011 said:


> well. we have no airway here...my thought were going toward et tube or naso tube. And I may be getting my drugs mixed up here so if I am let me know. Narcan is used for narcotic overdose and resp depression so thats why



What was his SPO2? work of breathing? colour? conscious state? breath sounds?

How can you say you have no airway? Was the child apoenic and not breathing? No, then you had an airway.

Naloxone is fast falling out of fashion just like lasix .... did this child have any signs of a narcotic overdose? 

You keep thinking like this you're gonna end up on the street and somebody is going to end up dead because of it.


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## marcus2011 (Nov 9, 2010)

This is all the info we have got for our paper. I will write it myself but thank you for your input on this matter


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## EMSrush (Nov 9, 2010)

MrBrown said:


> You keep thinking like this you're gonna end up on the street and somebody is going to end up dead because of it.



While your statement may be factually accurate, I can think of nicer ways to provide input for someone who is just beginning medic school and is looking for some constructive feedback.


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## reaper (Nov 9, 2010)

Yes Brown, you could have been nice and said. "Don't screw up or people will die!" 


See? Much nicer!


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## jrm818 (Nov 9, 2010)

As a practical matter, for completing the assignment, perhaps your "treatment plan" should consist of conducting a proper assessment.  This could consist of many of the suggestions above.  You can list possible treatments depending on findings, but I think a reasonable instructor would understand a hesitance to treat based on such limited information.


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## Melclin (Nov 9, 2010)

Did people not read the bit where he says that's all the information he's been given?



marcus2011 said:


> This is all the info we have got for our paper. I will write it myself but thank you for your input on this matter



Unless your instructor is an idiot, I'm pretty sure what he _expects_ is that everybody will launch into tubes and drugs and other stuff they don't really understand yet (you're all just starting after all), but what he _wants_ is for people to say, "There isn't enough information, I'd do a proper assessment" OR "BLS before ALS" in some form or another like, "I'd provide supportive care to hospital" or something. I strongly suspect its one of those teaching exercises where he makes a point of how fast everyone rushed into treatments they didn't understand based little to no information. 

If not and your instructor actually expects you to launch into IVs, tubes and drugs based on that info then do yourself a favour and switch to a different course.


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## MrBrown (Nov 10, 2010)

Melclin said:


> If not and your instructor actually expects you to launch into IVs, tubes and drugs based on that info then do yourself a favour and switch to a different course.



Ssssssh don't tell where Brown is moonlighting as a Clinical Instructor to make extra money


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## Melclin (Nov 10, 2010)

MrBrown said:


> Ssssssh don't tell where Brown is moonlighting as a Clinical Instructor to make extra money



You know you're a hard worker Brown. CI and supervisor for all those Brownology PhD candidates.


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## MrBrown (Nov 10, 2010)

Lets not forget the Honours students enrolled in Faking It 102


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## FrostbiteMedic (Nov 10, 2010)

MrBrown said:


> Lets not forget the Honours students enrolled in Faking It 102


I'm proud to say that I am his top student in that class.....soon I will have my B.S.


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