# Pediatric Scenario



## WTEngel

USAL asked me to come up with a good general peds scenario for you guys. So here it is...


18 month old, CC of fever and respiratory distress x 12 hours. Call is at 0200 on a night in November. 

On arrival you find a 18 month old, average weight, male patient with HR 165, respirations of 55 per minute, SPO2 93%, cap refill exactly 2 seconds, mid axillary temp of 100.1, crying and fussing. The patient's color is average, not great, not terrible, with the general "sickly" appearance."

You identify audible nasal secretions, with some inspiratory "caving" of the chest, lung sounds are generally clear in all fields, although adequate auscultation is not possible while the patient is crying.

Please identify most appropriate initial treatment based on a logical differential diagnosis, and follow up care. Bonus points for anyone who can identify what the hospital's most likely plan of treatment would be based on the patient's probable diagnosis.


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## fast65

Right off the bat I was considering croup/epiglottitis, any drooling? Stridor? Cough? 

I'm going to start off with some blow-by O2 while mom holds them. Hopefully that will resolve the respiratory distress. I really don't like that respiratory rate or the sternal retractions, but we'll see how the blow-by helps.

 Has the child been eating/drinking normal amounts? Skin turgor? Any change in urination/bowel movements?

I'll forego the IV right now and we'll get going to the hospital. If it happens to be croup, I imagine the hospital will start a trial of racemic epi, but I'm probably wrong 

Sent from my mobile command center


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## Katy

Certainly a sick baby, and in need of the hospital assistance. First thing I'm going to do is attempt to relieve respiratory distress and raise oxygen saturation levels, by giving the patient oxygen. This is also in my hope going to relieve the baby of some fussing and crysing, so I could better auscultate the lungs. A further health history needs to be discussed on the way, questions like, 
"How long has the baby had this fever ?"
"How is the baby functioning as far as releasing wastes from the body ?"
"How is his apetite ?"
"Any other complaints such as coughing ?" 
"Have you been ensuring the baby gets adequate amounts of fluids ?"
Answers to some of these questions will help me determine if I need to start and IV before I get to the hospital.


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## WTEngel

I will wait for a few more replies before I start to go into more detail, however I will say you should be able to rule in a few specific diagnosis based only on the information given. 

There are no hidden details, what you see is what you get...


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## BigBad

Meningitis, helicopter.   Nuff said.


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## Katy

BigBad said:


> Meningitis, helicopter.   Nuff said.



Why would you call meningitis before a respiratory condition such as croup ? Croup is my first thought, as the child shows the major signs and lungs appear to be in general pretty clear.


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## fast65

I suppose it could be meningitis, the fever, tachypnea, and tachycardia match. However, there was no mention of bulging fontanelles or a rash, which I'm sure would have been noted in the original scenario with our assessment.

 If it turns out to be meningitis I don't see "helicopter" being our main treatment. We can establish an IV and run some fluids because he'll probably be dehydrated, then the hospital can do a spinal tap and possibly give some antibiotics and maybe steroids. They'll probably put him on some acetaminophen for the fever.


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## thegreypilgrim

WTEngel said:


> 18 month old, CC of fever and respiratory distress x 12 hours. Call is at 0200 on a night in November.


 Prodrome of URI?



> On arrival you find a 18 month old, average weight, male patient with HR 165, respirations of 55 per minute, SPO2 93%, cap refill exactly 2 seconds, mid axillary temp of 100.1, crying and fussing. The patient's color is average, not great, not terrible, with the general "sickly" appearance."
> 
> You identify audible nasal secretions, with some inspiratory "caving" of the chest, lung sounds are generally clear in all fields, although adequate auscultation is not possible while the patient is crying.


 So, to summarize we have a febrile, tachypneic, toxic appearing child with some increased work of breathing. Has he hit all the appropriate developmental milestones? Is he consolable? Good muscle tone? Percussion sounds? Feeding habits? Urine output? Lacrimation? Vomiting/diarrhea? Any relevant medical history?

For the moment, I'm going to call this a pneumonia - and based on his age and clinical presentation I'm thinking bacterial. Although croup/epiglottitis or RSV are possibilities.



> Please identify most appropriate initial treatment based on a logical differential diagnosis, and follow up care. Bonus points for anyone who can identify what the hospital's most likely plan of treatment would be based on the patient's probable diagnosis.


 This child appears to be quite ill, but at the moment I'd provide supportive care.

Supplemental O2 via blow-by, ECG, IV access for fluid bolus and watch for changes while we head to the nearest hospital with pediatric services.

In hospital I imagine they'd want a chest radiograph (PA and lateral views) and draw labs for BMP, CBC w/differential, and possibly cultures. Start him on empiric antibiotics (unlikely to identify the offending organism), watch for respiratory deterioration, and continue fluid therapy as needed.


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## Melclin

*I hate children.*

We need more paeds scenarios. I'm so s**t at kids.

Thinking about things that kill kids with resp distress...

1. FBAO  (Febrile and enough of a hx to be pretty sure its not this)
2. Epiglottis  
3. Croup  

Maybe meningitis. Fontanelles?

Is he barking? Is he drooling? Swallowing? Stridor? Hx of croup? 

Pending further info...
-If its croup and he gets a little more lethargic, we can neb some adrenaline but I don't think he's there yet.
-If hes got a non-blanching rash we'll get some ceftriaxone into him. Ask mum for the weight. I imagine 600-700mg.
-Some fluid. 200mls over the time we have him. 
-O2.


Hospital. Sepsis bloods, cultures, lactate, Chest xray, lumbar puncture, fluid resuscitation and antibiotics. Strep pneumoniae?


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## WTEngel

*Alright...*

So, let me put you guys back on track.

In this scenario, just as in real life, croup would have been obvious. In the absence of stridorous breath sounds, I would not jump to this diagnosis. The copious nasal secretions also make this less than likely. 

Epiglottitis would have been obvious also. Had there been mention of heavy drooling, higher temperature, etc. this might have been more likely.

Asthma and bronchiolitis are out. With the absence of lower airway wheezes in the presence of good air movement, asthma/bronchiolitis is pretty easily ruled out. Now, don't mistake the absence of wheezes as an absolute indication that lower airway constriction is not present. Sometimes kids are not able to move enough air to produce wheezes, however with the crying and fussing, this is not the case with this patient. There is also an elevated temperature for this patient combined with thick nasal secretions, making asthma an unlikely contender for the top spot.

Meningitis? Helicopter? I am not even sure where this came from, but it is not reasonably thought out, so I won't address it.

So, a few questions for you guys: 

Is this patient febrile? If so, what is your criteria that defines a "febrile" patient.

Is this child's SPO2 critically low? If so, what are your parameters that define critically low SPO2 in peds? Will placing oxygen on this patient help raise the SPO2? What is the likely cause of the lower than normal SPO2?

How sick is this kid? I see some saying they are very sick. Why do you say this? Would you transport this patient with lights and sirens? No lights and sirens?

Does this child need an IV? 

So there are a few points to ponder. Let me know. I will say again, all you need to know about this patient is in the original scenario. There is nothing hidden. Don't read too much into it and make it something it is not. 

One person has mentioned the most likely diagnosis, however no one has mentioned the most appropriate first treatment yet...


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## fast65

If we're gonna start fresh, I'm going to head down the RSV pathway. The patient is really isn't that febrile, from what I remember, fever's in pediatrics down necessarily have to be treated unless over 100.4 F. 

RSV tends to be more prevalent in the fall and spring, so that increases my index of suspicion for this child. The symptoms all match RSV, and I suspect it's only in the beginning stages due to the low-grade fever and absence of a cough. An SPO2 of 93% isn't terrible for a kid, but with the tachypnea and retractions, I do believe this kid can benefit from a little oxygen therapy, and if we have it, we'll give him some humidified O2. 

As far as a line is concerned, depending on how far out from the hospital I am I'll probably get an IV. If it is RSV then the hospital will establish an IV anyways and run some fluids, so I might as well get that going early on. I'm thinking about 200-240 ml to start. 

Once we're at the hospital they take a nasal swab and do a rapid test for RSV, then the line of treatment will be humidified O2 and IV fluids. If his fever spikes then they'll probably give him some antipyretics.

EDIT: Oh, and no I would not transport this patient code 3, he's sick, but not extremely sick.


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## Katy

fast65 said:


> If we're gonna start fresh, I'm going to head down the RSV pathway. The patient is really isn't that febrile, from what I remember, fever's in pediatrics down necessarily have to be treated unless over 100.4 F.


You have to remember though that this temperature was taken at the axillary site, and the temperature is usually considered to be one degree below the actual temperature. So, this babies temperature would actually be considered 101.4, therefore making it a significant enough fever for medication treatment. This is precisely why I don't like using axillary temperatures, because they are always 1 to 2 degrees lower than the actual temperature of the patient.


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## fast65

Happy said:


> You have to remember though that this temperature was taken at the axillary site, and the temperature is usually considered to be one degree below the actual temperature. So, this babies temperature would actually be considered 101.4, therefore making it a significant enough fever for medication treatment. This is precisely why I don't like using axillary temperatures, because they are always 1 to 2 degrees lower than the actual temperature of the patient.



Oh yes, I forgot about the site it was taken. Thanks for pointing that out, I just woke up and am only on my second cup of coffee


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## Katy

fast65 said:


> Oh yes, I forgot about the site it was taken. Thanks for pointing that out, I just woke up and am only on my second cup of coffee


No issues, thats what were all here for. Even still, the patient's fever isn't too too high, but it will now be considered high enough for treatment.


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## fast65

Indeed it is, however, we don't actually care acetaminophen on our rigs here, so I'll let the ED worry about that. It's not too worrisome, but as you pointed out, it is now high enough for treatment.


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## Katy

-To address the questions; yes, this patient is febrile. Why and how do I come to this conclusion ? Usually, if the fever is over 100.5 I consider it significant, if it is below that but still elevated, but it is simply a low-grade fever and usually nothing to worry too much about. 

-Now, to the next question, no, I would not consider this patient to be critical as far as low SPO2 is concerned. Is his saturation level low ? Yes, but there is a difference between a low saturation level and a critical one. I would closely moniter his SPO2 for any drop, and would apply oxygen.

-I say this child is sick because we have a whole lot of "flags" flying up showing us he is. Fever, elevated respirations, low SPO2, and the general "sick" appearence are all signs that there is a more serious underlining issue. And no, I would not transport with lights and sirens, this patient is sick, but isn't code-level from the given information in the OP.

-Again, given the information in the OP, I would go ahead and start and IV. It is likely that this child is mildly dehydrated and one will be started at the hospital anyways. 

Based on all this, I will also go with the assumption of RSV, but, I'm also leaning to the possiblity of early stages of Pneumonia. Chest X-Ray will be able to most likely tell if Pneumonia is the cause.


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## thegreypilgrim

WTEngel said:


> Asthma and bronchiolitis are out. With the absence of lower airway wheezes in the presence of good air movement, asthma/bronchiolitis is pretty easily ruled out. Now, don't mistake the absence of wheezes as an absolute indication that lower airway constriction is not present. Sometimes kids are not able to move enough air to produce wheezes, however with the crying and fussing, this is not the case with this patient. There is also an elevated temperature for this patient combined with thick nasal secretions, making asthma an unlikely contender for the top spot.


 Like you said, the absence of adventitious breath sounds is not sufficient to rule out anything, especially not in a crying/fussy/squirmy kid. It could sound more or less "normal" but there could still be consolidation or thick secretions obstructing airflow or impeding gas exchange.



> Is this patient febrile? If so, what is your criteria that defines a "febrile" patient.


 Technically no, since the reading was still <39C but since this was an axillary measurement I wouldn't be surprised if it was falsely low. I'd hold off on antibiotics until I got a rectal temp.



> Is this child's SPO2 critically low? If so, what are your parameters that define critically low SPO2 in peds? Will placing oxygen on this patient help raise the SPO2? What is the likely cause of the lower than normal SPO2?


 As of the moment, no. As long as it holds at >90% without lethargy or some sort of complicating feature of his history a blow-by mask (if that) should be fine.



> How sick is this kid? I see some saying they are very sick. Why do you say this? Would you transport this patient with lights and sirens? No lights and sirens?


 With an increased work of breathing and poor general appearance that's two legs of the PAT that are "abnormal". This coupled with the moderate decrease in SPO2% I'd say he's sick, but not critical at this point. No lights and sirens.



> Does this child need an IV?


 Yes.


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## exodus

Has anyone tried to clear out the nose yet and see if constant monitoring of the nares will help the o2 and stress breathing? 







I know when I have a really bad cold sometimes it gets mildly difficult to breathe when i have my nasal secretions running down my throat, now add this to a baby crying relentlessly.

A baby crying extremely hard could also mimic labored breathing. Seeing a small baby give a temper tantrum will many times use accessory muscles to try and balance out their o2 levels.

So how do people feel about simply clearing out the airway?

Edit: I don't think *rapid* cooling is needed, but lets turn off the heat and pull the child out of all the blankets he's in.


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## Handsome Robb

If possible I'd want a rectal temp. If it isthe 101.4 like Happy suggested I'd consider some acetaminophen 15 mgs/kg PR (only way we carry it) Other cooling measures like exodus said as well as try and clear his nose as well.

No lights/siren, he needs someone smarter than me when it comes to peds but where I'm at we don't have long transport times. Rural I *might* consider them intermittently to keep mom happy but I don't think its prudent in this scenario. 

His SpO2 isn't awful but you could try some O2 blow-by to help them a little bit and to try and calm the little bugger down to get a better set of lung sounds, maybe consider humidifying it? If his SpO2 started to drop and work of breathing didn't begin to calm down maybe some racemic epi nebbed through a mask, probably gonna be blow-by if he is as agitated as it sounds but I don't know how I feel about the possibility of elevating his HR even farther with the epi.

IV if possible but I don't wanna continue to agitate this kid.

RSV sounds like a good thought so I'll agree with fast on that.

We haven't gotten to peds yet so I may be WAY off on this one.


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## DESERTDOC

Lets go with viral.

Clear his nose.

Nebulised saline.

Tylenol, PR.

Check his sugar.

Fluid bolus NS x1.

C-2.


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## Smash

BigBad said:


> Meningitis, helicopter.   Nuff said.



Meningitis eh?  How much helicopter are you going to give them?  IV helicopter or IM helicopter?  I prefer to go with a large bolus of helicopter followed by an infusion to maintain therapeutic levels of helicopter in the body.

Helicopter is not a treatment.  Helicopter is a means of transport that is grossly overused in the US.


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## usafmedic45

> Helicopter is not a treatment. Helicopter is a means of transport that is grossly overused in the US.


....mostly by people uncomfortable with their own knowledge or skill level but still too lazy or stupid to do anything about it.


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## IRIDEZX6R

Most logical *initial* intervention? 15lpm o2 nrb would be the first thing that comes to mind. Especially with the sat02 at 93% on RA.


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## WTEngel

Alright! Now we are getting somewhere...

This kid is sick, but really not too terribly bad.

RSV is the picture I was trying to paint. Temperature slightly elevated, cruddy looking, fussy, lower than normal SPO2, and most importantly-

COPIOUS NASAL SECRETIONS.

For those that want to apply oxygen first, nice try, but it will not likely get you anywhere. This is not a failure to oxygenate, but more a difficulty with ventilation. Because of the obligate nose breathing infants have, anytime they have a large amount of nasal secretion it effects their ability to ventilate. They get irritable, start crying, and begin mouth breathing. 

The caving of the chest is not necessarily accessory muscle use or intercostal retractions, but actually the chest pulling inward as the infant pulls negative pressure to breathe. The air cannot move in fast enough due to the secretions blocking the majority of the nasal passage.

Applying oxygen will only dry out and thicken these secretions.

For those who said suction, that is spot on. You suction these kids, and then you will likely suction some more, and then most likely prepare to suction some more. Performing a nasal lavage with normal saline and a 10 or 12 fr soft catheter will really make these kids pissed off, and probably scare the parents, but afterwards, the improvement will be remarkable. They will very literally be breathing like normal. Beware though, within about 30 minutes or so, the secretions will build back up, and they will need suctioning again.

After suctioning, some blow by oxygen isn't a bad thing, but probably not necessary. These kids will most likely need a 20 cc/kg isotonic crystalloid bolus, possibly followed by a repeat. The increased respiration and decreased PO intake will have them dehydrated.

Antipyretic treatment for low grade fever is acceptable, however, if you do not have a documented temp above 100.4 then I don't think it is justifiable. So either obtain a true temp, or allow the fever to persist. Fever is not a bad thing. Malignant fever with persistent high temps is a bad thing, but low grade fevers are part of the body's initial immune response.

Usually we try not to completely abolish the fever. As you mentioned earlier, our criteria is 100.4 and greater (38 C) if the child looks miserable. If they appear to be tolerating it well, we will hold off. Acetaminophen q 4 hrs or Ibuprofen q 6 hours. Try to stick with one or the other, unless you absolutely can not get the temperature down with only one.

Try to keep mom and dad from holding the child too much or keeping them covered up. This is some sort of natural parenting instinct that kicks in. When there is a fever, parents put more clothes on and keep the kids bundled up for whatever reason. One light layer (onesie or shirt and diaper) in an average temperature room is good. Educate them that the body needs to be allowed to regulate its own temperature, and covering the child up could lead to malignant hyperthermia. Also be careful of reducing the temperature too quickly, or covering the child up and allowing the fever to "spike." Some of the literature identifies this as a possible cause of febrile seizures.

Antibiotics in the field? Please don't. RSV is a virus, they will not do anything. Even if this was bacterial, antibiotics in the field do nothing to treat symptoms, and administration of antibiotics prior to drawing cultures is highly frowned upon (at least where I come from.) The hospital may administer antibiotics in this case, only as prophylaxis from secondary bacterial infection while the kid is fighting off the virus.

Care at the hospital will include: monitor, suction, IV, o2 PRN, lab work, fluid bolus PRN, and supportive care. Most of what they do will center around relieving symptoms, while the body naturally clears the virus. As I mentioned earlier, they may provide antibiotics to prevent secondary infection, that is provider choice. This will only be done after cultures are obtained.

I think I covered it all. 

A few pro tips:

Auscultating lung sounds of the crying infant can be difficult. Listen during inspiration if possible to try and identify lower airway abnormalities.

Croup has a high pitch barking cough, inspiratory stridor, and fever. It usually strikes in the middle of the night after the child has been put down for bed. Heavy nasal secretions are not usually present. Don't irritate these kids. Cool air, racemic epi if you have it, humidified o2 or nebulised saline if you don't. When these kids get angry, their airway can become extremely tenuous. Steeple sign on X ray...

Epiglottitis will present with trouble swallowing, not necessarily trouble breathing. What I am trying to say is that the swelling usually will not cause the inspiratory stridor that you hear in the croup patient. These kids posture forward and drool a lot. The croup patients typically do not drool as much, as they have the ability to swallow without much discomfort. Thumb sign on X ray...

Pneumonia will typically have the same symptoms of asthma, along with a fever. You will hear lower airway wheezes, and there should be no abnormality in the upper airway. Consolidation on X ray...

Asthma/Bronchiolitis will typically present without a fever (except in the case of secondary infection exacerbating current condition.) These patient have trouble exhaling, not trouble inhaling. The constriction of the lower airways makes it difficult to exchange gas. The constriction of the lower airways may also lead to an absence of wheezes until they have had one or two treatments, at which time they will sound much worse then when you started. They should be able to begin to produce the thick secretions that have been accumulating in the lower airways. Hyperinflation and possible atelectasis on X ray...sometimes, but not always...

FBO is a wildcard. Acute onset, no history of worsening condition (i.e. child was looking sickly earlier and now appears to be worse.) Possible high pitch whistling, trouble swallowing, etc. An actual aspiration will typically cause much worse symptoms, and the patient will likely be in extremis. Silhouette of toy car or coin on X ray....consider possibility of radiotranslucent aspiration, which will barely/not be visible.

Ok, I am getting tired. I think that covers a lot. Please add in your own experience or comments. This is not meant to be all encompassing by any means, just a general presentation for you to consider in your practice.


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## abckidsmom

Excellent scenario, and well-explained.  I really wanted to play, but I just can't type more than a couple of paragraphs on my phone without going crazy, and it was a mobile internet kinda weekend.

The only thing I have to add is that we do carry a bulb syringe, and it would go a ways toward helping this kid.  It is astonishing the amount of snot it can remove from the nasal passages.  Not as effective as a small french catheter, but sometimes those aren't stocked, or can't be found or whatever.  The OB kit is nice and prevalent on every ambulance.


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## PFD2171

*Kiddo*

Took a very interesting pediatric airway course once that applies to some of the differentials that were tossed about prior to the solution. Treatment number one should be to calm the child, a crying child w/o inflammation can decrease their airway size to 1/6th of normal, add any inflammation and you have an issue.


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## abckidsmom

PFD2171 said:


> Took a very interesting pediatric airway course once that applies to some of the differentials that were tossed about prior to the solution. Treatment number one should be to calm the child, a crying child w/o inflammation can decrease their airway size to 1/6th of normal, add any inflammation and you have an issue.



So, what specifically would you have done to calm this particular baby?  I think it's useful to have thought out this plan beforehand.


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## PFD2171

*Kiddo*



abckidsmom said:


> So, what specifically would you have done to calm this particular baby?  I think it's useful to have thought out this plan beforehand.


I agree you always need a plan before any procedure, activity, etc.. Having the child held by parents is usually the best but does not always work sometimes distractions is helpful. You also need to realize that not all children will like you and bring in someone to help who may have a stronger affinity with children or this child. Also weigh out what procedures have to do be done right now or  could wait till later. Most of us don't have Dr. McCoy scanners with us so we can't just scan our patient and say this is exactly what is wrong with them and most of our treatments are broad strokes not specifics. So decide what of your broad strokes will benefit this child the most and keeping them calm with an optimally open airway may be your best bet.


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## abckidsmom

PFD2171 said:


> I agree you always need a plan before any procedure, activity, etc.. Having the child held by parents is usually the best but does not always work sometimes distractions is helpful. You also need to realize that not all children will like you and bring in someone to help who may have a stronger affinity with children or this child. Also weigh out what procedures have to do be done right now or  could wait till later. Most of us don't have Dr. McCoy scanners with us so we can't just scan our patient and say this is exactly what is wrong with them and most of our treatments are broad strokes not specifics. So decide what of your broad strokes will benefit this child the most and keeping them calm with an optimally open airway may be your best bet.




OK, well in this particular kid...is he too sick to suction?  too sick to be strapped into his carseat for the ride to the hospital whether he wants to or not?  Is he sick enough that we don't want him agitating his airway and think it's worth the increased risk for him to be unsecured in the ambulance?

Does he need to remain NPO or if nursing or a bottle makes him happy, can he have something to eat?

This kid is 18 months old.  What toys are you going to reach for to try and grab his attention?  The stuffed animals in the compartment over the bench?

That's what I was getting at.  What do you think?


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## exodus

Perfect time to throw a childrens DVD into your laptop or mounted DVD player after you get going and have the mother hold the laptop allowing the child to watch some random cartoon / animation.


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## Katy

exodus said:


> Perfect time to throw a childrens DVD into your laptop or mounted DVD player after you get going and have the mother hold the laptop allowing the child to watch some random cartoon / animation.


I find it very hard to believe that a 18 month old will hold the animation in interest for very long, _especially _if they aren't feeling well.


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## exodus

Happy said:


> I find it very hard to believe that a 18 month old will hold the animation in interest for very long, _especially _if they aren't feeling well.



I wouldn't know honestly. I've seen them hold attention before, even on sick kids. But never had one really sick.  This is from personal experience at the house, not on the rig.


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## abckidsmom

exodus said:


> Perfect time to throw a childrens DVD into your laptop or mounted DVD player after you get going and have the mother hold the laptop allowing the child to watch some random cartoon / animation.



I have the Talking Tom app on my phone, and I haven't yet seen a kid big enough to make purposeful vocalizations not love it.  Even if mom is looking at it and talking to it over the kid's shoulder, they think it's hillarious.

Also, bigger kids (3-4) think the Geico brostache app is hillarious.


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## usafmedic45

> Most logical initial intervention? 15lpm o2 nrb would be the first thing that comes to mind. Especially with the sat02 at 93% on RA.



That's a bit of overkill and you'd be called to account for that decision at the next audit and review session if you worked in the system I worked in.  The sat is 93% for crying out loud.


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## fast65

IRIDEZX6R said:


> Most logical *initial* intervention? 15lpm o2 nrb would be the first thing that comes to mind. Especially with the sat02 at 93% on RA.



Having 15 lpm of oxygen gusting into an 18 month olds face is just going to upset them even more, not something we want to do, especially with a child in respiratory distress. As usafmedic said, the O2 sat is 93%, blow-by will do just fine, but as WTEngel suggested, suctioning is more important here as the O2 will dry the secretions. 

You've passed your national registry already, now you need start making clinical decisions based off of multiple factors, not just a single number.


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## Katy

IRIDEZX6R said:


> Most logical *initial* intervention? 15lpm o2 nrb would be the first thing that comes to mind. Especially with the sat02 at 93% on RA.


That does seem like quite a lot for a 18 month old with a mildly to moderately low SPO2 at best. Why would you not pursue with nasal suction and blow-by if needed ?


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## usafmedic45

> Why would you not pursue with nasal suction and blow-by if needed ?



Because he's an EMT-B and doesn't know any better?  That's most logical initial conclusion until evidence is presented to the contrary.


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## Katy

usafmedic45 said:


> Because he's an EMT-B and doesn't know any better?  That's most logical initial conclusion until evidence is presented to the contrary.


Well, if this is in fact the reason why, this further proves that people who want to further the education of EMT's are incorrect. They need to better educate themselves on the topics briefly covered before they can move on, like oxygen administration.


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## WTEngel

In my experience, the best way to calm these children is to alleviate the nasal congestion. 

Obviously the child cries and is very unhappy during the suctioning process, but once you are done and they can breathe easier, they very literally become a "normal" child until the next time they need to be suctioned.

Normally relieving the respiratory distress will go a long way to calming the child.

Swaddling them lightly will help also if they do not have a profound fever and will tolerate it.

Once suctioned, if they take a pacifier with "sweet ease" or "toot sweet" that suckling will calm them quite a bit...

High flow o2 blowing in the face with a non re breather, nasal cannula, etc. will go a long way to pissing them off and giving you something to fight with them about during transport...


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## Katy

WTEngel said:


> In my experience, the best way to calm these children is to alleviate the nasal congestion.
> 
> Obviously the child cries and is very unhappy during the suctioning process, but once you are done and they can breathe easier, they very literally become a "normal" child until the next time they need to be suctioned.
> 
> Normally relieving the respiratory distress will go a long way to calming the child.
> 
> Swaddling them lightly will help also if they do not have a profound fever and will tolerate it.
> 
> Once suctioned, if they take a pacifier with "sweet ease" or "toot sweet" that suckling will calm them quite a bit...
> 
> High flow o2 blowing in the face with a non re breather, nasal cannula, etc. will go a long way to pissing them off and giving you something to fight with them about during transport...


All of these are good points, I hope you have more Peds scenarios planned.


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## usafmedic45

Happy said:


> Well, if this is in fact the reason why, this further proves that people who want to further the education of EMT's are incorrect. They need to better educate themselves on the topics briefly covered before they can move on, like oxygen administration.



Well, if you increase the education standard- not the same thing as increasing the skill set- to something other than the unholy trinity of knee jerk O2 administration (no O2, nasal cannula or NRB at 15 L/min) then it remedies the problem at least in the proactive sense.  Think of it as putting on a tourniquet to stop the bleeding.  The problem is that if you don't go back and correct the shock of the massively undereducated EMTs from years past, the "patient" (in this case, the system and its real patients) is still likely to suffer until natural attrition takes care of the problem.


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## zzyzx

Looking forward to seeing more peds scenarios!


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## Anjel

usafmedic45 said:


> Because he's an EMT-B and doesn't know any better?  That's most logical initial conclusion until evidence is presented to the contrary.



I take offense to that. 

Im an EMT-B and I know better.


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## exodus

Hey! And a basic was the first to even mention trying to clear the airway! 

And I wouldn't even go with regular blow by O2, I'd throw the humidifier on it first, then let them take that.


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## usafmedic45

Anjel1030 said:


> I take offense to that.
> 
> Im an EMT-B and I know better.


Well, you've presented evidence to the contrary of the norm.


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## Katy

exodus said:


> Hey! And a basic was the first to even mention trying to clear the airway!
> 
> And I wouldn't even go with regular blow by O2, I'd throw the humidifier on it first, then let them take that.


Even after suctioning if his 02 saturation is still down, which could be a slim but possible outcome, what is the humidifier going to do to help the patients SP02 when it is staying down ?


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## Melclin

Great scenario.

I love that feeling when you do a scenario and you have no idea whats going on then at the end you learn a whole pile of stuff and you're thinking, I am so glad I learned that before I ran into it on the road.

More paeds scenarios! I know so little about paeds.


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## exodus

Happy said:


> Even after suctioning if his 02 saturation is still down, which could be a slim but possible outcome, what is the humidifier going to do to help the patients SP02 when it is staying down ?



Nothing really. It's there to stop the secretions from drying and clogging the airway.


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## fast65

Melclin said:


> Great scenario.
> 
> I love that feeling when you do a scenario and you have no idea whats going on then at the end you learn a whole pile of stuff and you're thinking, I am so glad I learned that before I ran into it on the road.
> 
> More paeds scenarios! I know so little about paeds.



Same here, these scenarios are an amazing way of expanding our knowledge. I look forward to more pediatric scenarios.


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## HMartinho

WTEngel said:


> USAL asked me to come up with a good general peds scenario for you guys. So here it is...
> 
> 
> 18 month old, CC of fever and respiratory distress x 12 hours. Call is at 0200 on a night in November.
> 
> On arrival you find a 18 month old, average weight, male patient with HR 165, respirations of 55 per minute, SPO2 93%, cap refill exactly 2 seconds, mid axillary temp of 100.1, crying and fussing. The patient's color is average, not great, not terrible, with the general "sickly" appearance."
> 
> You identify audible nasal secretions, with some inspiratory "caving" of the chest, lung sounds are generally clear in all fields, although adequate auscultation is not possible while the patient is crying.
> 
> Please identify most appropriate initial treatment based on a logical differential diagnosis, and follow up care. Bonus points for anyone who can identify what the hospital's most likely plan of treatment would be based on the patient's probable diagnosis.



How is their BP?


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## Handsome Robb

your way behind the eightball. dude.


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## Papa

sounds like ARDS to me.


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## FFEMT427

Smash said:


> Meningitis eh?  How much helicopter are you going to give them?  IV helicopter or IM helicopter?  I prefer to go with a large bolus of helicopter followed by an infusion to maintain therapeutic levels of helicopter in the body.
> 
> Helicopter is not a treatment.  Helicopter is a means of transport that is grossly overused in the US.



Hey smash do you usually drip in helicopter or pump it and I assume doses are given in kilograms(I laughed for 15 min straight after reading this comment)


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