# Some Pediatrics



## Sam Adams (May 16, 2012)

First time presenter, long time reader. It won't be the most challenging of scenarios, but will hopefully bring up some interesting learning points. If you're BLS, play BLS. If you're ALS, play ALS. 

I'm going to *attempt* to present this much akin to the wise folk over at Flightweb. If you haven't seen them, I recommend spending a few weeks going through their cases.

You're are working with a partner who matches your certification level in an ambulance full of whatever you need. It's a nice spring afternoon and you're dispatched to a 2 yom vomiting on a street in a neighborhood that's in "transition". You immediately recognize the name of the small dead end street and recall a homicide that occurred there not long ago. You and your partner back the truck down the street and are met by a 10 year old boy who points to the stairs and says without much emotion, "all the way up". You huff and puff your way to the 3rd floor apartment where a well dressed middle aged women points you into the bedroom and says that he's been sick all day. You arrive at the patient's side to find him: sitting on the edge of the made bed being dressed by a woman who reports that she's his mother. She's managing (quite well) 2 other children and getting your patient dressed. She states that he had a poor appetite all yesterday and started vomiting just before he went to bed.

Go.


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## blindsideflank (May 16, 2012)

Well let's get the, basics here. 
Poor appetite yesterday was the first sign of any symptom, or anything different from the norm?
Vomiting since last night, has it gotten better? Worse? More often? What does it look like? Has it changed?
Any other s/s pain etc. Anything make it worse or better?

Kids medical hx, meds allergies last ate/drank and what. Fam hx, any current sickness in house, has this happened before? Socioeconomic situation ( you've given a decent picture) drugs around mold  etc.

Then vitals please?

I hope that not too generic to start things off, I'll come guns a blazin once this gets rolling


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## bigbaldguy (May 16, 2012)

What's the room and house look like, any odors any odd things lying around? Other children look healthy? Sick childs behavior is normal in regards to situation. Is he alert, does he appear to be scared, does he look at you.


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## WTEngel (May 16, 2012)

Vitals including temperature

Toe to head exam with palpation of abdomen in all 4 quadrants checking upper right for liver descension or bleeding, rigidity, guarding and signs of abuse/trauma

Assess neurological status, pupillary response and identify any trauma to the head neck and back

I do not suspect GI issues given the information, as NV is typically combined with diarrhea in these cases.

Infection or "stomach virus" is a wild card, with no mention of a fever, I am probably not going down the infection route.

I am thinking possible NAT given that the child and mother are not mentioning any known traumatic incident.

Establish IV access for potential fluid resuscitation, place child in min-stim environment, transport rapidly to closest pedi specialty center with trauma services. Prepare to control airway should neurological status deteriorate and the patient lose their ability to clear secretions.

Just my two cents, I may be way off. Maybe I am a cynic, but being that I have seen this type of situation a few dozen times before, I am a bit jaded.


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## Sam Adams (May 16, 2012)

blindsideflank said:


> Well let's get the, basics here.
> Poor appetite yesterday was the first sign of any symptom, or anything different from the norm?



No



blindsideflank said:


> Vomiting since last night, has it gotten better? Worse? More often? What does it look like? Has it changed?



last night: partially digested vomitus. This afternoon clear fluid. No frank blood. Mother reports last PO was an attempt at water which promptly came back up. Apparently what goes down, comes back up ...



blindsideflank said:


> Any other s/s pain etc. Anything make it worse or better?



No other reported pain/ discomfort, just the (assumed) nausea and PO induced vomiting.


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## Sam Adams (May 16, 2012)

bigbaldguy said:


> What's the room and house look like, any odors any odd things lying around? Other children look healthy? Sick childs behavior is normal in regards to situation. Is he alert, does he appear to be scared, does he look at you.



3 floor apartment building with a separate apartment per floor. First 2 floor hallways could be better, could be worse. The apartment you're in is clean and well kept. It is the grandmother's residence and appears to be a central meeting point for her family. She is "grandma day-care" while mom is at work. The children (approximately 6 present) are all (including the patient) clean, well fed, clothing appropriate for the weather and are being kids. The patient is acting appropriately for a 22 month old (looks at mom when you walk in the door, but a perceived familiarity with medical personnel).


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## crazycajun (May 16, 2012)

Please provide baseline vitals and assessment findings. Also this is grandma's house so the assumption of a clean environment has to be ruled out until the status of the actual residence is known. Has there been any unusual order form urine output? Color? Has he had any bowel movements? Any associated fever? Trouble swallowing?


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## Handsome Robb (May 16, 2012)

I'm with WTEngel on this one. 

Kid goes in the "sick" category and I'm not going to dilly-dally on scene. I'm not comfortable with peds at all though after my recent experiences. They scare the bajeebers outta me. 

Anything in or around the child's mouth that may suggest some sort of ingestion? Any signs of trauma or abuse? 

Still waiting on neurological status. Tracking me? Interacting? Lethargic? PERRL? GCS? Can mom help calm him? They seem to usually be able to do a pretty good job of chilling the little tykes out. 

Still waiting on vitals including a BGL and temp if we are so lucky in our beautifully stocked ambulance. 

Still waiting on HAM.


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## Sam Adams (May 16, 2012)

WTEngel said:


> Vitals including temperature
> 
> Toe to head exam with palpation of abdomen in all 4 quadrants checking upper right for liver descension or bleeding, rigidity, guarding and signs of abuse/trauma
> 
> Assess neurological status, pupillary response and identify any trauma to the head neck and back



Walking up to the child you observe that he is ~ 18-20 kgs and is in no apparent distress. As mentioned before dressed appropriate for his age and the weather. He is clean and is neither under or over weight for his age. He is not tripoding there are no supraclavicular retractions. He speaks w/o difficulty and again you notice an apparent familiarity w/ health care providers in his eyes. 

PE: Big toe cap refill is < 2 secs. you notice age appropriate minor bruises to his shins and knees. His LEs are otherwise unremarkable. His pelvis is unremarkable w/ no apparent incontinence of urine or feces. When asked mom reports normal urinary patterns w/o hematuria, not dark, normal smelling. Last BM was last night and was normal. The child grants permission to lift up his shirt and palpate his abd. It's soft non-tender x 4. non distended, no obvious trauma. His lower back is unremarkable. As you're pulling out your stethoscope to listen to LS's your partner begins to get the child's PMH, meds and Hx. You slide your stethoscope in between his shirt and back and appreciate rhonchi on the L base. While repositioning your 'scope you think you hear the word "lasix" but you're not sure. It could have been "when was he "last sick". His LS are otherwise clear to auscultation with good tidal volume bilaterally. You question mom about the patient having a cough or cold recently and she states he was hospitalized for bronchiolitis 2 weeks ago for 6 days but has been fine since d/c. You attach your pulse oximeter to his big toe and start to slide your scope down the front of his shirt to auscultate an apical rate and check if it correlates w/ your pulse ox when you notice a "zipper" down the front of his chest. (did you really hear the word lasix?) Apical rate matches brachial and big toe pulse oximetry. His torso is otherwise unremarkable. No retractions. No signs of trauma. His neck is unremarkable. No JVD. No tracheal shift > 3 mm He has a short cropped hair cut and there is no obvious trauma. Pupils = and reactive to light at 2-3mms no jaundice. There are moist mucus membranes and his teeth are clean. No obvious odor to his breath or person.

He has a BP of 104/66 HR: 108 RR: 20 SaO2: 97% and his skin is warm dry non-tenting w/ a tympanic temp of 98.8.

You ask about the "zipper" and mom states he had surgery ~ 1 year ago because he "outgrew his original shunt and they had to repair it". She goes on to mention what sounds like a VT shunt due to a birth defect. She denies a PFO and says it had to do with his ventricle. Aside from the thoracic surgery he has a HX of: bronchiolitis and asthma.

Meds: Albuterol, Aspirin, Captopril, Lasix, Plavix, Singulair and Zantac.

He has No Known Drug Allergies.

Mom finishes getting him dressed picks him up and starts to carry him down the stairs in front of you. You quickly gather up your gear and follow her out the door and into the ambulance.

The Level 1 children's hospital where he had his procedure done is about a 15 minutes away. There is a closer Level 2 pediatric center about 5 away.


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## WTEngel (May 16, 2012)

Take him to the hospital where he is followed so he can get his shunt revised.

In real life this scenario would have gone more like:

You walk up three flights of stairs and are greeted by mom, who informs you she needs you to transport her and her child to XYZ Children's Medical Center for shunt complications.

Enough said.

edit to add: 

If your protocols call for it (like mine did when working peds critical care) you could palpate the bulb and possibly tap the shunt depending on the site of the complication.

Kids surgical site would likely have been visible behind the ear, although with long hair it could be obscured.

Additionally, not sure why he would have a zipper scar along the chest. Did he have a cardiac defect repair also? An abdominal scar perhaps, but not the typical chest "zipper" scar.

Also, it is a VP shunt (abbreviation for VentriculoPeritoneal) not VT shunt


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## WTEngel (May 16, 2012)

^^^^^^400 Posts^^^^^^^

And congratulations to me....I expect all of the privileges that typically come along with captain status...


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## Handsome Robb (May 16, 2012)

I want to take him to the level I where he was treated before. It'll avoid an extra transport and bill later and I don't see anything screaming time sensitive at this point but I'm still not going to spend much time fooling around on scene or in the box before going en route to the hospital. 

Being on the new side I'd toss him on the monitor for my own piece of mind, work on IV access but I'm not going to go over the top trying to get a line. 2 shots and I'm finished Let the pediatric center that starts pediatric lines every day get a line. If poo really hits the fan I can drill an IO. Since I'm awesome and got my line on the first shot  I'll nab a BGL off the flash chamber and hang a bag TKO, I'm not super keen on giving him a fluid bolus. I'd be thinking of a .15 mg/kg (3 mg total) dose of zofran for the little one to get him feeling a bit better and hopefully ward off any future vomiting. 

Now just monitor him en route. This can't be that easy. I feel like there's a curveball coming in hot sooner or later.


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## Sam Adams (May 16, 2012)

WTEngel said:


> Take him to the hospital where he is followed so he can get his shunt revised.



agreed.




WTEngel said:


> If your protocols call for it (like mine did when working peds critical care) you could palpate the bulb and possibly tap the shunt depending on the site of the complication.
> 
> Kids surgical site would likely have been visible behind the ear, although with long hair it could be obscured.
> 
> ...



You assume it's a VP. Shunt and look behind the ears to find nothing. No scars. No bulbs. Nothing.

In the back of the ambulance you attmpt and get an IV on the 1st attempt. Your thorough and get a BGL: 97 mg/ dl. You KVO the fluids and begin t/p to the facility where he had the shunt placed. Enroute you go over the info you have including the VT shunt. 

Mom says no. Not VT shunt. BT shunt. B as in boy.

How does this change things? Still going to "his" facility? Zofran was mentioned. Still gonna give it? Anything else we want?


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## usalsfyre (May 17, 2012)

Sam Adams said:


> agreed.
> 
> 
> 
> ...



Changes....nothing really. He sure as death and taxes doesn't need a different surgeon cracking him open and rooting around. Zofran isn't a drug I'd be horribly scared of in this case, I'd just want an EKG in hand to look at QT perhaps.

We're not really at "OMG" levels yet...


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## Aidey (May 17, 2012)

Correcting it to BT shunt still doesn't really help all that much. What is the underlying heart condition?


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## WTEngel (May 17, 2012)

Things are starting to add up now, somewhat.

The chest scar makes sense. I am not following the vomiting chief complaint though. I am used to it being referred to as a Blalock not BT or Blalock Tausig, so I guess it threw me a bit there. I am also replying on the move, so forgive me if I haven't read all the pertinent details..

At any rate, yes I am absolutely taking this child to the hospital he is normally followed at. Begin fluid resuscitation as appropriate. Thrombolytic therapy may be in order to relieve, but not necessary at this time, he seems to be managing. 

Our surgeons preferred the Sano over the Blalock if at all possible (less clotting typically), although they usually don't make the ultimate decision until they were in the chest and could look at the anatomy. 

I am wondering why the Blalock is still in place and they have not proceeded with the BD Glenn. By this point he is only about a year out from a Fontan...he is nearly 2 years old, right? Is this kid a hypoplast or a tet?

SPO2 of 97% is interesting, especially considering he still has his shunt in place, although I guess if it has a clot the pre ductal sat might be high (no mixing), but you said the post ductal sat was high (big toe) so these things don't necessarily add up in my mind... 

Anyway, I have a lot of questions. There are some things in your scenario that don't quite paint the picture I would expect to see in this situation.


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## Sam Adams (May 17, 2012)

Sorry. No zebras here. What ultimately ended up happening was, we t/p the pt in a position of comfort to the hospital that performed the surgery without any complications. I had never heard of a B.T. Shunt and asked what it was and for. Mom didn't know exactly what it was, but said that it was for a "single L ventricle". Sensing further information wasn't forthcoming I asked if she would allow me to use my smartphone to look it up and she consented. 

Thinking that others hadn't heard of a Blalock-Taussig Shunt I brought it up here. But you know-it-alls  seem to already have a pretty good grasp on it. 

I too questioned why it was still in and that further corrective action hasn't been taken. A 10-15 minute t/p didn't allow me to get that far into it with her. I attribute his SpO2 of 97% to some lingering complications of his hospital course for the bronchiolitis. I'm still waiting for follow-up from our medical director but am thinking the vomiting was just a virus of sorts, maybe acquired during his last hospital stay.

I'm still doing a lot of research on this and will post accordingly.

Fire away.


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## WTEngel (May 17, 2012)

Sounds like she may be describing a hypoplastic left heart, although I guess it could be a left ventricle dominant cardiac anatomy?

Typically these parents have a pretty good grasp on the medical condition of their child, but it isn't abnormal to encounter clueless ones either.

The kids SPO2 I would have expected to be lower considering he still has mixing of the blood with the Blalock.

Anyway...decent scenario. Not much field treatment to be done for the kiddo, unless you want to finish his Fontan for him...which it sounds like he might need.


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## Sam Adams (May 17, 2012)

WTEngel said:


> The kids SPO2 I would have expected to be lower considering he still has mixing of the blood with the Blalock.



Good point. I see what you're getting at.


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## Handsome Robb (May 17, 2012)

Well I learned something new. Thanks Sam Adams!


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