Pediatric Scenario

[Smash]

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.

 

[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.

 

[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.

 

[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.

 

[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.

 

[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.

 

[abckidsmom]

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.

 

[PFD2171]

Kiddo

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.

 

[abckidsmom]

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?

 

[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.

 

[Katy]

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.

 

[exodus]

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.

 

[abckidsmom]

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.

 

[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.

 

[fast65]

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.

 

[Katy]

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 ?

 

[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.

 

[Katy]

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.

 

[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...

 

[Katy]

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.