Scenario #1: A sick little girl

[taporsnap44]

Being a paramedic student, I always seem to learn a lot from scenarios. So with that said, I believe doing scenarios with a lot of input from various members at different training levels will be an exceptional learning tool. So here is the first one.

Date and Time: Monday, October 05, 2009 at 1900
Scenario: Dispatched for 9 YO F unresponsive

Arrive on Scene and the dad meets you out front, he is worried but not frantic, he leads you inside to his 9 YO daughter who is lying on the couch in a daze. She is awake but she is sluggish in her movements.

History – No medical history
Medications – No medications
Allergies – NKDA

Father’s statement - The farther states that she began feeling bad about 3 days ago and it has progressively gotten worse. He states that she has only had Pedialite and toast since Friday which she has vomited up most of the time. He also states that she has been complaining that her stomach hurts. He says that he had called her pediatrician who diagnosed her over the phone with a virus. He then tells you that he went to work this morning and left her with her grandmother and when he got back, something just was not right and that’s why he called.

Assessment – Alert and oriented but sluggish, Skin – hot and dry, Blood pressure 90/palp, Pulse – 130, Respirations – deep and labored, SpaO2 94% on RA.

Proceed with a differential diagnoses and possible treatment plan. If you ask questions I will fill them into the assessment.

 

[amberdt03]

Being a paramedic student, I always seem to learn a lot from scenarios. So with that said, I believe doing scenarios with a lot of input from various members at different training levels will be an exceptional learning tool. So here is the first one.

Date and Time: Monday, October 05, 2009 at 1900
Scenario: Dispatched for 9 YO F unresponsive

Arrive on Scene and the dad meets you out front, he is worried but not frantic, he leads you inside to his 9 YO daughter who is lying on the couch in a daze. She is awake but she is sluggish in her movements.

History – No medical history
Medications – No medications
Allergies – NKDA

Father’s statement - The farther states that she began feeling bad about 3 days ago and it has progressively gotten worse. He states that she has only had Pedialite and toast since Friday which she has vomited up most of the time. He also states that she has been complaining that her stomach hurts. He says that he had called her pediatrician who diagnosed her over the phone with a virus. He then tells you that he went to work this morning and left her with her grandmother and when he got back, something just was not right and that’s why he called.

Assessment – Alert and oriented but sluggish, Skin – hot and dry, Blood pressure 90/palp, Pulse – 130, Respirations – deep and labored, SpaO2 94% on RA.

Proceed with a differential diagnoses and possible treatment plan. If you ask questions I will fill them into the assessment.

what is her temp, lung sounds, and glucose level?

 

[redcrossemt]

what is her temp, lung sounds, and glucose level?

Agreed - additional assessment of temperature (core if possible), lung sounds, blood glucose level, pupils, and ecg. Would also like to know about urine output, as well as if any OTCs have been given for the pain or fever.

Without additional information, my initial treatment thoughts consist of supplemental oxygen and a fluid bolus. Possibly acetaminophen as well for the fever. My bet is hypovolemia secondary to an infection and limited intake.

 

[Smash]

Temp. Blood glucose and ketones. Breath sounds. Any smell on her breath? ECG. Pupils. Neuro assessment. Any signs of meningism? Any family history of diabetes? Any history of polyuria, polyphagia or polydipsia? Bowel motions? Any medications taken/given? Any access to medications, legal or ortherwise?

Pending more detail I'd be leaning towards DKA, possibly secondary to an infective process.

Oxygen, IV, bolus fluid, transport. Watch conscious state, consider intubation if pt tiring or GCS dropping. If inubated, maintain EtCO2 at pre intubation levels.

Keep a close eye on monitor at all times.

 

[DV_EMT]

I'd like lung sounds and urine output as well. And the fever temp if one is present?

 

[MrBrown]

Here's what I am thinking

Hot, dry skin - fever and dehydration
Deep, laboured resps - trying to excrete excess CO2
ALOC - rising level of CO2
Tachycardic - possibly one of the ubiquidose 400 causes, sign of physiological stress

 

[Akulahawk]

At this point, I'm thinking what you've got on your hands is a 9 YO that is likely hot, dry, and sluggish from an infective process... possibly the flu. I'd also be concerned about a small bowel obstruction...

Neuro: alert & oriented... but sluggish. Nuchal rigity?
Eyes: PERRLA?
Lungs: unk
Cardiac: pulse 130. heart sounds? unk
abd: complains of pain. tenderness? rebound tenderness? sounds?
glucose: unknown
Bathroom: urine output? last observed BM?

My tx for now: O2 by NC, IV fluid bolus (20mL/kg), if the 9 YO is too hot - APAP if allowed locally. D25 or D50 (per protocol) PRN if hypoglycemic. Transport C2 to facility of parent's choice. Reassess frequently during transport.

This kid looks "sick" but (so far) not scoop & run C3 sick, based on what's known so far.

The above plan WILL LIKELY change based on additional reported findings...

 

[taporsnap44]

Temperature: 101* orally
Lung sounds: Clear and equal bilaterally
BGL: Reads HI
Pupils: PERL
ECG: Sinus Tach
Urine output: Farther states she has been urinating more than usual even with not eating or drinking much over last 3 days.

No smell on her breath.

Abdominal assessment: Tender in all 4 quadrants w/ active bowel sounds.

Grandmother confirms family h/x of diabetes.

 

[MrBrown]

I'm going with DKA

 

[DV_EMT]

Well if her lungs weren't clear... I would gone with bilateral pneumonia. But now idk what... I think dka is a possibility

 

[rescue99]

Temperature: 101* orally
Lung sounds: Clear and equal bilaterally
BGL: Reads HI
Pupils: PERL
ECG: Sinus Tach
Urine output: Farther states she has been urinating more than usual even with not eating or drinking much over last 3 days.

No smell on her breath.

Abdominal assessment: Tender in all 4 quadrants w/ active bowel sounds.

Grandmother confirms family h/x of diabetes.

The magic answers that give a possible diagnosis away.....diffuse abdominal pain and frequent urination.

 

[SoCal]

possibly HHNK?

I know HHNK is seen in older Type 2 Diabetics however, with no keytones on the breath and the BGL of HI, you could be possibly dealing with a sick little girl. Pts. presenting with HHNK are severely dehydrated and develops over time and results in polyuria, polydipsia, tachycardia, and dry membranes just like DKA. Also HHNK will lead to lethargy and confusion.

Just my guess....

 

[rescue99]

possibly HHNK?

I know HHNK is seen in older Type 2 Diabetics however, with no keytones on the breath and the BGL of HI, you could be possibly dealing with a sick little girl. Pts. presenting with HHNK are severely dehydrated and develops over time and results in polyuria, polydipsia, tachycardia, and dry membranes just like DKA. Also HHNK will lead to lethargy and confusion.

Just my guess....

DI is another possibility...

 

[SoCal]

That's true^^ possibly undiagnosed till now?

 

[usalsfyre]

HHNK is possible due to the posibility of an infective process, but I'd go with DKA until proven otherwise. Family hx of diabetes, IDDM or NIDDM? A DI pt is probably not going to present as "HI" on a glucometer.

As of now treatment plan is an initial fluid bolus followed by maintnance, standard airway monitoring, and transport to a pediatric center by whatever method is practical.

 

[MrBrown]

So do we have a proper BGL rather than just the monitor says "high" ??

I'd go with 10ml/kg fluid bolus and transport

 

[rescue99]

HHNK is possible due to the posibility of an infective process, but I'd go with DKA until proven otherwise. Family hx of diabetes, IDDM or NIDDM? A DI pt is probably not going to present as "HI" on a glucometer.

As of now treatment plan is an initial fluid bolus followed by maintnance, standard airway monitoring, and transport to a pediatric center by whatever method is practical.

You are probably correct. Glucose probably won't be high. New onset IDM is most likely going to be the dx. Just had throw all potentials into the ring. 1 hour at the ER and they'll have the correct diagnosis.

 

[triemal04]

HHNK is possible due to the posibility of an infective process, but I'd go with DKA until proven otherwise. Family hx of diabetes, IDDM or NIDDM? A DI pt is probably not going to present as "HI" on a glucometer.

As of now treatment plan is an initial fluid bolus followed by maintnance, standard airway monitoring, and transport to a pediatric center by whatever method is practical.

If I'm remembering right pancreatitis can cause or contribute to HHNK if the pt allready has underlying NIDDM; could help to explain the abdominal pn, though it's usually more specific than reported.

Even with the lack of an odor on the pt's breath, the rapid/deep respirations are more indicative of ketoacidosis, which won't be seen in HHNK.

So do we have a proper BGL rather than just the monitor says "high" ??

I'd go with 10ml/kg fluid bolus and transport

The vast majority of glucose meters seen outside a lab will not read higher than 500 or in some cases 600mg/dL and lower than 10mg/dL. What's the upper limit in New Zealand?

 

[MrBrown]

The vast majority of glucose meters seen outside a lab will not read higher than 500 or in some cases 600mg/dL and lower than 10mg/dL. What's the upper limit in New Zealand?

Ours go up to 33 mmol/l but i have never seen it that high

 

[triemal04]

Ours go up to 33 mmol/l but i have never seen it that high

So about the same as the ones used here. Curious, what about the lower limit? Numbers aside, the point is that getting a "proper" cbg reading may not be possible with the equipment available. Of course, as long as you know your equipment this isn't a issue; "low" means VERY low, and "high" means VERY high; treat accordingly.