Transcript Case Review *The Uncooperative Patient *Pediatric Cardiac Arrest

Amy Gutman MD
EMS Medical Director
[email protected]
 Provide follow-up on interesting calls
 Provide positive feedback
 Review anatomy, physiology & management of
important clinical conditions
 Close the “circle” from prehospital to hospital care
 PMH
 2004: GSW
 L2 incomplete cord transection at L2
 Left kidney nephrectomy
 Splenorraphy
 TBI & seizures
 2004: Polymorphic VT requiring defibrillation
 Implanted AICD recommended but family
declined
 Placed on beta-blocker therapy
 Patient physically punched in unknown area
 Chest vs neck?
 Initially c/o of SOB
 Subsequently became unresponsive
 Albuterol administered with no improvement
 Patient pulseless & apneic at ALS arrival
 14:11:03
 14:12:28
 14:12:53
 14:13:13
Call Received
Call Dispatched
Enroute
On Scene
 Less than 3 minutes between call & on scene
 Statistics show increased survival if less than 5
minutes to patient contact
 BLS 1st on Scene: “PT found unconscious. Resp
Arrest, No Pulse. Shocked 2 times. CPR
administered. Report by witnesses said PT hit in
the throat and possibly having an asthma attack.”
 ALS Report: “Pt supine on porch, CPR by BLS in
progress. Pt placed in unit. Assessed, Carotid
pulse with spontaneous breathing alebit 6x min.
BVM maintained with oral airway in place to assist
spontaneous respirations. MD notified with no
orders given. Transported L&S to Children’s.”
 Confirmed absence of pulse/ respirations
 CPR started
 2 shocked delivered for VF rhythm (AED)
 AED recordings show VF
PEA
VT
Sinus
 ROSC & spontaneous respirations post 2nd shock
 Hospital Treatment
 Patient intubated
 Labs including toxicology negative
 Head, neck & abdominal CT unremarkable
 EKG normal
 PICU & Disposition
 Due to PMH of VT, concern if arrhythmia was culprit
 Cardiology consulted
 Echo demonstrated tricuspid regurgitation
 Implantable ICD placed prior to discharge
 Placed on anti-epileptics for seizure activity
 Cardiac rhythm disturbance
secondary to trauma
 Usually young people during
sports
 Blunt, non-penetrating
precordial impact
transmitted to heart muscle
causing arrhythmia
 Pre-existing conditions make
individuals more vulnerable
 Treated with AICD & often
antiarrythmics
 Dispatch Time: 1420
 On Scene : 1426
 Upon your arrival, you find a 7 y/o female in the
school office unable to speak but appears to be
lucid & understanding your questions
 What is your next step?
 Airway
Open, no vocalization
 Breathing
18/minute; SPO2 99% ra
 Circulation
Pulse is 80
 Disability
Awake, alert, but unable to
speak
 What is you next step?
 S
 A
 M
 P
 L
 E
Signs Symptoms
Allergies
Medications
PMH
Last oral intake
Events leading up to the emergency
 What management is
indicated?
 What protocol does
this fall under?
 Was leaving this child
on scene the right
thing to do?
 Child was admitted to the
ICU at Children’s
 MRI demonstrated a
stroke in the “verbal” /
pareital territory
 Currently unknown as to
the extent, if any, of
disability
 Pediatric Sickle Cell
 Altered Mental Status
protocol
 Patient refusals
 Gut feelings when
dealing with children
 Recessive RBC disorder from
abnormal shaped hemoglobin*
 Hemoglobin S RBCs become
sickle-shaped with difficulty
passing through small vessels if
“oxidative stress”
 Sickle-shaped cells block small
vessels limiting blood-flow
causing ischemic-type pain,
stroke, MI
 Terms:
 Sickle cell “pain”
 Sickle cell “crisis”
 Acute Chest Syndrome
 Progressive occlusive
disease of the circle of
Willis & feeding arteries
 Results in vascular
stenosis & occlusion
 Mortality
 10% adults, 4.3% childrenfrom cerebral hemorrhage
 50-60% affected individuals with gradual deterioration of
cognitive function from recurrent strokes
 History
 Transient to severe neurologic deficits
 Adults commonly hemorrhagic; pediatrics commonly
ischemic
 Pediatric SSX
 Hemiparesis, sensory impairment, involuntary movements,
headaches, dizziness, seizures, MR, persistent neurologic
deficits
 Exam depends on location & severity of hemorrhage or
ischemia
 General health maintenance: PCN
prophylaxis, pneumococcus
vaccination, hydroxyurea, folic acid
 Multi-disciplinary treatment includes
ABX, analgesia, IVF, surgery,
psychosocial
 Transfusions with iron chelation
reduce pain crises, risk of ischemic
complications
 Moyamoya treatments are
neurosurgical & anticoagulation
 Pediatric AMS should always result in
transportation via EMS
 ANY new focal neurological deficit requires
immediate transport
 SCD in pediatric patients can be especially
challenging to manage
 Clear, cohesive documentation of findings
[email protected]