Pediatric Case Reviews

1. Pediatric Case Reviews Amy Gutman MD EMS Medical Director Prehospitalmd@gmail.com

2. Case Review Objectives • 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

3. Case 1 ~Pediatric Cardiac Arrest

4. Patient Information • 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

5. HPI • 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

6. Call Times • 14:11:03 Call Received • 14:12:28 Call Dispatched • 14:12:53 Enroute • 14:13:13 On Scene • Less than 3 minutes between call & on scene • Statistics show increased survival if less than 5 minutes to patient contact

7. Patient Narrative • 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.”

8. EMS Treatment Summary • 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

9. Follow-Up ( • 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

10. CommidoCordis • 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

11. Case 2 ~Pediatric AMS

12. Dispatch: “7 yo female needs transport to the hospital” • 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?

13. Primary Survey • 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?

14. Secondary Survey • S Signs Symptoms • A Allergies • M Medications • P PMH • L Last oral intake • E Events leading up to the emergency

15. Physical Exam

16. Treatment • What management is indicated? • What protocol does this fall under? • Was leaving this child on scene the right thing to do?

17. Patient Outcome • 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

18. Points for Discussion • Pediatric Sickle Cell • Altered Mental Status protocol • Patient refusals • Gut feelings when dealing with children

19. Sickle Cell Disease (SCD) • 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

20. Moyamoya “Puff of Smoke” • Progressive occlusive disease of the circle of Willis & feeding arteries • Results in vascular stenosis & occlusion

21. Circle of Willis Moyamoya

22. Moyamoya Presentation • 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

23. SCD Treatment • 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

24. Case Summary • 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

25. Questions? prehospitalmd@gmail.com