Flights - Shaken

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Welcome to the sixth and final case in our Air Care and Mobile Care Flight Orientation Curriculum! 

Every few weeks throughout the spring and early summer, we have posted a series of cases published to help spur some thought and discussion on the management of the critically ill patients we take care of in the pre-hospital environment.  These virtual flights are used to highlight some key considerations in the management of blunt trauma, penetrating trauma, STEMI, and several other common disease processes seen on Air Care.

Comments will be open for 2 weeks after which time, a post containing expert commentary and curated commentary from the community will be published to reinforce the key learning points brought up in discussion.

http://pixabay.com/en/epilepsy-seizure-stroke-apoplexia-156105/

http://pixabay.com/en/epilepsy-seizure-stroke-apoplexia-156105/

You are sitting on the helipad during your UH shift talking with the flight nurse when the tones drop for a pediatric scene call.  You gather yourself after you have that crap your pants moment that everyone has with pediatric scene calls and whip out your smart phone with your pediatric application of choice.  You begin to write down doses and sizes on your tape on your leg based on the report of the patient’s weight from the providers on scene.

You land in an elementary school parking lot to the delight of the children at the local school.  Cars begin to slow and pull over as you exit the helicopter and walk to the squad.  You walk to the side door of the ambulance and find 6 EMTs crammed in the squad.

They tell you they have a 3yo WM with no significant past medical history for whom they called for Air Care after arrival at the scene when they found the child with generalized tonic clonic activity and they are a 40 minute drive from any hospital.  The daycare worker reports that the child was fine until an hour ago when he began to act very sleepy.  20 minutes before your arrival, he began to have “seizures” and that is when they called 911. 

When you walk in the ambulance you notice a hematoma on the child’s head but the daycare denies any trauma or recent illness, but are unsure how he received the hematoma on his head or the bruises to the extremities.  They say they noticed that when the child was dropped off, but didn’t question any further.

 Physical Exam

  • Vitals: P: 145, BP: 100/65, RR: 38, O2 Sat: 86% on BVM, Glucose: 114

  • General: in acute distress, unresponsive to painful stimuli, generalized convulsions

  • Cardiovascular: tachycardic

  • Pulm: clear BS bilaterally

  • Abdomen: soft, nontender, nondistended

  • Musculoskeletal: multiple bruises to the upper and lower extremities in varying stages

  • Neuro: convulsive like movements of the upper and lower extremities, large hematoma over the occiput, pupils with right pupil 5mm, fixed and left pupil 4->2mm, sluggish

Past Medical History

  • None

  • UTD on immunizations

Interventions prior to arrival

  • Being bagged

Questions

Are there any immediate procedures that need to be performed?  Are there any medications that need to be given immediately?  What if the child is still unresponsive after benzodiazepines?

If you decide to intubate this child, describe what mediations you would use for rapid sequence intubation and sedation?  Would you place the child on the ventilator and how would you determine tidal volume and rate?

Would you be concerned for elevated ICP on this child’s exam?  What medications, maneuvers, and strategies would you consider to mitigate this?

The parents show up on scene as you are about to move the child to the stretcher and are insistent to fly with the child.  Are you concerned for non-accidental trauma?  Do you let them fly with you or how do you explain to them that you are denying them the ability to fly with their sick child?

*To help facilitate discussion, when commenting please precede your answer to a particular question with Q1, Q2, etc.