Reference no: EM133636282

Scenario:

You and your partner are completing morning chores at the station when you are dispatched to treat a child who fell from a third-story balcony. When you arrive in the quiet subdivision, you are flagged down by a frantic mother who points toward her 2-year-old son. You then see a toddler lying face up on the driveway approximately 3 feet from the house. The mother tells you that she turned her son over but did not move him any further.

The toddler is lying motionless. His eyes are open, but he does not focus on you or his mother as she stands crying beside him. You observe an adequate respiratory rate with good bilateral chest expansion. The boy appears pale and has cool, dry skin.

Patient is pale, lying motionless, making no eye contact. Responds to verbal stimulus. Airway is open and breathing is adequate and without retractions. Pulses are weak and skin is pale and cool.

You use the PAT to form a general impression of the patient. Based on his abnormal appearance and circulation, you determine the child is sick and requires rapid treatment. The combination of your knowledge that children are more prone to head injuries than adults because of the larger size and weight of their heads as compared with the rest of their bodies, the MOI, and your general impression of the patient leads you to suspect the child may have a closed head injury.

You immediately assign one of the fire fighters the task of maintaining manual cervical spine precautions. You ask your partner to apply 100% supplemental oxygen via nonrebreathing mask as you expose the child to a rapid trauma assessment. This examination reveals a mildly distended abdomen and an obviously deformed right thigh. You prepare to transport the child to a Level 1 pediatric trauma center.

Patients skin is cool and pale. Pulse 170, regular and distally weak but centrally strong. BP is 86/48. RR 40, unlabored. SaO2 99% on 12L/m via NR. Cap refill is 2-3 seconds.

Question: As you prepare to stabilize the patient for transport, he begins to vomit. While maintaining manual cervical spine stabilization, the child is log-rolled using a coordinated movement. Suctioning is performed to clear the airway. After suctioning, the child's oxygen saturation falls to 90%, his respiratory rate decreases to 16 breaths/min, and work of breathing increases. Your partner immediately begins bag-mask ventilation.

Recognizing the child is at risk for aspiration, you measure the child using a length-based resuscitation tape and gather the appropriate intubation equipment.

The child is successfully intubated with a 4.0 uncuffed ET tube using in-line cervical spine stabilization for the potential cervical spine injury. You confirm ET tube placement by direct visualization of the vocal cords, bilateral breath sounds, a positive capnography waveform, and etco2 reading.

You then secure the ET tube at the 12-cm mark at the teeth. Your partner continues to provide bag-mask ventilation at a rate indicated with waveform capnography and etco2 readings while you reassess the patient. You and your crew apply a cervical collar, secure the child to a pediatric spine board, and pad the voids with a blanket. You load him on the ambulance and cover him with blankets to keep him warm.

At ten minutes into the call: Patients skin is cool and pale. Pulse 174, regular and distally weak but centrally strong. ECG shows narrow complex tachycardia. BP is 78/46. RR 20, via BVM. SaO2 97% on 100% O2. Pupils equal and reactive. Cap refill is 4 seconds.

Based on the patient's vital signs and condition, you determine he is in compensated shock. You insert a 20-gauge peripheral IV catheter in both antecubital fossae and initiate a normal saline bolus. When you used the length-based resuscitation tape earlier, you estimated the child's weight to be approximately 12 kg, so you plan to administer a total of 240 mL (20 mL/kg).

You contact the receiving Level 1 pediatric trauma center. The physician agrees with your assessment and treatment and advises no further orders at this time. Vital signs remain unchanged.