You just received a dispatch to a working class neighborhood townhouse for a two year old vomiting. Great. Another BS call. "Why does a parent call EMS because her kid is simply vomiting?", you ask your partner as you pull up the residence. The residence appears neat on the outside but the inside is cluttered but clean. The mother, obviously pregnant in her third trimester, holding the girl, tells you her daughter has been vomiting for the past hour or so and also had diarrhea. She apologized for calling you but she was concerned that the child had emesis x5 in the short time she was sick, and she was not sure but felt she saw blood in her liquid stool. Not only that, she says she is not acting right. She would have taken her to the hospital herself but she is snowed in from the heavy snow fall.
As you approach the child, she makes eye contact with you but seems a little listless and pale. She appears to be of normal weight and build for a 2 year old. She lets you take vitals with mother present. R24, normal and non labored; PaO2 98%; P110, S/R; BP 80/p (you still haven't whipped out the bad habit of your partner of getting a palp pressure as an initial on scene pressure); T 37C. Skin is a warm and dry with poor turger and cap refill of 3 seconds.
Mother states the patient has no PMX, was born full term with no complications or congenital defects, and immunizations are up to date. Mom stated the child ate breakfast of cereal and had a P&J sandwich for lunch with chocolate milk. In fact, she says embarrassingly, that she found her already awake in the kitchen helping herself to a box of Count Chocula when she awoke in the morning, with pantry cabinets open. When asked about potential ingestion of cleaning materials, she stated no, as they are under the sink secured by a latch that the child has not yet been able to open.
What other scene survey and/or patient assessment findings would you like to know?
So, what is the differential diagnoses?
What prehospital treatment does this kid need?
What is the appropriate destination for this kid?
If you have a suspicion, who will you call for consult?
What treatment will this kid get in the ER?
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ReplyDelete1. I'd like to identify everything in the cabinets the pt had access too. I'd also like to see the vomitus/diarrhea.
ReplyDelete2. Ingestion poisoning, gastroenteritis, intussusception.
3. Support of the ABCs, IV if accessible w/ a fluid bolus. If poisoning confirmed possibly activated charcoal.
4. Pediatric specialty facility if available, if not, generally the larger the facility the better.
5. Poison control / medical control w/ toxicologist available.
6. Labs, IV, fluids, potentially gastric lavage, potentially CT to check for intussusception.
Is she febrile ?
ReplyDeleteAny rashes ?
Blood sugar ?
Vitals are good for her age. I'd only do an IV if she started to deteriorate, as an upset, screaming, sick kid, as you fish for a vein, upsetting Mom in the process, is not a road I want to go down.
DaveO
Afebrile. No rashes. Normal blood sugar. Good questions to ask.
ReplyDeleteGastroenteritis is the obvious, but often not the correct diagnosis on calls. It is a diagnosis that can burn many providers, especially physicians.
Intusception is something to think about but consider with that there is most often pain with peristalsis and often the jelly-like stool.
Mom keeps her meds in the cabinet.
Mom's iron supplements (remember, she is pregnant) are open and the container appears almost empty, though it should not be.
In this case, poison control should be consulted and Pediatric specialty facility is the appropriate destination, not the local hospital, if possible.
With this information, do we have a clue now with approximate time of ingestion?
Do we still want to consider charcoal or lavage? Remember, these are usually only best if done less than an hour from ingestion.
What is the concern and what is the best treatment plan, prehospital and in the ED?
Remember, we don't just treat the vitals, especially in kids.