scenario

You will have to make three responds to three different students. In your respond, you should show agreement and explain in details why you agree with the student.
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Here is the scenario:
You are called to a 4-year-old girl with respiratory distress. She was seen by her doctor 2 days ago, noted to have significant wheezing, and begun on home nebulizer therapy and steroids. Over the 2 days she has experienced increasingly more labored breathing and listlessness. General appearance: Anxious little girl, sitting up, in moderate respiratory distress, sleepy, but answers questions appropriately. Circumoral cyanosis present

Assessment:

Airway: Patent, patient speaks

Breathing: Moderate intercostal and subcostal retractions are present. Diffuse expiratory wheezing, crackles present throughout lung fields.

Circulation: Heart tones difficult to hear because of respiratory noise, thread peripheral pulses. Cool, slightly mottled extremities, capillary refill time 3 to 4 seconds

Jugular venous distention (JVD) present during exhalation

Initial Vital Signs:

P 150, BP 100/85, RR 36, estimated weight 15 kg.
What would be your intial treatment be and why?
Progression – Patient becomes somnolent between IV attempts, slowing respirations, becomes apneic and pulseless. IV infiltrates and is now unsuccesfful. EKG monitor reads VTach.
What would be your treatment be and why?

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**** Here is the first student answer:
What would be your intial treatment be and why?

The initial treatment for a patient susceptible of having refractory status asthmatics are; maintain the position of comfort or fowler?s position, supplemental oxygen via non-rebreather mask at 15 LPM with 500 mcg nebulized atrovent because the patient may have excessive mucus production , bronchospasm, and to some extent pulmonary edema that is primarily managed by position.

Progression – Patient becomes somnolent between IV attempts, slowing respirations, becomes apneic and pulseless. IV infiltrates and is now unsuccesfful. EKG monitor reads VTach.

What would be your treatment be and why?

For a witnessed V-tech patient, I would shock the patient with a 30 J, start chest compression while my partner is securing the airway through intubation. After two minute cycle of CPR, reassess the rhythm, pulse, and exchange position with my partner to avoid fatigue. I would also obtain IO access to give Epi 1:10,000 0.15mg every 3-5 minutes. If the v-tech is still showing on the monitor, we will deliver another shock with 60J , resume chest compression and consider Amiodarone 75mg IO bolus if the V-tech is still persisted. Repeat the 2 minute cycle of CPR with evaluating rhythm, pulse, and checking Hs and Ts.
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**** Here is the second student answer:
Initially, my treatment would focus on ABCs. I would position the patient appropriately, more than likely in the sniffing position with padding behind the shoulders, thus opening the airway and ensuring airway patency. Next, I would focus on the breathing and circulation. The labored breathing and wheezing is a major cause of concern for us, so I would first place the patient on high flow O2 via simple face mask or NRB, then I would administer 2.5mg of Albuterol in 2.5mL of NS via SVN and attempt to correct this issue. Due to the poor perfusion in the lung fields, this is probably causing her JVD and delayed cap refill. Therefore, the breathing issue must be corrected immediately. Children deteriorate at a much faster rate than adults, so if left untreated it could lead to respiratory failure or arrest. I would then attempt to gain IV access, but I would not administer a fluid bolus due to the crackles in the lung fields and the JVD. A corticosteroid such as decadron or solumedrol may also be indicated, but it should not delay further treatment as its effects are not immediate. Once we complete these steps and gather a SAMPLE & OPQRST, would we initiate rapid transport to a capable facility.

This was a witnessed arrest, therefore we will defibrillate as soon as possible. I will have my partner begin chest compressions at 100/per min while I prep the patient for a shock. My partner will use a simple adjunct such as an OPA with a BVM supported by 15L O2, and he will alternate 30 compressions and 2 breaths for 2 minutes unless I am ready to shock prior to. I would set the Joule setting to 30J and immediately defibrillate. If the rhythm is unchanged, we will continue with 2 minutes of CPR and use an IO needle to gain access to the circulatory system. At this point, it would be better to go ahead and drill due to the prior attempts at an IV being unsuccessful. I would administer 0.15 mg Epi 1:10,000(0.01mg/kg) via IO and at the end of the 2 minute cycle, administer a shock of 60J. If the rhythm still remains unconverted, we will continue CPR and administer 75mg of Amiodarone(5mg/kg) and consider endotracheal intubation if O2 sats are low or we are not getting adequate chest rise and fall. We will only perform this step if absolutely necessary, as children’s airways are much smaller and could be difficult to intubate. After the 2 minute cycle is complete, we will then administer another shock, of 115J(max 10J/kg) and assess the rhythm. If this leads to an unshockable rhythm such as PEA or asystole, then we will continue CPR, give another 0.15 of Epi, and treat our H’s & T’s. If pulses are regained, we will check the blood pressure and administer an antiarrythmic drip if it is to low. We will then proceed to ROSC care, and continue to support the patient and provide rapid transport. Overall, pediatric compromise is a delicate situation, but if the proper steps are followed and are timed appropriately, then the provider has done an excellent job no matter the outcome.
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**** Here is the third student answer:
What would be your initial treatment and why?

The initial treatment for the patient?s condition is to give oxygen therapy in order to assist the child in breathing. A non-rebreather mask may also be used. Another device that can help in the patient?s breathing is a humidified high flow nasal cannula which allows flows greater than a patient’s highest inspiratory flow demand to be brought via nasal cannula. Oxygen is given at first, typically in a greater amount than is required, however the amount of oxygen can be accustomed at a later time. Occasionally, in individuals in whom carbon dioxide levels have stayed high for some time, extra oxygen can lead to slowing of the movement of air in and out of the lungs and a hazardous additional increase in the carbon dioxide level. In such individuals, the dosage of oxygen has to be more cautiously regulated. I may administer 0.15 of Epi 1:10,000 IV because the patient exhibits a diffuse expiratory wheezing.

Progression – Patient becomes somnolent between IV attempts, slowing respirations, becomes apneic and pulseless. IV infiltrates and is now unsuccessful. EKG monitor reads VTach. What would be your treatment and why?

As the child?s condition worsens, I would ask my co-paramedic to position defibrillator pads on the child. As they do this, I would intubate the child and provide her with 100% oxygen and 15 Lpm. The child will then need to be transferred to the hospital. While with the patient, I would convey a 30-J shock then start applying cardiopulmonary resuscitation for two minutes and obtain IO access. After giving CPR for two minutes, I would assess the pulse rate of the patient. If the pulse rhythm can still receive shock, I would send another 60-J shock and start CPR for two minutes. After this procedure, I would give 0.15 mg of Epinephrine 1:10000. If IO cannot be created, I would render 1.5 mg of Epinephrine 1:1000 via the ET tube and after which, I would give the patient a saline flush. Pulse rate will be re-assessed including the rhythm. When shock is still possible I would repeat the second procedure which is to provide a 60-J of shock, CPR for two minutes, and this time, I would administer Amiodarone 75 mg. Underlying causes will be then be treated. When asystole is observed, CPR will again be rendered for two minutes and a 0.15 mg of epinephrine 1:10,000 will be administered. If the pulse is present, I will start with ROSC.