hammerpcp Posted April 9, 2007 Share Posted April 9, 2007 Called to a school code four (lights and sirens) tiered response with fire right ahead of you. You get the call as a five y/o male SOB. Arrive scene-elementary school, pt is in the library with several teachers present. You see a child in no obvious distress, standing, fire department surrounding and talking to him, he appears to be looking away form you. Let's start form the basics. What's your first move? Link to comment Share on other sites More sharing options...
Dustdevil Posted April 9, 2007 Share Posted April 9, 2007 Me and my partner take over the patient assessment and have the firemonkeys start gathering info from teachers and staff regarding the situation, history, and status of parental notification. Alternatively, if the firemonkeys are of proven reliability, the most reliable one stays with me to assist in the assessment, while my partner works on interviewing the staff so that the information received is sure to go with us. Link to comment Share on other sites More sharing options...
JonathanGennick Posted April 9, 2007 Share Posted April 9, 2007 Arrive scene-elementary school, pt is in the library with several teachers present. You see a child in no obvious distress, standing, fire department surrounding and talking to him, he appears to be looking away form you. Let's start form the basics. What's your first move? Do I know for certain that the child standing and talking is the patient? Link to comment Share on other sites More sharing options...
hammerpcp Posted April 9, 2007 Author Share Posted April 9, 2007 Yes, this child is the patient. Good idea to take over from the firemonkeys. They have been coddling and talking to the pt. When you take over you notice that the child is still looking to the left and is not responding to you or even acknowledging your presence. The teachers say that this child was reading in another room in the library when one of them tried to talk to him and he would not respond. The teacher then led the child into the adjoining room- he walked on his own but needed to be guided in the direction the teacher wanted him to go. He was still verbally unresponsive and did not seem to be making movements with any particular purpose. For example, he would walk a few steps in one direction as if with intent, but would then stand there "looking off into space". After approximately ten minutes with this teacher, the boy apparently took several steps and then collapsed to the ground. At this point 911 was activated. The boy's eyes remained open while on the floor and he still appeared to be looking off to the left. The pt has no medical history, no allergies and nothing like this has ever happened before according to staff and parents who were notified by phone. Your next move? Link to comment Share on other sites More sharing options...
dahlio Posted April 9, 2007 Share Posted April 9, 2007 Next step I would take is to get a set of vitals. That'll give you some idea of whats going on. Link to comment Share on other sites More sharing options...
spenac Posted April 9, 2007 Share Posted April 9, 2007 Vitals, including BGL and pupils. Link to comment Share on other sites More sharing options...
ERDoc Posted April 9, 2007 Share Posted April 9, 2007 Slap the sh!t out of him and tell him, "Quick faking it, get back to class slacker!" I have a few questions, but after that I will stay out of it. Hopefully in my abscence someone else will get it. Does he respond to threatening stimuli from either side? Does he follow an commands? Any obvious paralysis or lack of movement in any area? Is there any loss of bowel or bladder control? Do the parents know of any recent hea trauma? Any recent significant streesors in the boys life? Link to comment Share on other sites More sharing options...
hammerpcp Posted April 9, 2007 Author Share Posted April 9, 2007 Slap the sh!t out of him and tell him, "Quick faking it, get back to class slacker!" I have a few questions, but after that I will stay out of it. Hopefully in my abscence someone else will get it. Does he respond to threatening stimuli from either side? Does he follow an commands? Any obvious paralysis or lack of movement in any area? Is there any loss of bowel or bladder control? Do the parents know of any recent hea trauma? Any recent significant streesors in the boys life? Okay, so you slap the sh!t out of him and then the teachers get mad about having to clean the poo up. No response to any stimuli. You snap your fingers in front of his eyes and his gaze does not change. He does not respond to painful stimuli applied to any extremity or shoulder. Doesn't follow any commands. He is able to stand and walk unassisted- no paralysis of the lower limbs. Both arms are moving occasionally with some minor tremors in the left. Pt has been incontinent of urine. Every one denies recent trauma and there are no visible wounds/contusions etc. Stressors (I am assuming you are asking about psychological stressors) are unknown but it doesn't seem likely. Heart rate is around 130 bpm and is sinus on the monitor. Sats are 98-100% (Fire has applied O2-they get a little credit even though I am sure there was no critical thinking involved in this decision). Strong palpable pulses distally in all extremities (your BP cuff is too small for his leg and too large for his arm.) His colour isn't bad and there is no diaphoresis. Pt is breathing at approx 20-22 breaths per minute and they seem adequate. CBG is "Lo" which means it is below 1.1 mmol/L. Pupils are 6 and non reactive according to your partner who may or may not be an idiot (it's your first shift together). So? EDIT: to include profanity. Link to comment Share on other sites More sharing options...
crazycanuck Posted April 9, 2007 Share Posted April 9, 2007 From hammerpcp's post: "When you take over you notice that the child is still looking to the left and is not responding to you or even acknowledging your presence." >Deviated eyes and ALOC. Makes me think neuro involvement.... Can we have some more specific info such as GCS, any response to noxious stimuli or any motor response? From hammerpcp: "The teachers say that this child was reading in another room in the library when one of them tried to talk to him and he would not respond. The teacher then led the child into the adjoining room- he walked on his own but needed to be guided in the direction the teacher wanted him to go." >Non-responsive, still able to perform actions but not purposefully, would lead me to question whether or not this child was having a complex-partial seizure, definitiely still thinking neuro involvement (but still need to R/o hypoglycemia, trauma, infection, PMH, etc. Give us some more info please). Do we have any other info about actions during this time? Did the child display overt automatisms such as lip-smacking behaviour, or repetitive hand gestures, or any repeated facial movements/grimaces? from hammerpcp: "He was still verbally unresponsive and did not seem to be making movements with any particular purpose. For example, he would walk a few steps in one direction as if with intent, but would then stand there "looking off into space". " >Well on initial thought I was thinking, was the kid messing around, but that being said, (correct me if I'm wrong) kids aren't great at victim sims or faking symptoms. So- this type of behaviour, though it could have a non-organic basis such as attention-seeking or psychosomatic, does suggest this needs to be pursued and many many things need to be ruled out in an otherwise healthy child who is displaying sx of transient deficits and ALOC. from hammerpcp: "After approximately ten minutes with this teacher, the boy apparently took several steps and then collapsed to the ground. At this point 911 was activated. The boy's eyes remained open while on the floor and he still appeared to be looking off to the left." >Can we get a more specific description of this "collapse"? Was it a fall direct to the ground, with no hands put out for protection, how did the child drop, was it stiff or was he limp and slumped to the ground? Was there any motion during that time, any tonic/clonic activity, any coordinated or uncoordinated muscle movement? Was there any alteration in respiration? Any report of gurgling noises or any utterance at all from the child? Was there any deviation of eyes or did they remain fixed to the left the entire time. The pt has no medical history, no allergies and nothing like this has ever happened before according to staff and parents who were notified by phone. Your next move? > I want vitals first off. I want a complete H&P and as much info as possible from bystanders on the questions above. Now that you have arrived- you say the child is standing but still unresponsive and looking to the left? Current LOC? Current vitals? Describe his behavior now with him standing, is he responsive to verbal, motor, withdraw form painful stim? Describe his eyes, are they still fixed left or does he have any nystagmus? Any loss of bowel or bladder control? Any bleeding on lateral tongue or cheeks? I also want to know- you said the child is standing but still unresponsive? Did he get up right after he fell? Get some info about this transition from on the floor to back standing up. Did he just get up and then was altered again, or was he out of it the whole time? Hase he been responsive at all? So start with the basics: - Give us current vitals and answer some qns on HPI. BGL, get kid on monitor, O2 if you think you need it (he's been altered for awhile, it probably can't hurt), transport. As far as further assessment goes, it appears this child clearly needs some further investigation. I say look for the basic stuff first- prev trauma, possible ingestion, fam hx of seizures, psychological status, any info you get. Then, depending on the answers- I say eventually this kid will get a complete neuro workup and if that is clean w/o any physiological basis we go from there. Initial thought in the back of my head is neuro- seizure, some type of syndrome (Panayiotopoulos among many other seizure disorders), or non-organic seizure, BUT before I jump the ship on the complicated d/dx I want to know if we have ruled out the basics. Interesting case hammerpcp, thanks for sharing. Let's see where we're going with this. PS. One day I will learn how to quote, I hope this is legible enough. Edited to add that I had not seen your last post yet hammerpcp. Before I make any more comments I'm leaving this to stew awhile. Thanks. Link to comment Share on other sites More sharing options...
medic001918 Posted April 9, 2007 Share Posted April 9, 2007 I'm curious as to a complete set of vital signs as well. My first thoughts would be an absence seizure given the gaze and the overall presentation. But the glucometer reading makes me wonder if something else might be going on as well. Is his skin diaphoretic? Dry? I think I would probably do a repeat BGL in case I had a bad sample (it's happened to me before). Does he respond to the finger stick? If it comes up the same, maybe consider half an amp (12.5 gm) D50 or D25 depending on your protocols and what you carry. I would want to see if that causes any change in his presentation. Since he's at school, there might not be any really well versed in his medical problems. They only have the parents sheet to go off of and who knows how recently it was updated to reflect any current condition. What time of day is it? Would he have eaten? Can any of his classmates provide information about if he's eaten and how much? Sometimes you can pull some information there even though they're kids. I'm inclined to agree with crazy though about the neuro involvement. However that could be secondary to a hypoglycemia as well. Shane NREMT-P Link to comment Share on other sites More sharing options...
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