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Amy Gutman MD EMS Medical Director [email protected] Provide follow-up on interesting calls Provide positive feedback Review anatomy, physiology & management of important clinical conditions Close the “circle” from prehospital to hospital care PMH 2004: GSW L2 incomplete cord transection at L2 Left kidney nephrectomy Splenorraphy TBI & seizures 2004: Polymorphic VT requiring defibrillation Implanted AICD recommended but family declined Placed on beta-blocker therapy Patient physically punched in unknown area Chest vs neck? Initially c/o of SOB Subsequently became unresponsive Albuterol administered with no improvement Patient pulseless & apneic at ALS arrival 14:11:03 14:12:28 14:12:53 14:13:13 Call Received Call Dispatched Enroute On Scene Less than 3 minutes between call & on scene Statistics show increased survival if less than 5 minutes to patient contact BLS 1st on Scene: “PT found unconscious. Resp Arrest, No Pulse. Shocked 2 times. CPR administered. Report by witnesses said PT hit in the throat and possibly having an asthma attack.” ALS Report: “Pt supine on porch, CPR by BLS in progress. Pt placed in unit. Assessed, Carotid pulse with spontaneous breathing alebit 6x min. BVM maintained with oral airway in place to assist spontaneous respirations. MD notified with no orders given. Transported L&S to Children’s.” Confirmed absence of pulse/ respirations CPR started 2 shocked delivered for VF rhythm (AED) AED recordings show VF PEA VT Sinus ROSC & spontaneous respirations post 2nd shock Hospital Treatment Patient intubated Labs including toxicology negative Head, neck & abdominal CT unremarkable EKG normal PICU & Disposition Due to PMH of VT, concern if arrhythmia was culprit Cardiology consulted Echo demonstrated tricuspid regurgitation Implantable ICD placed prior to discharge Placed on anti-epileptics for seizure activity Cardiac rhythm disturbance secondary to trauma Usually young people during sports Blunt, non-penetrating precordial impact transmitted to heart muscle causing arrhythmia Pre-existing conditions make individuals more vulnerable Treated with AICD & often antiarrythmics Dispatch Time: 1420 On Scene : 1426 Upon your arrival, you find a 7 y/o female in the school office unable to speak but appears to be lucid & understanding your questions What is your next step? Airway Open, no vocalization Breathing 18/minute; SPO2 99% ra Circulation Pulse is 80 Disability Awake, alert, but unable to speak What is you next step? S A M P L E Signs Symptoms Allergies Medications PMH Last oral intake Events leading up to the emergency What management is indicated? What protocol does this fall under? Was leaving this child on scene the right thing to do? Child was admitted to the ICU at Children’s MRI demonstrated a stroke in the “verbal” / pareital territory Currently unknown as to the extent, if any, of disability Pediatric Sickle Cell Altered Mental Status protocol Patient refusals Gut feelings when dealing with children Recessive RBC disorder from abnormal shaped hemoglobin* Hemoglobin S RBCs become sickle-shaped with difficulty passing through small vessels if “oxidative stress” Sickle-shaped cells block small vessels limiting blood-flow causing ischemic-type pain, stroke, MI Terms: Sickle cell “pain” Sickle cell “crisis” Acute Chest Syndrome Progressive occlusive disease of the circle of Willis & feeding arteries Results in vascular stenosis & occlusion Mortality 10% adults, 4.3% childrenfrom cerebral hemorrhage 50-60% affected individuals with gradual deterioration of cognitive function from recurrent strokes History Transient to severe neurologic deficits Adults commonly hemorrhagic; pediatrics commonly ischemic Pediatric SSX Hemiparesis, sensory impairment, involuntary movements, headaches, dizziness, seizures, MR, persistent neurologic deficits Exam depends on location & severity of hemorrhage or ischemia General health maintenance: PCN prophylaxis, pneumococcus vaccination, hydroxyurea, folic acid Multi-disciplinary treatment includes ABX, analgesia, IVF, surgery, psychosocial Transfusions with iron chelation reduce pain crises, risk of ischemic complications Moyamoya treatments are neurosurgical & anticoagulation Pediatric AMS should always result in transportation via EMS ANY new focal neurological deficit requires immediate transport SCD in pediatric patients can be especially challenging to manage Clear, cohesive documentation of findings [email protected]