April 2016 Case Study

In honor of our Pizza and Peds event coming up on May 2nd, we are going to be going over a pediatric case study today. This was donated to us by a friend of the blog. 

You and your partner are dispatched to a private residence for a report of difficulty breathing on a three month old. As you arrive on scene, and officer yells, “I’m carrying her out to you!” You look at the officer’s arms and see a limp, unresponsive, and undersized child that has a back brace on. The patient’s mother refuses to exit the home to tell the crew any type of history, medications, allergies, etc. The officer on the scene tells you that the only thing that he knows that she was premature (born at 24 weeks) and had spinal surgery for an unknown problem last week at a children’s specialty hospital.The patient is approximately 3kg.


  • Pt is a GCS of 4 (Occasionally moaning to painful stimuli, but with no movement)
  • Skin is cool, pale, and dry
  • Absent brachial pulses, but irregular and weak carotid pulses noted in the 80s
  • Respiration is shallow, bradypneic (rate of 4-8bpm)
    • L/S are clear bilaterally
  • No obvious DCAP-BTLS noted
  • Pupils are dilated/=/sluggish bilaterally
  • Patient’s diaper is dry


  • HR: 80/irregular
  • RR: 4bpm/irregular/shallow
  • SpO2: 76% on R/A
  • Unable to determine B/P
  • Glucose: 86mg/dl
  • EtCO2: 16mmHg
  • Temp: 96.4°F


  • Evidence of trismus noted; BVM ventilation initiated; crew has no access to paralytics
  • EKG monitor placed revealing sinus arrhythmia and not ST abnormalities
  • Manual IO established in the L medial tibia
  • Initiated 20cc/kg bolus
  • Transported emergently to local community hospital approximately ten minutes away from scene


  • Follow up with community hospital reveals elevated white count and lactate levels
  • Patient underwent RSI and intubated in ED
  • Flown to children’s specialty hospital; en route patient arrests
  • Ongoing resuscitation at specialty hospital for approximately forty minutes where patient was later pronounced dead


  • What would you have done differently?
  • If s/s of shock persist despite fluid boluses, which pressor agent would you consider?
  • How much fluid would you consider before initiating a pressor agent?
  • What is the role of RSI in pediatrics?

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