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Pediatric Patient, Case Study Examples

Pages: 8

Words: 2274

Case Study

Introduction

In many tertiary hospitals worldwide, pediatric patient emergencies occur frequently. The leading cause is insufficient resources to handle the rising number of patients needing care. This implies that there might occasionally be a staffing shortage, which could cause delays in patient care. Additionally, as was already indicated, there might not be enough equipment or resources on hand to suit every patient’s demands. Lastly, delays in patient care may result if an ambulance has been summoned but cannot arrive in time before transport is required. The importance of pediatric retrievals is that they provide a means of documenting the cause of death; they also provide information on the stage at which cancer was present or absent in different organs and thus help establish whether it was present at all times or just during one phase. Pediatric retrieval is an important part of the obstetrician or gynecologist’s role in the management of patients with a suspected pregnancy. The retrieval should be performed as soon as possible after diagnosis to prevent fetal death or injury due to delay in diagnosis and management. This paper seeks to discuss the clinical and infight management of a pediatric patient who needs immediate transfer to an intensive care unit. 

Clinical Management/Interventions

First of all, the patient has an acute respiratory failure. Therefore, she will require weaning from high flow oxygen and intubation. She is also hypotensive with a systolic blood pressure of only 70 mmHg. This is a very concerning situation as her BP has fallen to this low level despite high-dose vasopressor administration. In addition, the patient’s GCS is 11/15, indicating that she is becoming more unwell despite treatment with vasopressor drugs and IV fluids. Blood gas analysis should be performed to identify any causes of this decrease in her oxygenation status. A chest x-ray may show evidence of pneumonia or interstitial pneumonitis, causing further respiratory distress (air trapping). These findings should be discussed with the referring hospital as they may suggest other treatments, such as long-term steroids or antibiotics, which might be required to treat infection/pneumonia.

The initial management has been stabilized by a high flow of oxygen and IV Cannulation with no success. The patient has a GCS of 11/15. Her HR is 130bpm. BP is 74/40, and SpO2 is 98% (Huang, Cai, and Su, 2019). The patient has an established diagnosis of sepsis. The treatment for this condition includes supportive care and antibiotics. There is currently no evidence that additional interventions are required. At this point, the best treatment for the patient would be to initiate intravenous fluids, antibiotics, and ventilatory support with oxygen therapy to maintain her oxygenation as per normal standards.

The clinical management of this patient is urgent, with a high risk of significant deterioration. As such, the referring hospital must respond rapidly to this patient. The first step in quickly responding to this patient is to ensure that all staff are aware of the situation and understand their role in providing care for the patient. This will include having available an appropriate number of resources such as intravenous fluids, antibiotics, and other drugs that may be required on the scene by the team. The second step in rapidly responding to this patient is ensuring that diagnostic tests have been performed and any relevant results are shared with the receiving facility. This may involve requesting that a bedside ultrasound scan be performed on-site, or that blood tests be sent out for analysis at another facility if necessary. Finally, if an air ambulance is required to transport this patient, it must be dispatched as soon as possible. Ideally, this should occur within two hours of notification and only after all diagnostic tests have been completed at the referring hospital and any additional resources required have been arranged from outside sources.

Other Clinical Interventions

The clinical management/ interventions required at the referring hospital before aeromedical transport include:

Anaphylaxis: Urgent management of anaphylaxis with epinephrine (0.01 mg/kg) and glucagon (0.01 mg/kg) should be instituted immediately. If there is no response, glucagon 1–2 mg intravenously will give rapid onset of action but may need to be repeated if hypoglycemia persists. Glucagon may also be used as a nasal spray in patients with severe hypoglycemia who cannot take oral therapy due to vomiting or diarrhea or as a contra-indication for IV therapy. If this fails, give nebulized albuterol (1–2 puffs).

Seizures: General principles for managing seizures include giving benzodiazepines such as diazepam (10–20 mg intravenously). In addition, phenytoin sodium can be given orally at a 4–6 mg/kg dose every 4 hours.

Transportation of Patient and the Parent

The family will be transported by ambulance with the patient on board. The family is seated in the back of the ambulance, with oxygen and suction equipment available. A first aid kit is also on board. The team includes a pilot, one nurse, and an emergency medical physician (EMD) who will provide ongoing care for any complication that may occur during transport. They will be trained for this situation and must have experience dealing with children who may have had recent viral infections or encephalitis-like illnesses.

Steps

  • Cover the patient in a blanket to keep them from getting too cold, and put it in the back of an SUV or van with a heater below the box to stay warm.
  • Ensure there is plenty of water for the parents and, if possible, give them some food as well as drinks for them as well so they will not be hungry during their journey to the hospital.
  • If possible, dress the patient in layers so that if they get too hot or cold, they can adjust how many clothes they wear without being uncomfortable and make sure they have extra blankets available to stay warm during transport to a hospital.

Inflight Management Plan

The patient was loaded onto the helicopter and transferred to an emergency department at our hospital 150 km from the receiving facility. Her vital signs remained stable during the flight but were abnormal on arrival at our hospital. The paramedics in flight asked for an oxygen saturation reading as part of their standard clinical assessment (SAC). This good practice identifies patients who may benefit from supplemental oxygen therapy, such as high-risk neonates, ventilated patients, or those with chronic lung diseases like asthma. A SpO2 reading of 98% on ten l/min of O2 via a Hudson Mask indicates that the patient requires further investigation before we can offer them any form of treatment or support for their condition. It is planned that once on board the helicopter, the patient will receive one dose of antibiotics intravenously (IV) to cover any possible infections that may have been acquired before transfer Once stable on board the aircraft, further care can be discussed with flight staff, who will be able to administer additional drugs if necessary. When on board, this patient must remain comfortable, so I would recommend that she receives blankets and pillows in addition to having her head elevated.

The inflight management plan with linkage to the aeromedical retrieval environment is as follows:

  • The patient undergoes intravenous cannulation using a vascular access device and an intravenous line (IV) before being placed on oxygen, heated humidified air, and warmed intravenous fluids via an infusion pump.
  • There will be a requirement for cardiac monitoring during transport, so a pulse oximeter may be required.
  • Blood cultures are obtained from all patients who present with sepsis; this includes infants and children who may have underlying conditions such as diabetes mellitus.

The Boyles and Dalton laws affect the patient because they will increase the temperature, humidity, and noise levels. The Boyles and Dalton laws are known to cause a change in body temperature if someone is exposed to heat or cold for an extended period. The body temperature changes can be caused by dehydration or heat stroke. For example, if someone is exposed to high temperatures for an extended period, their body temperature will increase. This is because the body’s natural response is to cool down when exposed to a high temperature. If someone suffers from dehydration, they will also start feeling thirsty, which may lead them to drink more fluids than usual and could also lead to dehydration. The Boyles and Dands laws can also cause problems with vibration depending on the intensity of the vibrations being experienced by the person concerned (for example, if they are being transported by a helicopter). Vibration can cause pain in muscles stretched through exercise or movement.

Literature

Sepsis is increasingly common and is the leading cause of death for people receiving hospital care. Sepsis is most common in sick or injured people but can also occur in healthy people. Sepsis can cause multiple organ failures and death, making it a life-threatening condition that needs to be treated very away. According to the Centers for Disease Control and Prevention, 2 million Americans are hospitalized yearly with sepsis or septic shock (CDC). An estimated 17% of nonfatal hospitalizations in 2015–2016 were attributed to sepsis or septic shock. Sepsis and its consequences alone caused more than 1 million deaths worldwide in 2016. This report describes rates of diagnosis and treatment of sepsis and other essential outcomes at one day postonset among adults treated in U.S. emergency departments (EDs) between 2011 and 2016. Sepsis is a life-threatening organ dysfunction caused by the over-accumulation of toxins or the body’s response to infection. It is characterized by a series of events that occur without an identifiable source for the infection. The first event is the activation of the inflammatory response. This results in the production of cytokines and chemokines that attract neutrophils to the site of infection and activate them to release enzymes that degrade tissue. The third step triggers the release of proinflammatory mediators such as interleukins, tumor necrosis factor (TNF), and interferons. These compounds act on adjacent cells to cause them to secrete cytokines and other chemicals that stimulate further cell proliferation, deposition of collagen, and vasodilation. The fourth step includes producing and releasing acute phase reactants from damaged tissues such as platelets or leukocytes. These substances trigger further reactions leading to neutrophil recruitment, tissue component destruction, and developing sepsis lethality.

There are various steps undertaken for such a patient. First, the patient is assessed by the team leader and other members of the nursing staff, who may also be present during this process. Review information gathered from previous assessments and current findings with the patient, family, or carer (if appropriate). Secondly, there is a review of medical records and laboratory results obtained before admission. Ensure that they are up-to-date following hospital policy and practice. Lastly, the specialists assess current conditions by one nursing staff member who has received training in pediatric resuscitation techniques and will have witnessed similar situations in their career. This person will be familiar with the patient’s medical history, physical examination findings, and treatment needs. They should also thoroughly understand how children respond physiologically when exposed to high altitude conditions.

In conclusion, it is critical to identify this as an urgent case, so the speed of care delivery must be paramount. The team should consider ensuring no delays in assessment, treatment, or transportation may affect the outcome. The team should also consider the need for support during this time (medical staff) and how they can provide this support (pre-alerted by phone or email). In this case, the transportation will involve Air ambulances that will land at an airport or helipad near the hospital where they are needed and transfer their patient immediately into hospital care without delay. Some hospitals have helipads that allow patients direct transfer from air ambulance to land ambulance for emergency transport to the hospital. The patient has an identified condition that requires prompt treatment. The urgency was from hypertension, increased RR, and Elevated HR for a 12year old. Therefore, the decision was made to transfer her to the hospital for further management. 

Bibliography

Cecconi M, Evans L, Levy M, Rhodes A. Sepsis and septic shock. The Lancet. 2018 Jul 7;392(10141):75-87.

Evans C, Creaton A, Kennedy M, Martin T, editors. Retrieval medicine. Oxford University Press; 2016 Nov 17.

Evans L, Rhodes A, Alhazzani W, Antonelli M, Coopersmith CM, French C, Machado FR, Mcintyre L, Ostermann M, Prescott HC, Schorr C. Surviving sepsis campaign: international guidelines for the management of sepsis and septic shock 2021. Intensive care medicine. 2021 Nov;47(11):1181-247.

Gyawali B, Ramakrishna K, Dhamoon AS. Sepsis: The evolution in definition, pathophysiology, and management. SAGE open medicine. 2019 Mar;7:2050312119835043.

Huang M, Cai S, Su J. The pathogenesis of sepsis and potential therapeutic targets. International journal of molecular sciences. 2019 Oct 29;20(21):5376.

Levy MM, Evans LE, Rhodes A. The surviving sepsis campaign bundle: 2018 update. Intensive care medicine. 2018 Jun;44(6):925-8.

Martin-Gill C, Doyle TJ, Yealy DM. In-flight medical emergencies: a review. Jama. 2018 Dec 25;320(24):2580-90.

Pickard-Gabriel CJ, Fang R, Cannon JW. Aeromedical Evacuation of Patients with Abdominal, Genitourinary, and Soft Tissue Injuries. Aeromedical Evacuation. 2019:147-63.

Ryu J, Kim J, Choi-Kwon S. Infection Prevention Performance among In-Flight Cabin Crew in South Korea. International Journal of Environmental Research and Public Health. 2021 Jun 15;18(12):6468.

Sarker MS, Uddin MA, Zaman MM, Khan MK, Hasina A, Rahman MM. Fitness to Fly in Patients with Lung Disease. Central Medical College Journal. 2021;5(2):116-25.

Stewart, R. K., Oreck, S. L., Teske, L., & Waterman, B. R. (2019). Orthopedic Patients. In Aeromedical Evacuation (pp. 165-174). Springer, Cham.

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