Mindblown

[chbare]

You are a paramedic working in an austere clinic but have limited radiology and laboratory resources. Assume you have a fairly comprehensive assortment of pharmaceuticals and standard equipment that would be found on an ambulance in a country with a reasonably progressive EMS system.

The grandmother of a one year old male brings the patient into your triage area. The patient appears to be awake, generally well developed for his age and crying vigorously.

Take it from here.

[ERDoc]

"So grandma, what's going on today?"

[chbare]

"I think he ate something bad!"

[Timmy]

^{Try and calm things down a little to improve our chances of good assessment.}

^{What did he eat?}

^{Remove clothing.}

^{Did nana bring the child & maternal health book along?}

^{What’s the kid’s weight?}

^{Skin & appearance (cyanosis, rash, pale, flushed, moving all limbs etc.).}

^{Respiratory Assessment (rate, rhythm, depth, auscultation, SP02, use of accessory muscles).}

^{Temp & heart rate.}

^{AMPLE history, happened before? has the child ingested the same food before?}

[chbare]

"I think he swallowed my blood pressure pills?"

No health book available.

His weight is right in the middle of the range that would be expected for a patient of this age.

Skin is pink, war, dry with moist and pink mucous membranes.

Respiratory rate is 30 and non-laboured, no signs of respiratory distress, pulse is 130 strong and regular, blood pressure is 90 systolic, temp is normal, SPO2 is 97% on room air, L- this am about 2 hours ago, E-Pill bottle found on floor, grandma did not bring the bottle with her to the clinic.

No medical evacuation resources are available and you will have to deal with the patient for an extended period of time, assuming you want to do so.

A-NKA, M-None, PmHx- Healthy, thriving carpet commando,

[triemal04]

Type and number of pills and what is the estimated time of ingestion.

[chbare]

She does not remember the number of pills and think they are called something on the lines of "Topol or something like that." Time of ingestion was approximately one hour ago.

[triemal04]

Guess she probably means "toprol." So it's potentially a beta-blocker OD. Call, or have her call, her pharmacy, confirm what the pills were, when her prescription was filled last, and with how many pills. And see if she's taking anything else. Find out if there's anyway that something else could have gotten into the pills other than the kid, and why she thinks it was the kid in the first place.

Real beta-blocker OD's, especially with extended release pills are no joke. If that's what this is, while the kid is currently fine, bad things may happen. This kid needs to be in a PICU, preferably in a hospital with a good toxicologist. Start working on making that happen.

While that's going on, place kid on monitor, continously monitor the heartrate and BP, start 2 lines, and since you happen to have a niftly little istat run the chem8 cartridge. At one hour and no signs of problems it'd be worth considering activated charcoal. For a 1 year old this will require a NG tube and probably some sedation. I'd get this ready but I'd like a little more confirmation that there was an ingestion before I started the procedure.

Have large doses a glucagon and an epi drip ready to support the BP. If you are really in a high-speed austere environment you could do a lipid infusion...but that's a bit outside my area of expertise. Probably need to wait until the kids reaches the PICU.

[chbare]

You will have to deal with everything relating to the patient and for this scenario, assume no medical evacuation is available.

Monitor has been applied and is reading a sinus rhythm at 130 that appears appropriate for the patient's age. Peripheral lines have been placed and labs are cooking.Let's say we contact the grandmothers doctor and we now know that the patient has indeed ingested an unknown amount of her Beta blockers. Additionally, this is the only medication that the patient has ingested. A reassessment of the patient is essentially unchanged at this time.

Are we going with activated charcoal? Is a nasogastric tube mandatory? Are there any considerations regarding the use of sedation if we decide to administer charcoal? (Sorry but there is a typo on the age, you have a five year old male not a one year old, everything else is unchanged however).

[triemal04]

I'd still like to contact the grandma's pharmacy if possible. This will give at least the worst case scenario for how much the kid could have taken, and if it's an extended release pill or not.

With a 5 year old...I think I'd go ahead and give charcoal now. Between the grandmother and you talking to the kid (and the flavor sweeteners that some AC's come with) you should be able to talk him into drinking it. The issue with sedating for an NG tube would be that even a drug that leaves the respiratory drive intact (like ketamine or etomidate) will still have his LOC depressed; ups the risk of aspiration. I think if it came down to that I'd use a small dose of etomidate to place the NG tube, then after he was awake start to administer the charcoal.

I'd also take a minute to talk with the kid away from the grandma. Ask him if he took anything that day or was playing with grannies pills.

Cross your fingers that this isn't the real deal, because if it is, you can sustain him, but not fix him.