Dchart Narratives Acute Question & Answer Guide (With Explanation)

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3 DCHART Narratives: 1. DX: Acute onset ataxia, fever, cough, and seizures Gender: Male Age: 2 Height: N/A Weight: N/A Vitals Temperature: 104 F/40.0 C Blood Pressure: 90/65 mmHg Heart Rate: 90 Respiratory Rate: 20 Pulse Oximetry: 99% Signs and Symptoms Fever; cough; seizures; difficulty sitting and walking History Medical: Previously well Social: Lives in rural Tanzania Medications: N/A Differential Diagnosis Encephalitis Meningitis Brain neoplasm Post-infectious cerebellar ataxia Ataxia Patient Workup HIV – negative Malaria – negative CXR – negative Mantoux test negative Ambulation observation Diagnosis Post-infectious cerebellar ataxia Ataxia Cerebellar ataxia Truncal ataxia Actual Outcomes Treatment Antibiotics for presumed pneumonia Phenobarbital Carbamazepine Disposition Ataxia and nystagmus resolved by 2 weeks post-admission. Patient 2: DX : Cough and Stridor with cry Gender: Male Age: 2 Height: N/A Weight: 30 lb/14 kg Vitals Temperature: 101.2 F/38.4 C Blood Pressure: 98/63 mmHg Heart Rate: 150 Respiratory Rate: 24 Pulse Oximetry: 100% RA Signs and Symptoms Barky cough; stridor; fever; crying; acute-onset upper airway obstruction History Medical: Past history of croup Social: Lives with mom Medications: N/A Differential Diagnosis Airway foreign body Bacterial tracheitis Epiglottitis COPD Hamartoma Patient Workup History Past history of Croup Diagnosis Croup Stridor Actual Outcomes Treatment This child was treated with a single dose of dexamethasone 0.6 mg/kg orally and did not require any additional treatment. If he had stridor at rest, epinephrine nebulizer treatment would be indicated. Disposition This child was sent home from the ED after his Dexamethasone dose. Standards of Care Suggested Approach Notes Viral croup is the most common cause of Acute Airway Obstruction in children aged 6 months to 6 years. In a child with classic symptoms, barky cough and inspiratory stridor, the diagnosis of croup is based on the history and physical examination alone. Less than 1% of children with acute onset of inspiratory stridor will have another diagnosis, including epiglottitis, bacterial tracheitis, or a foreign body aspiration. Suggested Workup Croup can typically be diagnosed from clinical features If there is uncertainty in diagnosis or a concern providers can use diagnostic tools such as x-rays or laboratory tests. Suggested Treatment Nebulized epinephrine can provide rapid, relief of respiratory distress and is indicated, if the patient has stridor while at rest. The onset is within 10 minutes, and the effect lasts 1-2 hours. One oral dose of dexamethasone 0.6mg/kg is the recommended treatment for mild and moderate croup where a barky cough is present and the patient may have stridor with agitation. The effect of the dexamethasone treatment will last several days usually through the worse part of the illness. Patient 3: DX: Acute onset, seizure with placement of intraosseous cannulation Gender: Male Age: 19 months Height: N/A Weight: N/A Vitals Temperature: 101.0 F/38.3 C Blood Pressure: 80/66 mmHg Heart Rate: 129 Respiratory Rate: 30 Pulse Oximetry: 83% RA Signs and Symptoms Mom states fever today, gave acetaminophen before coming to Mall. Mom said that based on past seizures, PCP said to wait 5 minutes and then call 911 History Medical History : Two previous febrile seizures Social History : Lives with mother Medications : NKDA Differential Diagnosis Seizure disorder Febrile Seizure Status epilepticus Non-accidental trauma Closed head injury CNS neoplastic disease Ingestion of foreign substance Patient Workup History Patient had seizure activity, was drooling with some emesis near mouth initially when found on his side. Physical Exam Patient had some grunting respirations, clear lung sounds. Eyes did not track movement, patient did withdraw from pain but was not alert. Left leg was noticed to be moving significantly more than right leg. No head trauma noted, normal bumps and scrapes noted. Labs EKG Capillary Blood Glucose Diagnosis Febrile seizure Complex febrile seizure Status epilepticus Actual Outcomes Treatment En Route- Intraosseous (IO) Cannulation attempt, IO successful, IV attempt, EKG, Versed. 4 doses (see below) totaling 6.2mg EKG showed Sinus tachycardia Capillary Blood Glucose – 125 On arrival to hospital – Vitals, IV attempt, fluid bolus via IO, Labs, Urine, planned for 1mg Ativan IV if patient starts seizing again. Response to treatment- IM and first IO Versed had little to no effect on patient, third dose of versed 1.5mg IO did stop seizures for a short while, 2.5mg IO versed stopped seizures upon arrival at hospital and provided for patient improvement. Oxygen and airway positioning moved oxygen saturation from 82% RA to 100%. IO attempt on Left Proximal Tibia failed, we think because the pediatric IO did not fully penetrate and failed to seat correctly. The decision was made very quickly to second IO attempt despite our first failure. The second IO required more force to get past the soft tissue to get the IO to seat but functioned very well after that. The patient’s airway was very positional so after stabilizing the patient, I would manually hold his head upright for most of the ride in. Disposition Pediatric ICU

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