Case Study

It is 15:00 hrs on a frigid winter day. You and your crew have been enduring a particularly cold spell and the post holiday blues. Morale and energy levels are both down. You have been working the day shift and have not turned a wheel. With three hours left to go you are already planning the supper you will cook at home. Your partner is snoozing on the couch while the soap operas continue on TV Suddenly the tones go off and you look at each other in surprise.

You are dispatched to a lower income neighborhood for an injured infant. The details of the injury are unknown. The dispatcher reports it appears the child is breathing but the caller hung up before any more information could be obtained. They are attempting to call back but are getting a busy signal.

Your arrival is noted by most residents of the apartment/town house complex. One neighbour waits for you by the door of the apartment house and directs you up to the third floor. She reports her friend (Nicole) knocked at her door hysterically crying and saying something was wrong with her baby. She reports Nicole told her she went to wake Roger up from his nap and couldn’t get him to “act

right”. This lady then phoned for the ambulance and returned to Nicole’s apartment. She reports the baby is lying quietly, but she believes he is breathing. There appear to b no scene hazards at this time.

You discover a run down-one bedroom apartment littered with toys, clothes, blankets, and beer bottles. It appears several people have been occupying the room sleeping on the floor. There are full ashtrays throughout the room and the air is thick with smoke. At present there I only one person in the room and she is kneeling over an infant who is lying on the floor beside the couch. The infant is not moving. The female (Nicole) is crying and kissing the infant.

Nicole reports she laid the crying infant (Roger) on the couch while she went to heat him a bottle. When she returned from the kitchen she found him lying on the floor in the present state. She appears nervous and anxious when you question her. She now denies any story of him awakening strangely from a nap. Her history is somewhat vague She reports a past medical history of colic and says he ha had a cold for the past few days and has been cranky. She reports no other past medical history. She says he was a full term healthy baby and is now six months old.

Roger is lying supine. He is wearing a diaper shirt, soiled diapers, and is covered with a blanket. He is not making any audible sounds. He appears to be breathing at an irregular rate and depth. His brachial and apical pulses correspond but are slightly slower than normal. His skin is pale cool and dry. His eyes are closed. Pupils are equal and reactive, although sluggish to respond. Capillary refill is within two seconds. No obvious trauma is noted to the head and face. His chest appears unremarkable. Lung sounds are present and equal throughout. His abdomen is unremarkable. His diaper is soiled with both urine and feces. He has a severe diaper rash. There are several bruises in various stages of healing to his upper arms. His lower extremities are unremarkable

1.Your tentative diagnosis for this infant is:

2. This infant’s vital signs are:

3. This patient requires:

4. The “normal” respiratory rate for a six-month-old is:

5. This call should raise suspicions of child abuse due to:

6. You should ask this mother if she might have shaken or hit her child so you can accurately determine mechanism of injury.

7. You should report your suspicions of abuse:

8. This patient should be packaged:

9. The first concern when assessing an infant or child is:

10. The number one cause of death among infants and children is:

11. The most common type of trauma in children is:

12. This child’s present injuries combined with the history indicate he may be suffering from:

13. When opening the airway of an infant:

14. When assessing, treating, and transporting this patient you should separate the mother from the child.

15. This patient should be considered:

16.The E.C.G is:

17. This rhythm should be treated by:

18. Intravenous access is:

19. The suggested endotracheal tube size for a six-month-old is:

20. Your patient experiences a seizure en route. You should:

21. This child’s seizure is most likely caused by:

22. Of the following, which finding most accurately reflects brain hypoperfusion?

23. The preferred site for intraosseous infusion in this child would be:

24. Attempts to intubate an infant or child should not exceed:

25. You could make this call easier for the crew by:

Aehlert, Barbara RN PALS Pediatric Advanced Life Support Study Guide; Mosby Lifeline; 1994.

Dietrich & Shaner; Pediatric Basic Trauma Life Support; Basic Trauma Life Support International 1995.

Mack, Daniel; EMT-B Certification Preparation and Review Second Edition; Mosby Lifeline 1996.

Walt A. Stoy and the Center for Emergency Medicine; Mosby’s EMT Basic Textbook; Mosby Lifeline: 1996.

The answers to these questions are to industry standards and may not necessarily be correct according to local protocol. If there is any discrepancy between these answers and local protocol, please follow the protocol for your area as set out by your Medical Director.

Heather MacKenzie-Carey is a paramedic who has over 15 years of EMS experience in Nova Scotia and Alberta. She is currently teaching in the Paramedic Program at the Southern Alberta Institute of Technology. She has a Bachelor of Science degree in Health Education from Dalhousie University in Nova Scotia and a certificate in Social Work from the University of Waterloo.She can be reached at geomac@cadvision.com or www.turningpointgroup.com.

Canadian Emergency News and the author of this quiz grant permission for readers to copy it for personal and departmental educational purposes. All other reproduction and re-publication without written consent is prohibited.

This Article is reprinted by permission from the author (Heather MacKenzie-Carey) and the Canadian Emergency News. It originally appeared in the December 1997 / January 1998 issue (volume 20, number 6).

Pulse	100 regular
Blood pressure	90 systolic
Respiration	Irregular rate and depth approximately 30 minute; lung sounds equal and clear throughout
Skin	pale, cool, dry
Level of Consciousness	decreased, responds to pain by withdrawing
Weight	approximately 8 kg
Pulse Oximetry	94 %
E.C.G.

EMS Quiz

By Heather MacKenzie-Carey

Vitals

1.Your tentative diagnosis for this infant is:

2. This infant’s vital signs are:

3. This patient requires:

4. The “normal” respiratory rate for a six-month-old is:

5. This call should raise suspicions of child abuse due to:

6. You should ask this mother if she might have shaken or hit her child so you can accurately determine mechanism of injury.

7. You should report your suspicions of abuse:

8. This patient should be packaged:

9. The first concern when assessing an infant or child is:

10. The number one cause of death among infants and children is:

11. The most common type of trauma in children is:

12. This child’s present injuries combined with the history indicate he may be suffering from:

13. When opening the airway of an infant:

14. When assessing, treating, and transporting this patient you should separate the mother from the child.

15. This patient should be considered:

16.The E.C.G is:

17. This rhythm should be treated by:

18. Intravenous access is:

19. The suggested endotracheal tube size for a six-month-old is:

20. Your patient experiences a seizure en route. You should:

21. This child’s seizure is most likely caused by:

22. Of the following, which finding most accurately reflects brain hypoperfusion?

23. The preferred site for intraosseous infusion in this child would be:

24. Attempts to intubate an infant or child should not exceed:

25. You could make this call easier for the crew by:

Your comments are appreciated!

Just complete this form. Click on Submit when ready to send.

Your name:

Email address:

Any comments about the Case Study?

EMS Quiz

By Heather MacKenzie-Carey

Vitals

1.Your tentative diagnosis for this infant is: A. febrile seizures B. croup C. head injury D. child abuse

2. This infant’s vital signs are: A. within normal limits B. all elevated C. suggestive of shock D. B and C are correct E. none of the above

3. This patient requires: A. oxygenation with a non-rebreathing mask B. oxygenation hyperventilation with a bag valve mask C. oxygenation and ventilation with a bag valve mask D. that the use of oxygen be limited

4. The “normal” respiratory rate for a six-month-old is: A. 50 B. 40 C. 20 D. 12

5. This call should raise suspicions of child abuse due to: A. the location and types of bruises B. the vague history of the event C. the inconsistency of event and injuries D. all of the above

6. You should ask this mother if she might have shaken or hit her child so you can accurately determine mechanism of injury. A. True B. False

7. You should report your suspicions of abuse: A. True B. False C. Only if asked D. Only if you receive a subpoena

8. This patient should be packaged: A. in trendelenburg position B. head elevated C. spinally immobilized D. B and C

9. The first concern when assessing an infant or child is: A. breathing status B. pulse and blood pressure C. amount of movement D. response to external stimuli

10. The number one cause of death among infants and children is: A. drowning B. poisoning C. child abuse D. none of the above

11. The most common type of trauma in children is: A. deceleration injury B. blunt injury C. crush injury D. open injury

12. This child’s present injuries combined with the history indicate he may be suffering from: A. physical child abuse B. sexual child abuse C. neglect D. emotional child abuse

13. When opening the airway of an infant: A. do not hyperextend the neck B. keep the neck totally neutral C. tilt the head forward D. tilt the head back as far as possible

14. When assessing, treating, and transporting this patient you should separate the mother from the child. A. True B. False

15. This patient should be considered: A. Load and go B. Stay and stabilize

16.The E.C.G is:

17. This rhythm should be treated by: A. giving epinephrine B. giving Lidocaine C. providing oxygenation D. A and C are correct

18. Intravenous access is: A. not necessary B. recommended for immediate fluid resuscitation C. recommended as a potential medication or fluid route D. best achieved through an Intraosseous route

19. The suggested endotracheal tube size for a six-month-old is: A. 2.5-3.0 mm ID. B. 3.5-4.0 mm ID. C. 4.5-5.0 mm ID. D. 5.0-5.5 mm I.D.

20. Your patient experiences a seizure en route. You should: A. consider extubation B. consider diazepam C. consider epinephrine D. consider intubation

21. This child’s seizure is most likely caused by: A. infection B. metabolic imbalance C. hypoxia D. inter cranial bleed

22. Of the following, which finding most accurately reflects brain hypoperfusion? A. altered level of consciousness B. sluggish pupillary response C. hypotension D. bradycardia

23. The preferred site for intraosseous infusion in this child would be: A. anteriolateral aspect of the fibula B. anteriomedial aspect of the femur C. the middle third of the radius D. anteriomedial aspect of the tibia

24. Attempts to intubate an infant or child should not exceed: A. 5 seconds B. 10 seconds C. 20 seconds D. 30 seconds

25. You could make this call easier for the crew by: A. having child abuse protocols in place B. having access to a defusing or debriefing C. having good working relationships with out­side support agencies such as child welfare D. all of the above

Your comments are appreciated!

Just complete this form. Click on Submit when ready to send.

Your name:

Email address:

Any comments about the Case Study?

1.Your tentative diagnosis for this infant is:

2. This infant’s vital signs are:

3. This patient requires:

4. The “normal” respiratory rate for a six-month-old is:

5. This call should raise suspicions of child abuse due to:

6. You should ask this mother if she might have shaken or hit her child so you can accurately determine mechanism of injury.

7. You should report your suspicions of abuse:

8. This patient should be packaged:

9. The first concern when assessing an infant or child is:

10. The number one cause of death among infants and children is:

11. The most common type of trauma in children is:

12. This child’s present injuries combined with the history indicate he may be suffering from:

13. When opening the airway of an infant:

14. When assessing, treating, and transporting this patient you should separate the mother from the child.

15. This patient should be considered:

17. This rhythm should be treated by:

18. Intravenous access is:

19. The suggested endotracheal tube size for a six-month-old is:

20. Your patient experiences a seizure en route. You should:

21. This child’s seizure is most likely caused by:

22. Of the following, which finding most accurately reflects brain hypoperfusion?

23. The preferred site for intraosseous infusion in this child would be:

24. Attempts to intubate an infant or child should not exceed:

25. You could make this call easier for the crew by: