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PE24.1-23 | Pediatric Emergencies — PBL Case

CLINICAL SETTING

It is 11:30 PM at the emergency department of a government district hospital in a small town in Tamil Nadu. Dr Kavitha, a final-year MBBS student on emergency posting, is present with the duty medical officer. An autorickshaw pulls up to the entrance and a father rushes in carrying his 2.5-year-old daughter, Meena, wrapped in a blanket. The mother follows, crying. The father says, 'She had a fit at home — she is not waking up. Please save her.' The family are agricultural labourers; the child has had diarrhoea and vomiting for 5 days and refused to eat for 2 days. This is Meena's first visit to a hospital for this illness; they had given her coconut water and some home remedies.

Trigger 1: Trigger 1: Meena Arrives — Initial Assessment

On rapid visual assessment: Meena is limp with eyes half-open, making occasional moaning sounds. She does not respond to her name being called. She responds to painful stimuli (sternal rub) by withdrawing. Her skin is mottled. The father reports: 'She had a shaking fit for about 4–5 minutes just before we left home. It stopped by itself. Before the fit she was very weak and could not even stand. We don't know about any fever medicines — she had fever for 4–5 days.' Vital signs on arrival: HR 160/min; RR 46/min with audible grunting; SpO₂ 78% (room air); temperature 39.1°C; blood glucose (bedside glucometer) 1.6 mmol/L (29 mg/dL). Weight estimated at 12 kg. There is no IV access.

DISCUSSION POINTS

  • Using the AVPU scale, what is Meena's level of consciousness? What immediate life-threatening problems have you identified from this rapid assessment?
  • What is the correct immediate sequence of actions in the first 2 minutes? Which problem do you address first — airway, hypoglycaemia, or fever? Justify your prioritisation.
  • Meena had a 4–5 minute convulsion at home that stopped spontaneously. Does this meet the definition of status epilepticus? If she were still actively convulsing, what would you give, by which route, and at what dose?
  • SpO₂ is 78% with grunting. What oxygen delivery device would you choose and why? What FiO₂ do you expect to achieve?
Click to reveal Trigger 2: Trigger 2: IV Access and Examination Findings (discuss previous trigger first!)

Trigger 2: Trigger 2: IV Access and Examination Findings

Dr Kavitha attempts IV access in the right antecubital fossa — the vein collapses. She tries the dorsum of the hand — again unsuccessful. Two minutes have passed. The duty doctor mentions that the only other option may be an intraosseous (IO) needle. While the team works on access, another student performs a quick physical examination. Findings: anterior fontanelle — sunken; eyes — sunken with absent tears; mucous membranes — dry; skin turgor — skin pinch returns very slowly (>3 seconds); abdomen — mildly distended with no rigidity; there are no heart murmurs; the liver is at the right costal margin (not enlarged). There is no rash or petechiae. Pupils are 3 mm bilaterally and reactive. A further blood glucose measurement confirms 1.6 mmol/L.

DISCUSSION POINTS

  • Classify Meena's dehydration severity using IMNCI/WHO criteria. What Plan does this require?
  • Calculate the correct IV fluid bolus dose for Meena (weight 12 kg). Would you modify the standard 20 mL/kg dose for any reason? Justify your decision with reference to her clinical profile (no hepatomegaly, no gallop, diarrhoeal illness).
  • What is the correct treatment for Meena's hypoglycaemia? Specify drug, concentration, dose in mL. Why must you not use 50% dextrose?
  • While awaiting IV access, Meena starts another generalised tonic-clonic convulsion. The team has no IV access. What is the immediate treatment? Name the drug, route, dose, and the maximum dose you would give. How would you position Meena during the seizure?
Click to reveal Trigger 3: Trigger 3: Fifteen Minutes Later — Partial Response (discuss previous trigger first!)

Trigger 3: Trigger 3: Fifteen Minutes Later — Partial Response

Intraosseous access was secured after two failed peripheral attempts. Dextrose 10% 24 mL was given over 5 minutes via IO — Meena's blood glucose is now 4.8 mmol/L. A 240 mL fluid bolus (20 mL/kg) of normal saline was administered. The second convulsion, which began after 1 minute, was terminated with rectal diazepam 0.5 mg/kg (6 mg). SpO₂ has improved to 93% on non-rebreather mask at 15 L/min. HR is now 148/min; CRT 3 seconds. Meena is now responding to voice (AVPU = V). However, the nurse reports that Meena's temperature has dropped to 35.8°C and asks for guidance. The parents are in the corridor, very anxious. The father is shouting that no one is explaining anything to them.

DISCUSSION POINTS

  • How do you classify Meena's temperature of 35.8°C? What are the immediate thermal care measures in this emergency setting? What complication of hypothermia must you specifically monitor for?
  • Meena has had two benzodiazepine doses (rectal diazepam once, hypothetically). If she were to have a third seizure, what second-line drug would you use? What is the critical precaution about the diluent? What monitoring is needed during infusion?
  • Reassess Meena's response to fluid resuscitation. Has her shock resolved? What is your target CRT and HR at 30 minutes? When would you give a second fluid bolus?
  • The father is demanding an explanation outside. How do you approach breaking bad news in this scenario? What framework or principles would guide your communication with an anxious, poorly literate family whose child is critically ill?
Click to reveal Trigger 4: Trigger 4: Stabilisation and Decisions (discuss previous trigger first!)

Trigger 4: Trigger 4: Stabilisation and Decisions

After 45 minutes: SpO₂ 97% (downgraded to simple mask); HR 130/min; CRT 2 seconds; BP 88/56 mmHg; AVPU = A (now alert, recognises mother, still weak). Temperature 36.6°C after skin-to-skin warming by the mother and a prewarmed blanket. Blood glucose 5.2 mmol/L on repeat. No further seizures. The doctor on duty asks the team to (a) decide whether Meena can be started on oral fluids or requires continuing IV; (b) advise on seizure prevention and when to restart oral feeds; (c) complete consent documentation for any further procedures. Meena's mother quietly asks Dr Kavitha: 'Is it our fault for coming so late? Will she be normal after this?'

DISCUSSION POINTS

  • Meena is now alert and clinically improving. Describe the criteria for transitioning from IV to oral rehydration therapy. At what point is it safe to start oral feeds?
  • What ongoing monitoring and precautions are required regarding seizure recurrence in the next 24 hours? What should the parents be counselled about recognising seizure recurrence and seeking emergency care?
  • How would you respond to the mother's question 'Is it our fault for coming so late? Will she be normal after this?' — demonstrate empathic communication that is honest without being false or dismissive.
  • What documentation must be completed for this case, including informed consent for any procedures already performed under the emergency exception? What does best practice require regarding consent documentation when parents were not reachable?

Group Task Assignments

Group 1: Collaborative Task

Group 2: Collaborative Task

Group 3: Collaborative Task

Learning Issues

Research these questions and bring your findings to the discussion.

  1. [PE24.1] What is the pathophysiology of cardiorespiratory arrest in children and how does it differ from adults? What are the PALS protocols for two-rescuer CPR, shockable rhythms, and defibrillation energy?
  2. [PE24.4] What is the definition of status epilepticus? What is the first-line, second-line, and third-line pharmacological management including exact doses, routes, and critical safety precautions (particularly phenytoin diluent)?
  3. [PE24.5] How do you assess the level of consciousness in a child using the AVPU scale and paediatric GCS? What are the causes of unconsciousness in a febrile child and how does the initial emergency management address multiple simultaneous threats?
  4. [PE24.3] What are the types of shock in children (distributive, hypovolaemic, cardiogenic)? How does the initial fluid resuscitation differ between septic shock, DKA, and cardiogenic shock? What clinical signs indicate shock improvement?
  5. [PE24.16] How do you classify dehydration severity using IMNCI/WHO criteria? What is Plan C and what is the correct Ringer's lactate regimen for severe dehydration in children vs infants?
  6. [PE24.6] What are the oxygen delivery devices available in an emergency setting, what FiO₂ does each deliver, and which device provides a fixed vs variable FiO₂? When is each device indicated?
  7. [PE24.17] What is the definition, clinical features, complications, and management of hypothermia in children? What are the immediate steps in an emergency setting with limited equipment?
  8. [PE24.22] What is the SPIKES framework for breaking bad news? How do cultural and literacy factors shape communication with families of critically ill children in an Indian rural setting?