Scenario 1
John is a 14 months old male who was found in the bottom of the backyard’s swimming pool by the mother –called 911. CPR was done at the site, intubated by EMT and received three rounds of epinephrine and took 25 –30 minutes to obtain a heart rate . He was air transported to Cooper trauma and admitted in the PICU.
Vital Signs : HR = 180/min, RR = 30 (vent rate), BP= 80/40, T = 96.5F.
Physical exam: GCS =3
No spontaneous movement noted, puffy face, pupils sluggishly reactive 3- 4mmm, coarse BS bilaterally, regular rate and rhythm, abdomen slightly distended, capillary refill > 6 sec and cool extremities NGT and foley catheter in place. Full mechanical ventilation, epinephrine drip at 0.2 ug/kg/min to maintained MAP >60 mmHg.
Head CT scan showed diffuse cerebral edema, Chest X-ray showed pulmonary edema. Started on fentanyl drip for pain and Midazolam drip for sedation to control cerebral edema. ABG : 7.13/ 39/55/ O2 sat = 90% BE = - 18 on PRVC : RR = 25 FiO2= 0.60 , PEEP = 12, Vt = 90
The parents are waiting in the family room for the physician to hear about their son ‘s condition. You have 10- 15 minutes to speak to the parents – waiting in the family room.
Other Data :
Presenting Situation : 14 months old male with the Near Drowning,
Diagnosis : Respiratory Failure – Pulmonary Edema /ARDS
Hypoxic Encephalopathy /Cerebral Edema
Patient Demographics:
Patient’s name: John
Father: 35 year old Black male - works as an accountant
Mother: 30 year old white female – works from home
Scenario 2
John has been in the PICU for almost 10 days – still unresponsive. Brain death test done but apnea test showed some agonal breathing – did not meet the criteria for brain death. The parents have been given updates by the medical team every day about John’s medical condition. You are the conducting another meeting with the parents to update and discuss the prognosis and treatment options for John.
Both of the parents look exhausted – they have not left the bedside except for meals and showers at the Ronald Mc Donald House. They are still hopeful but the daily struggle of John seemed to affect them very much.
You have 10-15 minutes to speak to the family to update them with John’s condition and discuss management options
Other Data: GCS = 4
John was off fentanyl and midazolam drip for 3 days
Off epinephrine drip for 5 days
NGT feeding started 5 days ago
EEG showed burst suppression
MRI : diffuse infarct all over the brain parenchyma
Chest X-ray : resolving pulmonary edema
Somatosensory evoked potential (SSEP): no function noted