Hot Seat Case #102: A Family of Four in a House Fire
Posted on: November 8, 2017, by : Caleb Ward MD
Caleb Ward MB BChir, Children’s National Medical Center
with Kristen Breslin MD Children’s National Medical Center
The Case
You receive a call from EMS stating they are en route to your facility with 4 children extracted from an apartment on fire. 16 Adults are taken to the nearby adult hospital. They have a 17-minute ETA. EMS states that none of the children appear to have any burns, but they are worried about smoke inhalation injuries. They state there is a:
- 15 year old girl who is “unresponsive” on the ground but breathing on her own
- 13 year old boy who seems to be hyperventilating
- 2 year old girl who received chest compressions but is now breathing on her own
- 9 month old baby who has labored breathing
You huddle with the RN in charge to prepare for their arrivals. She asks if you want to activate a Code Orange (Mass Casualty Notification).
The patients arrive and are seen by four assembled teams comprised of ED providers, trauma surgeons, anesthesiologists, and PICU providers. The parents of these children are present and add that none of the children have any medical histories and are otherwise healthy to their knowledge.
The 13-year-old boy appears very agitated, has a heart rate of 134, a respiratory rate of 32, and a BP of 131/67. He has shallow respirations but no wheezing. GCS is E4 V4 M6. He intermittently arches his neck back and has upward gaze of both eyes. He does not appear to have soot staining in the nose or oropharynx. An IV is placed and POC labs show that he has a pH of 7.4, pCO2 of 40 mmHg and HCO3 of 26 mmol/L. His lactate is 4.2mmol/L. The bedside carboxyhemaglobin level is 4% level.
The 15-year-old girl was reportedly found “passed out” by EMS but breathing spontaneously. They placed her on a non-rebreather. She has a heart rate of 110, a respiratory rate of 25, and a BP of 124/68. She is noted to have a few soot stained nasal hairs but normal oropharynx. She complains of being a bit short of breath. She has mild stridor and faint wheeze. An IV is placed and POC labs show that she has a pH of 7.3, pCO2 of 29 mmHg and HCO3 level of 18. Her bedside carboxyhemaglobin level is 16%.
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I think this is great case that elucidates some of the interesting challenges/judgment calls of PEM and EMS phone calls. It is certainly possible given the difficulty of assessing four pediatric patients on the scene by a generally adult trained EMS staff, all four patients could require very high level care: a possibly unresponsive 15 year-old, an altered 13 year-old, a 2 year-old who has already undergone chest compressions and a 9-month old with difficulty breathing. In these cases, it is not always possible but very helpful if our CNMC transport team is part of the pickup, because they can stay and help to be part of your nursing assessment team. Even if they are not part of transport, if they are in-house, I wonder if they could still come down help with the assessment. I think the decision to call a code orange is really based on your availability of your current resources, staffing, acuity of the current ED, estimated ETA of patients, etc.