Kasus 1

Deskripsi:
Evaluate Identify Intervene
Initial impression: PAT Cardiopumonary failure - Call for help
A: Lethargy, decrease of - Maintain airway
consciousness - Oxygen supllementation
B: Shallow and irregular with NRBM 8 Lpm
breathing - IV/IO access
C: Pale and mottled extremities - Cardiac monitoring : ECG
& Pulse oximetry (HR,
SpO2)
- Primary assesment
You are physician incharge in ED. Emergency medical services providers arrive with a 6 month old with
altered level of consciousness. The infant was reportedly picked up from day care and slept during the car
ride home. Her father reports that he was unable to get her to eat dinner. The infant lies listless in her father’s
arms. The emergency medical services providers were unable to establish peripheral intravenous access.
Patient looked lethargic, with shallow breath and irregular breathing. He looked pale with significant
mottling in extremities.

His weight is 8.6 kg. No sign of airway obstruction. Respiratory rate was 10-18/min and irregular; mild
subcostal and intercostal retractions; Spo2 93% on room air, increases to 95% with 100% oxygen with bag-
mask ventilation; lungs clear to auscultation. Heart rate was 160/min; pale; central pulses fair, peripheral
pulses weak; capillary refill about 4 seconds; mottled arms and legs; cool and dusky hands and feet; blood
pressure 84/30 mm Hg. He looked lethargic, responds to pain; pupils have sluggish reaction to light. Rectal
temperature 37.0°C.

Evaluate Identify Intervene

Primary Assessment - Patent airway - Maintain patent airway
A : No sign of airway obstruction - Respiratory failure (bradyp- - Oxygen supplementation
neu, severe air hunger, mot- - Monitor with pulse oximetry
B: tling, decrease of conscious- - Bagging if higher pressure
- RR : 10-18/min ness, hypotension) needed
(bradipneu) - Decompensated/Hypotensive - Ringer lactate IVFD
- Resp. pattern : irregular & shock - Check for random blood
shallow - Responds to pain (shock due sugar
- Resp. effort : mild to increase of intracranial - Keep comfort position
subcostal dan intercostal pressure) - Prevent hypothermia (with
retraction blanket)
- Breath sound : clear
- SpO2 : 93% on RA 
95% on bag mask
ventilation
C:
- HR : 160x/min
- Pulse : central pulses fair,
peripheral pulses weak
- CRT : 4 sec (>2)
- Skin color : pale, mottled
arms and legs, cool and
dusky hand and feet
 - BP : 84/30 (Hypotension)
- Skin color : pale, mottled
arms and legs, cool and
dusky hands and feet
- BP : 84/30 (hypotension)

D : AVPU
- Lethargy
- Response to pain
- Pupils : sluggish reaction
to light
E:
- Rectal temp : 37C
(normal)

From brief history taking, patient reportedly was “normal self” before being dropped off at day care. Day
care told dad that the infant took second nap before being picked up. Infant has demonstrated increasing
lethargy, decreased work of breathing, and irregular respiratory rate. No history of allergies or medication.
He was term newborn, didn't have any illness. Last meal was 6 hours ago.

Evaluate Identify Intervene

Secondary Assessment: Meningitis bacterialis Pdx : CBC, ESR, lumbal puncture
S : DOC, lethargic, bradypneu (CSF culture), EEG, CT Scan
(shallow & irregular), decreased
work of breathing, pale, mottling, Ptx :
weak pulse, hypotension Ceftriaxone
Corticosteroid
A : No history of allergies

M : No history of medications

P : No history of illness before

L : Last meal 6 hours ago

E : Infant was normal self before

being dropped off at day care and
took a second nap before being
picked up
Kasus 2
Deskripsi:
You are physician incharge in ED. Emergency medical services arrives with a 6-month-old boy brought from
his home after mother called 9-1-1 because her child had a seizure. She looked lethargic; eyes closed; no
visible reaction to his mother’s voice or noises in environment. Respiratory rate was wery slow with minimal
chest rise. Her skin was pink.
Evaluate Identify Intervene
Initial impression: PAT Respiratory failure - Call emergency response
A: Lethargic, unirritable by voices team
- Maintain airway
B: Slow RR with minimal chest - Oxygen Supplementation
raise - IV/IO access
- Cardiac monitoring: ECG
C: pink skin & Pulse Oxymetry (HR,
- SpO2)
- Seizure: Diazepam 10mg
per rectal

Snoring was heard, accompanied with paradoxical movement of chest and abdomen when breathing.
Spontaneous respiratory rate 12/min; shallow and regular; SpO2 80% on room air and 99% with bag-mask
ventilation with 100% oxygen at a rate of 30/min. Heart rate 146/min; dusky (before bag-mask ventilation
with 100% oxygen); strong central and peripheral pulses; capillary refill 2 seconds; blood pressure 88/56 mm
Hg. She looked lethargic; responsive to painful stimuli. Temperature 39.7°C, weight 7 kg.
Evaluate Identify Intervene
Primary Assessment - upper airway obstruction - Triple airway manuver
A : Snoring - Respiratory failure - Oxygen supplementation
- No shock condition with positive airway pres-
sure
B:
- IV/IO access
- RR: 12x/min - Vital sign monitoring
(Bradipneu) - Observe for seizure
- Resp. pattern: - IV/IO access
shallow & regular - Drugs: antipyretic
- Resp. effort:
Paradoxical
movement of chest
and abdomen when
breathing
- Breath sound:
Clear
- SpO2: 80% on RA ->
100% on BVM 30x/min

C:
- HR: 146x/min
- Pulse: strong central
and peripheral
pulses
- CRT: 2 sec
- Skin color: dusky
 (before
oxygenation)
- BP: 88/56
(Hypotension)

D:
- Lethargy
- Response to pain
E:
- Temperature : 39.7°C

She had fever and irritable for the last 3 days. Allergies was not known. Acetaminophen was given by
mother 2 hours ago. No history of previous seizure disorder. Last meal was 3 hours ago. Abrupt onset of
tonic-clonic seizure lasting approximately 5 minutes.
Evaluate Identify Intervene
Secondary Assessment: Febrile seizure (kejang - Diazepam IV 0,3-
S: Fever and irritable for demam) 0,5 mg/kg, slowly (1-
3 days 2 mg/min or within 3-5 min),
with maximum dose 20 mg
A: History of allergies - Antipyretic: Paracetamol
unknown 10-15 mg/kgBB/times

M: acetaminophen (2 hours
ago)

P: No history of previous
seizure

L: last meal 3 hours ago

E: abrupt onset of tonic

clonic seizure for 5 minutes