EMS World Clinical Challenge Tackles Adrenal Insufficiency

The EMS World Clinical Challenge is an EMS competition held annually during EMS World Expo. Teams of two participate in either BLS or ALS preliminary scenarios, and those with the best scores, as determined by expert judges, advance to a final scenario during the Expo’s last day. During the 2018 Clinical Challenge, held in Nashville, more than 40 ALS and 15 BLS teams competed for the grand prize of a trip to an international EMS convention.

The goal of the Clinical Challenge is to provide realistic simulated scenarios that challenge EMS providers to use their clinical knowledge, teamwork, and skills. The organizations behind it work hard to create simulations that allow crews to perform as many assessments, skills, and treatments as possible in a realistic manner. Challenge organizers hope these scenarios will provide an example of how simulated education can be an integral part of the medical community and help EMS professionals improve their clinical abilities in ways that positively affect patient outcomes in the real world.

This was the BLS/ALS preliminary scenario:

The Dispatch

You and your partner are dispatched to a single-family home for a 4-year-old male with an altered level of consciousness. You are assigned to a first-response unit, and the only transport unit in the area is approximately 15 minutes away. Upon arrival at the home, you are met by the nanny, who holds the patient in his arms. The nanny reports the patient has been sick for the past three days with nausea, vomiting, and anorexia. He also says the patient has a condition known as adrenal insufficiency and needs a medication administered emergently. The nanny says the parents have shown him the medication and instructions, but he has never given the medication before and is too afraid to do so now.

The child is limp in the nanny’s arms. He is breathing rapidly, and his skin is pale and dry. Your partner places the child on the couch and begins bag-valve mask ventilation while you look at the patient medical information sheet given to you by the nanny (pictured).

As you read the patient’s information sheet, he stops breathing, and your partner reports the child no longer has a pulse. How will you and your partner treat this patient? What are your treatment priorities?

Adrenal Insufficiency

Adrenal insufficiency is a condition in which the body does not produce cortisol, the body’s primary stress-response hormone. It is most commonly caused by damage to the adrenal gland, known as Addison’s disease. There are other causes of adrenal insufficiency, including genetic disorders such as congenital adrenal hyperplasia and any condition that inhibits the production of the ACTH hormone, which is responsible for activating cortisol secretion.¹ Primary adrenal insufficiency in pediatrics, such as congenital adrenal hyperplasia, occurs in approximately 1 in 15,000 births.²

Cortisol is an essential stress hormone that plays a significant role in the body’s response to illness or injury. Specifically cortisol helps regulate blood pressure and blood glucose levels. Those diagnosed with adrenal insufficiency must take a daily cortisol supplement to maintain appropriate body regulation. These patients may also need a high “stress dose” injection during severe illness or injury.¹ This is especially critical if the child has been sick and unable to take their regular cortisol by mouth. Any patient who presents with lethargy in combination with vomiting, hypoperfusion, or unresponsiveness must be emergently treated with an IM/IV steroid such as Solu-Cortef. In addition, all other measures such as perfusion and glucose level should be managed as appropriate.

Treating the Patient

After obtaining the medical history from the nanny and reading the medical information sheet, you recognize the patient suffers from adrenal insufficiency—specifically congenital adrenal hyperplasia. You understand the child has progressed into cardiac arrest as is unable to compensate due to his inability to produce cortisol appropriately. After recognizing the cardiac arrest, you and your partner move the patient to the floor and prioritize high-quality compressions. You work together to place defibrillator pads, perform a rhythm check, and continue compressions, along with bag-valve mask ventilations.

Your partner focuses on compressions and ventilation with the help of the nanny while you read the instructions for administration of the Solu-Cortef. Solu-Cortef is a glucocorticoid that contains hydrocortisone sodium succinate. It is the cortisol stress hormone that needs to be administered to allow the body to respond appropriately to the patient’s recent illness. The patient is unlikely to improve without its prompt administration. The dose is generally based on patient weight, and according to the medical information form, this patient should be administered 1 mL or 50 mg of Solu-Cortef as an intramuscular injection. Depending on your protocols, you may need to contact online medical direction for authorization to administer the medication. Another option would be to carefully guide the nanny in preparing and administering it.

The IM Solu-Cortef is administered in the patient’s lateral thigh, and you and your partner continue to focus on high-quality compressions and proper bag-valve mask ventilations with a BLS airway. As BVM ventilations are effective, you avoid performing an advanced airway procedure, knowing this is associated with worse patient outcomes in pediatric cardiac arrests. After several rhythm checks you find the patient has an organized rhythm and has regained a pulse. Upon arrival of the transport unit, you and your partner ensure the patient’s vital signs are stabilized and prepare to transport him to the closest appropriate facility.

More Information

For more information about adrenal insufficiency and congenital adrenal hyperplasia, visit the CARES Foundation website. The CARES Foundation, which provides research, education, and support for congenital adrenal hyperplasia, has resources that can help providers understand adrenal insufficiency and can assist EMS systems with the development of training and treatment protocols.

References

1. Children’s Hospital of Philadelphia. Adrenal Insufficiency, www.chop.edu/conditions-diseases/adrenal-insufficiency.

2. Perry R, Kecha O, Paquette J, et al. Primary adrenal insufficiency in children: Twenty years experience at the Sainte-Justine Hospital, Montreal. J Clin Endo Metab, 2005 Jun; 90(6): 3,243–50.

Jon A. Bailey is a lieutenant paramedic and paramedic preceptor with the Fairfax County (Va.) Fire and Rescue Department, as well as an instructor/evaluator in its training division.