Kiddo

[chbare]

The doc is happy to tube the kid in the ER and your partner Bub is an RT who happens to specialize in pediatric ventilator management.

Take care,

chbare.

[Kaisu]

Given that the tube and vent are in place, we continue A and A treatments for the bronchiospasm.. administer 1:1000 epi 0.1 – 0.3 subQ - it is an allergic reaction after all. This kid is going to be dehydrated. - 20 ml/kg NS bolus to be repeated up to 3 times to make sure BP stays up. All of these can be done while we beat feet to the other facility.

[chbare]

Good call on the fluids. If no contraindications exist, giving fluids can be quite helpful.

The ER staff prepares for RSI and one of the RN's gives the following:

Premedication:

Fentanyl 57 mcg IV

Atropine 0.2 mg IV

Induction:

Ketamine 19mg IV

Paralysis:

Sux 37 mg IV

You intubate with style and skill placing a 5.0 ETT without difficulty. You see the glottis, while one of the nurses notes lungs sounds and chest rise and fall. Capnography detects carbon dioxide and a nurse places an NG tube.

Seconds after placing the ETT tube one of the nurses states, "what the hell?" You turn to the monitor and note the following.

You guys did not think I would give you a simple respiratory call?

Take care,

chbare.

[Laura Anne]

Did some reading on the lovely google and came across tracheobroncho-malacia and was wondering if the kiddo is out of the age range for it? The intense respiratory efforts would compress the vessels in the thoracic region. Also, this is a type of disease associated with chronic heart conditions.

As far as treating the issues at hand, I'd wonder if the bradycardia was a result from the intubation, or something else? I'm guessing it's something else..... :roll:

[Kaisu]

OMG.. the kid brady'd down very fast and went into vfib... check pulse... begin CPR - pull PALS protocol out of your ass and prepare to shock - have someone check a pediatric device for proper dosages -

Pediatric vfib is rare - initial shock at 2 joules/kg, subsequent shocks at 4 joules/kg.

I've heard of about 100 kids being shocked - outcomes - 0

thanks a lot chbare

[chbare]

Ok, so we are guessing something bad happened? One of the nurses checks a pulse and cannot locate a radial, femoral, or carotid pulse. CPR is immediately initiated.

So, how are we going to treat this kid? Are there any problems we should suspect?

I like the critical thinking so far. It is not tracheobroncho-malacia or a chronic heart problem.

Take care,

chbare.

[Kaisu]

well, we've reached the end of my bag of tricks. As far as I can tell, this kid has arrested primarily due to respiratory failure, which is what happens to kids. I know this is the one thing I want to avoid at all costs because it is very difficult to get them back. Start working the code.. epi every 3 - 5 minutes, atropine, amidodarone. While this is happening, think about the Hs and the Ts - in this case hypoxia was the probable cause of the arrest - consider magnesium (last ditch).

Now if there is something else (and with you chbare, there usually is) I will wait to be educated.

Great scenario by the way - not everyone can write them like you.

[chbare]

Ok, I think an important question to ask is the following: Do I suspect a sudden onset problem or something that took some time to manifest? Prior to the intubation, this little guy was teaching right along, then suddenly we have cardiac arrest.

Could the cause be respiratory? Possibly. Could the cause be something else? Maybe. A good review of the H and T considerations is a good idea. I want you to take it a step further than what you learn in ACLS however. Think out side of the box when considering the H&T considerations. What kind of pathophysiology could we be dealing with? Most importantly, how will we manage it?

Take care,

chbare.

[Kaisu]

Any evidence of trauma and/or bleeding? temperature?

[chbare]

Nothing to indicate trauma temp is 99.9 F.

Take care,

chbare.