Daycare Dyspnea

[Timmy]

REALY???? tell me please that this was a typo or a joke.... if its a joke I get it and yes you got me.... if not then well please just shoot me now...

~Street

Why do you ask? Last time I checked, SP02 is part of a comprehensive vital signs assessment...

[Timmy]

I think I have given everyone the wrong impression here, I was basing my treatment on a croup presentation. I understand I haven't been througher in my investigation and assessment but in the initial states of Ben's assessment my diagnosis was leaning towards sever Croup based on the raspy cough, high pitched stridor Phx of croup and use of accessory muscles which are all characteristic of croup. I only had a kid present to ED with similar symptoms the other night.

Now, I did go to work today and I did read up on the clinical practise policy (feeling bad that I'd completely messed up and to ascertain my sanity level) in regards to paediatrics presenting in sever resp distress secondary to sever croup.

Someone has mentioned nebulised salbutamol, whilst a good idea there isn't any evidence to suggest wheezing and I would agree with chbare that salbutamol is not the drug of choice in this situation because stridor does not indiate bronchospasm.

An adrenergic agonist like Neb Adrenaline as a front line drug is a great idea (while it did cross my mind I didn't think to put it into my treatment at 2am when I initially published my first post.) Alpha receptor stimulation (that is a therapeutic effect of adrenaline) may contribute to mucosal vasoconstricting which interm can reduce the amount of oedema in the upper airway (providing the kid has croup, which hasnt been specified at this stage)

A corticosteroid like Dexamethasone can also be benifical in reducing the inflammatory response in the upper airway by reducing the number of certain white blood cells (I forget the appropriate name for this process but it's something to do with leukocytes). Prednisolone could also be used but in an emergency situation Dexamethasone would be the drug of choice as the onset, peak a strength of the medication are greater.

When you have a kid this sick (deminised bi lat lung sounds, extremely low SP02, tachypneic and general poor perfusion) then intibation, establishing an airway and getting some more oxygen flowing around is of great priorty, espcially in kids... As I'm sure your aware once your oxygen haemoglobin dissociation curve goes blow 85% it's very hard to establish there stats again, especially in kids because they use most backup mechanisms and crash pretty quickly because they have nothing left to fightback, per say.

But yes, I do agree... Poor assessment on my behalf, I defiantly should have assessed the patient to greater level before I go all out on a pharmacological rampage. But I would definitely like more info on this patient.

Could I also please have a general picture of the seen, is the kid crying? Is he floppy? Sitting up? Lying down? Alert? High amounts of 02 at this stage in an upright position. Maybe give Mum a call to gather a better picture on any relevant past history.

Anywho, I'm probably completely wrong (only been an RN for 2 weeks) but I appreciate any feedback... I'm here to learn

Edited December 24, 2009 by Timmy

[HellsBells]

There is still something that needs to be ruled out (albeit in double-quick time).

Care to share with us? don't really know what it could be

it seems as though the following have been ruled out

- asthma, no wheezes, no Hx of same

- Allergy, no previous Hx, no other signs/symptoms

- Epiglottitis- Seems to be ruled out after Mobey asked about drooling

So... what are you getting at? a foreign airway obstruction, as chbare mentioned?

[Kiwiology]

Lets go back to basics - what could it be?

I would suggest we do something pretty quick befofre this kid arrests; we've probably been on scene for 10 minutes, total time since this kid started having hypoxia is maybe 20 minutes

Edited December 24, 2009 by kiwimedic

[chbare]

FBAO.

Take care,

chbare.

[ambodriver]

Why do you ask? Last time I checked, SP02 is part of a comprehensive vital signs assessment...

I have a partner who relies so heavily on SPO2 and it drives me crazy. He's a piss poor medic. Do you really have to waste time throwing the SPO2 on when the kid is in obvious severe resp. distress? He's cyanotic w/stridor. Barring a foreign object in the airway, I'm going down the epiglot./croup route. (we have no evidence of a allergic rx) Lets have my partner start some racemic epi while I ready the intubation and cric equipment.

If the epi does nothing, I will intubate (utilizing versed per my systems SMO), while intubating I'll be looking for a foreign body and/or swelling of the epiglottis. If I see any evidence of this and cannot get the tube, I will be cric'ing.

Not slamming you BTW with the comment about the pulse ox. I just feel a good visual assessment is more reliable. We don't need a pusle ox. to tell us whats going on, and in this scenario out on the street with 2 people, I think it is a waste of time to be worried about that. I would probably bust out our SPO2 when we intubate since it has digital capn. on it as well.

merry xmas guys

Edited December 24, 2009 by ambodriver

[mobey]

I have a partner who relies so heavily on SPO2 and it drives me crazy. He's a piss poor medic. Do you really have to waste time throwing the SPO2 on when the kid is in obvious severe resp. distress? He's cyanotic w/stridor. Barring a foreign object in the airway, I'm going down the epiglot./croup route. (we have no evidence of a allergic rx) Lets have my partner start some racemic epi while I ready the intubation and cric equipment.

If the epi does nothing, I will intubate (utilizing versed per my systems SMO), while intubating I'll be looking for a foreign body and/or swelling of the epiglottis. If I see any evidence of this and cannot get the tube, I will be cric'ing.

Not slamming you BTW with the comment about the pulse ox. I just feel a good visual assessment is more reliable. We don't need a pusle ox. to tell us whats going on, and in this scenario out on the street with 2 people, I think it is a waste of time to be worried about that. I would probably bust out our SPO2 when we intubate since it has digital capn. on it as well.

merry xmas guys

We don't "need"

That's your argument?? Why not use all the tools at hand when assessing resp status?

I know damn well any ER doc will ask the $100 question when you present your intubated kid to him. "What was his SpO2 on room air?"

Don't you gather a "Baseline" to compare to after treatment?

Hmmm.... I guess we don't need a cuff to assess BP either.... Cap refil will suffice.

We don't need a thermometer to assess Temp either, skin to skin contact will do.

Heck... Why even use EtCO2 after he is intubated, you have a stethoscope!

IMO, using all the tools available is part of a complete assessment.

Maybe it takes you longer to snap on an SpO2 than it does me though.

[tniuqs]

'ambodriver'

I have a partner who relies so heavily on SPO2 and it drives me crazy. He's a piss poor medic. Do you really have to waste time throwing the SPO2 on when the kid is in obvious severe resp. distress? He's cyanotic w/stridor. Barring a foreign object in the airway, I'm going down the epiglot./croup route. (we have no evidence of a allergic rx) Lets have my partner start some racemic epi while I ready the intubation and cric equipment.

Well besides your personal view of Pulse Oximetry, this device is now considered a vital sign and if one goes back in the history and development many studies have proved quite conclusively that even experienced practitioners (all levels) are no where near as close to accuracy to even recognize life threatening condition based on the term "cyanosis" related to hypoxia: the previso being that one understands just what this tool is telling you. Or would you prefer to use a portable transcutanious PO2 probe ?

I wonder what your partner says that about of yourself or do you just have more "years of experience" ? Time for a partner change I would suggest if one has no confidence in ones partner this is a true "cabin" atmosphere that can lead to a wreck. Lets not rain on kiwimedics parade shall we and with over 400 views on this thread by many that wish to learn lets not go off the tracks PLEASE.

Query(s)

So with a toddler in respiratory extremus and very, very close to arrest we should jump right to nebulised epi when we have not ruled out a FBAO ?

1- The half life of epi is very short and can lead to "rebound" do we want that to occur ?

(a) Can BLS deliver Epi Side stream neb to a toddler ?

2- In a very stressed toddler (we do know that kids respond positively chonotropic ie faster heart rate) Epi is not selective beta affects ... could we be putting them over the top and cause them far more harm than good ?

3- Delivery of "said" SVN mask can cause a drop in FiO2 delivered can it not ?

(a) So just the change over from a NRM perhaps could bottom this kid ... tick tick tick.

4- In passing this is inspiratory and expiratory stridor (auscultated) So if was it was a migrating FBAO could this lead to a check valve and cause a pneumo ?

5- Have any of the ALS providers considered lidocaine nebulised for this Toddler ?

If the epi does nothing, I will intubate (utilizing versed per my systems SMO), while intubating I'll be looking for a foreign body and/or swelling of the epiglottis. If I see any evidence of this and cannot get the tube, I will be cric'ing.

If you see a big beefy looking epiglottis it may NOT be croup and even anesthesia guys I have worked with get a major "pucker factor" if they see this cardinal sign. Versed ? just Versed that is NOT RSI and do we even have a line in yet?

Then cric'ing a toddler? More bravado than brain very easy to say a tad more complex besides just what does your service provide you to do a cut down for peads ? Correct me if I am wrong kiwimedic this is a BLS crew and no intubation available in the first place perhaps revert to some BLS strategy first ?

Not slamming you BTW with the comment about the pulse ox. I just feel a good visual assessment is more reliable. We don't need a pusle ox. to tell us whats going on, and in this scenario out on the street with 2 people, I think it is a waste of time to be worried about that. I would probably bust out our SPO2 when we intubate since it has digital capn. on it as well.

WRONG and way bad attitude <insert Dinnozo head slap> and a WTF for good measure.

Kiwimedic

I would suggest we do something pretty quick before this kid arrests; we've probably been on scene for 10 minutes, total time since this kid started having hypoxia is maybe 20 minutes

Agreed ... or this kid is not going to get his presents from under the tree... hmm what to do ?

cheers

<late edit for verbal reprimand, place in ambodriver's file under bad attitude for a period not less than 12 months>

Edited December 24, 2009 by tniuqs

[scott33]

The child's environment, as well as the time of onset of symptoms should be ringing alarm bells.

[Kiwiology]

This is exactly what I wanted to see (or not see really) and why I put this up.

Everbody is all bug-eyed about croup and oh lets give him adrenaline, well lets give him salbutamol, lets intubatge, naaaaah lets give 'em bloody midazolam!

I'm not knocking you guys for this because when I got this presented to me by a Clinical Standards Officer I was like well he's got a history of croup, he's severely short of breath, one and one make croup.

Truth be told the kid had been left alone for two minutes playing with the lego and he choked on one. The crew in attendance went with croup, tried adrenaline nebules that didn't work and while doing another round the kid arrested, they ended up doing a cricothyrotomy which didn't work and it all sort of went down hill from there.

When we look at it in retrospect it all makes perfect sense; in the two seconds little Billy was left alone with the lego bricks what are the chances of him developing lift threatning severe croup with no history of being unwell? None!

The crew got sucked in, I got sucked in, most of us here got sucked in and right from the outset of the job when the EMD asked if the patient had any PMHx the words "severe croup" cropped up and everybody just went with that, never mind tip the kid up by his feet and a quick whack on the back probably would have expelled the obstruction.

Moral of the scenario is dont get sucked in, or just dont do peads calls

Merry Christmas