romneyfor2012 Posted November 13, 2011 Posted November 13, 2011 You arrive to find an infant (lets say 6 months old) that is cyanotic, sats in the 70s, all other vital signs normal for age (a little bit tachy). The mom says the patient was diagnosed with plastic left heart and was discharged from the children's hospital after having the first stage / procedure, "A Norwood" performed a few weeks ago. You check out the home health folder and find that the patient has "Hypoplastic Left Heart Syndrome" This is the cause of the cyanosis, there is no trick here, or some other hidden condition that should require you to play Dr. House. I have given you the diagnosis, so now the question is how many of us know what this is, and the proper way to treat it in the field. So start googling, and tell me why the child is blue, and what kinds of treatment you would offer in the field. P.S. The children's hospital is 50 miles away, there are closer adult facilities, and you can not fly the patient due to weather. This is not as uncommon as you may think, especially if you have a Pediatric Hospital (with cardiac capabilities) nearby that draws people in from great distances.
romneyfor2012 Posted November 13, 2011 Author Posted November 13, 2011 Sorry, do not know how this got posted twice, ADMIN, can you delete one of them ? Thanks
FireEMT2009 Posted November 13, 2011 Posted November 13, 2011 After googling it and reading it on pubmed health it is where the left side of the heart is not matured enought ot support the demands of daily life. The cyanosis you are seeing is normal for a child with this condition because the left side cannot produce the pressure needed to deliver oxygenated blood to the body. Therefore the right side has to do it all, which will cause failure overtime. The Noorwood surgery that you posted originally is where the surgeons form a new "aorta" by fusing togeter the pulmonary veins with the coronary veins and attaching them to the old hypoplastic aorta. Since the patient can only stay alive by keeping the ductus arteriousum open so that oxygenated blood can pass through the heart. has the parent given the patient their medication today or the last couple of days? If not then you need to get them to the children's hospital ASAP. The child needs the children's hospital because they are specially trained for this and more than likely will have the pediatric cardiologist that is the doctor for this patient. I would go with a sense of urgency to the pediatric hosptial. I would keep constant checks on their vitals and ekg. The ekg will probably be pretty funky due to the changes the heart has had to go through to continue to supply the body with oxygen. The low O2 saturation we are noticing is not going to be uncommon due to the lack of the left side to properly send oxygenated blod throughout the body. Therefore the pulse ox monitoring would be near useless. I would place the patient on blow by oxygen right now and transport urgently while monitoring their vitals and continue getting the history from mom on the way to the peds hosptial.
romneyfor2012 Posted November 13, 2011 Author Posted November 13, 2011 (edited) You are very correct in your description of the syndrome and corrective measures, but a bit off on the prehospital treatment plan, anyone else want to take a stab at it ? And P.S. it is difficult to find the correct treatment plan online as most websites discuss the symptoms, surgical treatments, and causes, but do not go into non-surgical treatment too much, so don't feel bad if you do not know. Edited November 13, 2011 by romneyfor2012
FireEMT2009 Posted November 13, 2011 Posted November 13, 2011 I truly have no idea how I would treat this child prehosptially. I would have to treat the symptoms as they appear. I am completely lost. I would definately want to call the child's cardiologist and get him to tell me what I need to do. Med control on this one. Is my treatment plan missing something or am I just way off into left field? Had the parents been giving their child their meds religiously like they are suppose to? What made them call 911? this is extremely strange to me since the parents couldn't handle the situation on their own so they called us for a reason. What's the CC via parent's report?
romneyfor2012 Posted November 13, 2011 Author Posted November 13, 2011 The sats are lower than usual today. Which is a clue, most of these parents will know what sat is normal, and where the sat should be. I will post a link to an article in white ink below, highlight over it to show the link and read if you want, I don't want to give up the answer so quickly as others may chime in later on. The variable that is different in this patient is the use of oxygen. Getting their sats up to a level we feel is normal is very bad for the patient, and a common prehospital/non-pediatric ER mistake: http://paramedicine101.blogspot.com/2009/11/blue-babies.html
Quakefire Posted November 13, 2011 Posted November 13, 2011 Pt needs O2, the left side of their heart is non functional and the right side is working to provide systemic circulation. I would find out which surgeries have been performed, avoid any meds that would increase the workload on the heart, and contact their pediatrician or cardiologist (which ever is monitoring the patient) for any specialized instructions
romneyfor2012 Posted November 13, 2011 Author Posted November 13, 2011 OK Quake, how much O2, by what method, what type of sat are you trying to target with O2 (where do you want the patient to be) ?
DFIB Posted November 13, 2011 Posted November 13, 2011 I will make a post and then read your article. First you say the respiratory rate is normal, and the baby is conscious? As a EMT-Basic. I would get the child 100% O2 delivery and position the child tilted to the left side and in the shock position. Possibly even lower the head a little. I have questions as to what I might could do if my scope of practice were greater. Could I give a child that small something to vasodilate and increase heart contractility? A little epi possibly? OK Quake, how much O2, by what method, what type of sat are you trying to target with O2 (where do you want the patient to be) ? I think i would bag this baby with 15 lts/min to try to achieve 100% O2
FireEMT2009 Posted November 13, 2011 Posted November 13, 2011 With this child you will more than likely never acheive near 100% O2 because the heart isn't pumping blood adequately so no matter how much oxygen you push into this baby it will only raise it someone what. Romney, What is the normal O2 sat for this baby?
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