chbare

Are there any significant physical findings that would give additional power to the presumptive diagnosis?

The find a few berry bushes in the back yard. No pesticides or chemicals are noted:

United States. No bites or stings, but he has been playing outside with his brother today. No access to pills today. No unusual smells.

There are no cleaning products in the house.

No medications in the house. The family recently moved in and have not unpacked any pharmaceuticals. The breath sounds are clear and in all lobes. The patient is very agitated and not at all oriented, but is awake. An IV has been placed and the patient is becoming more agitated.

Mobey, any chance of good follow up? Are you on good terms with the receiving facility? Something to strongly consider is writing this scenario up with your medical director and attempting to publish as a case study. Perhaps JEMS? This sounds like such a rate issue that even a case study would add something to the literature.

Sorry, can't help it. I am going through a bout of nostalgia.

Pulse oximetry is unchanged. Temp is 101.2 F. IV placed and BGL is slightly elevated. Sidestream capnography indicates a plateau shaped waveform with an EtCO2 of 22 mmHg.

A tad elevated for sure.

No history of smoke exposure from the parents. 138/80, 158, 44. Three lead shows sinus tachycardia.

No past medical or developmental problems noted. Parents appear very concerned but not overly dramatic. The patient does not maintain eye contact and appears to be interacting with stimuli that are not present.

Since we are monitoring CO2, what is the morphology of the waveform? Has this ever occurred before? If so, what was the cause, how was it treated and what was the outcome (did the patient require intubation)?

Yep, LOL. You guys are typically so spot on, I struggle to make a scenario last more than a few posts before everybody has it figured out. You note no overt scene hazards. The child's parents are home and you can insert any ethnic or apparent ethnic background you want. The child is sitting on the floor quickly moving his head in a lateral (side to side), repetitive manner. He appears to be breathing about 30 times a minute with a few periods of irregularity. SPO2 is reading 97% on room air. Your partner is pulling equipment for the baseline vital sign assessment.

I had this happen to a young, male patient in Afghanistan. Presented to our clinic with sudden onset, non-exertional angina. History was significant for smoking and moderate ethanol use. No known past medical issues or familial history. Ran a XII lead and he had some non specific ST changes and a left bundle branch block in addition to runs of sinus tach in the 130-140 range. Worked him up as an ACS. Gave ASA, NTG and loaded him with a Beta blocker. He was evacuated out and worked up in a military hospital. XII lead was normal, enzymes were negative and symptoms had resolved. He was discharged back to full duty. Saw him again a few days later with an identical work up. Again, the military hospital found nothing and told us our ECG machine was probably not calibrated. It occurred again and because it was close for him to return home on leave, he went back home and did a cardiology follow up. Subsequent follow up revealed he was diagnosed with vasospastic angina but well controlled on meds following the diagnosis. I'm glad you are feeling better.

At home, five year old male.

You are dispatched to a "child with difficulty breathing."

Congrats.

Agreed. You can trust somebodies word all day long but you'd best verify before making this an issue.

Well done Doc! Thank you for sharing.

I don't want to get too involved and incur the wrath of ERDoc, but the fact that we have initiated positive pressure ventilation in the setting of a pneumothorax may be more concerning than a spontaneously breathing patient with a small pneumothorax. Also, what about the location of the central line?

We will need labs a XII lead, a chest x-ray and a post intubation ABG, assuming we are satisfied with subjective and objective confirmatory findings. Also look at a foley and send for a UA.

Yeah, plus you may as well spread the love and give the admitting doc something to do. If you are really lucky everybody will complain about going IO even though it's a quick, safe and effective option...but that is another discussion.

Place an IO and begin infusing the sedatives and analgesics needed to keep the patient comfortable. Place two IO's if we need additional access. We can stabilise her and let the intensivist place a central line in the unit if needed.

Position the airway and assist ventilations with a BVM and high FiO2 and consider nasal airways. Are we able to maintain a patent airway and effectively ventilate and oxygenate? Depending on how things go I may consider slowly titrating small doses such as 0.1 mg. I mix 1 mg in 10 ml and can easily titrate small doses aimed at airway maintenance, ventilation and oxygenation end points. Also, look at her QT interval as methadone is known to prolong it. I'd hate to miss dysrhythmias as a possible cause or exacerbating factor.

Yeah, it's mild by most standards. Much more action than you would think. It will likely be a defining experience in a similar way to 2001 or Alien.