chbare Posted July 6, 2008 Share Posted July 6, 2008 You are a member of an ALS unit that has been called to a rural ER to transport a 4 year old patient diagnosed with status asthmaticus to a larger facility with pediatric pulmonary resources. Take it from here. Take care, chbare. Link to comment Share on other sites More sharing options...
Timmy Posted July 6, 2008 Share Posted July 6, 2008 I’m not really familiars with this problem but I’ll give it a stab. Is it a taxi run or is active treatment required? What was the medical officer hand over? Vitals? Meds? Phx? Hx? Ect… What meds have the hospital given? Salbutamol, Ipratropium? If so did the patient improve to bronchodilator’s? (I’m guessing not?) Have they given hydrocortisone sodium succinate or something similar like a steriod treatment? Is there some sort of medication the doctor has given you for transport? Link to comment Share on other sites More sharing options...
chbare Posted July 6, 2008 Author Share Posted July 6, 2008 You can provide any therapy you see fit. The sending physician reports the following: Four year old male (5 tomorrow) with a several month hx of asthma like s/s. Three prior ER visits and one admit. Other episodes responded well to rescue meds. (inhaled) However, he is not responding well to therapy currently. Past hx is negative except for the current problem. Pt has albuterol nebs and unknown oral meds at home. Parents do not know. Treatment so far: Hour long albuterol tx, weight appropriate dose of steroid, weight appropriate dose of epinephrine 1:1,000 IM. Current vitals: RR-54 shallow, labored, retractions, and the pt appears fatigued, P-155 narrow complex tachycardia on monitor, B/P-102/50, pulse oximetry-94% on a mask. (currently on a hour neb tx, that is placed to oxygen). Pt weight: 18.5 kg. Take care, chbare. Link to comment Share on other sites More sharing options...
Timmy Posted July 6, 2008 Share Posted July 6, 2008 Poor little fella! Bet his tired after all that! What’s the transport time to the peads unit? Lung sounds? I guess an expiratory wheeze would be obvious. I guess vitals are not very good at all. I guess his tachy from the epi but I’m not happy with the resps. Is there any cyanosis? and could I ask for a GCS please? Has the doctor diagnosed what stage his at with status asthmaticus? What sort of steroids have they given him? This may be a tad drastic but if his vitals drop more would RSI be an option? Link to comment Share on other sites More sharing options...
WelshMedic Posted July 6, 2008 Share Posted July 6, 2008 This is a primary ventilation problem that needs adressing emergently because this child is obviously starting to struggle. He is currently compensating, but will shortly be decompensating without adequate treatment. I'd also like to know how his ABG's are, by the way. My proposal: arterial line (primarily for the ABG's but also monitoring) parenteral beta2-adrenergic agonists (as long as the HR can take it) parenteral corticosteroids If all else fails, intubation and mechanical ventilation with low tidal volumes and a lengthened expiratory time to prevent barotrauma. Sedation with ketamine should be considered because of it's positive effect on bronchodilation (morphine should not be considered due to histamine release). Magnesium can be considered due to it's effect on the smooth muscle, but this will more likely be considered at the facility. WM Link to comment Share on other sites More sharing options...
itku2er Posted July 6, 2008 Share Posted July 6, 2008 In the rural area I live in we would fly this one. Link to comment Share on other sites More sharing options...
Timmy Posted July 6, 2008 Share Posted July 6, 2008 I was swing that way but was afraid I’d be bashed up for overreacting! Just for clarification, beta-2-adrenergic agonists relates to bronchodilating and Salbutamol doesn’t it? But, I agree with welshmedic, the kids not getting enough 02 so something needs to be done. Although intubating a kid would be scary! Why hasn’t the doctor already done all this? Also agree with Terri re aermomedical evac preferably by a service which offers paediatric specialists. Link to comment Share on other sites More sharing options...
WelshMedic Posted July 6, 2008 Share Posted July 6, 2008 Tim, Intubating a child is not quite as scary as you might imagine. Their anatomy tends to be slightly more straightforward than an adult. No, the problem is intubating a child with bronchospasm. ET intubation tends to exacerbate the problem as well as putting the child in danger of a barotrauma. Continuous nebs with salbutamol (yes, you were right...) and ipratropium (anticholinergic) seem to give a better outcome than early intubation and ventilation. The consideration we have to make in EMS is whether it is safe or not to transport before performing particular interventions. Intubating a child on the roadside in less than optimal circumstances could lead to more complications. This is the balancing act we perform on a daily basis. WM Link to comment Share on other sites More sharing options...
chbare Posted July 6, 2008 Author Share Posted July 6, 2008 Transport time will be about 20 minutes. You have no air-medical resources. The sending physician is a family doc who works the occasional weekend. Not a bad doc, but he is clearly very concerned about this kiddo and wants the patient at the other facility ASAP. He does agree with an ABG however, and if you want, the patient can be intubated prior to leaving the ER. ABG: PH-7.3 PCo2-62 Po2-68 HCO3-24 Chest X-ray: narrow mediastinum, flat diaphgram, and hyperinflated lungs. He was given solumedrol. The patient is starting to develop lethargy and his respiratory rate looks to be slowing down, lung sounds are decreased throughout. Good discussion so far. Take care, chbare. Link to comment Share on other sites More sharing options...
Kaisu Posted July 6, 2008 Share Posted July 6, 2008 This kid needs intubation and ventilation. I would not transport without it and a respiratory specialist to run the vent. Link to comment Share on other sites More sharing options...
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