Daycare Dyspnea

[Timmy]

I was the first one to ask about obstruction but you didn't run with it (good on yah Ben haha ) that's why I was banging the drum about croup. Just reinforces the fact of starting off your treatment and assessment in a basic manner then working your way up. Anyway, good scenario!

[chbare]

Thanks for the scenario. I am not too proud to admit I initially considered croup.

Take care,

chbare.

[melclin]

Sgt Pepperpants strikes again eh Ben?

[ambodriver]

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 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 ?

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

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>

Thanks for the response. Sometimes scenarios are hard to decipher. As I stated in my original posting, I would go with the croup/epiglot. route barring a an object in the airway. I guess the best thing would be to attempt back blows and thrusts to see if anything popped out and/or improved the condition. This is what I meant when I said "barring". If this were not to work, then it would be a "pucker" situation. So barring out the foreign object in the airway, I would treat this as croup. My tx. for this would be listed off my SMO's, nebulized EPI, if no improvement, then attempt intubation X 1. We don't have RSI in my SMO's. We used versed and etomidate. Etomidate is for adults only, so we are to used versed for sedation and intubation. You can't really rag on me for it, since I am not the medical director. Sorry. During intubation I'd be on the look out for a foreign object and swelling of the epiglottis. If I could not get the tube, I would cric. I'm not sure why you are disappointed with my treatment plan, or why exactly you take personal offense to my posting. People are strange around here. I see there is a little negative by my posting name, a -1 reputation. I find that quite amusing. Thank you!

I still stand by my response to the SPO2. Based on the appearance of this child I would not waste time with it. And I guess when I say waste time, I mean go digging for it, it is deep in our bag. So that situation is unique to us I guess. My priority would be on getting a line and some sort of airway intervention done immediately. Especially with the child who I quote the OP of thread has more cyanosis "than able to shake a stick at". This kid looks like shit and needs agressive, fast treatment. By looking at this kid I know SPO2 is less then ideal. The cyanosis tells me that. I think SPO2 is a great tool, however in this situation I would not worry about it. One thing I do love about SPO2 is trending. So I guess we could use it to see if the neb has helped the kid. However, I think a visual/auditory assessment with be a more reliable/quicker indicator of improvement. By no means did I mean to rile you up. This is a scenario on a forum which I glance at every so often, and I wished to respond. I know the die hards here like to treat this like a firehouse and bust balls etc. I want no part in that. cheers sir. hope you had a merrrrry xmas!

Here is a good write up that summarizes my position on Pulse Ox magic! http://tooldtowork.blogspot.com/2008/06/one-where-he-rants-about-pulse-oximetry.html

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.

whoa what kind of conclusions are you jumping to? Why are you taking this to a silly level? Let's be real here. I don't NEED the pulse ox in this situation AT ALL. Does cyanosis, stridor and DIB not ENOUGH EVIDENCE to determine whether this kid is in respiratory distress?? Do you need a baseline pulse ox to justify intubating the cyanotic kid with stridor to the doctors in your ER? If you do, it really sucks to work where you are. Pulse ox is NOT going to change my treatment of this patient. Will it change yours?

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

Hell if I never did a serious peds call ever again I'd be very very OK with that. But we know that isn't going to happen. So your thread is well appreciated by me. Thanks.

Edited December 28, 2009 by ambodriver

[streethealer535]

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

Timmy,

Please Let me Clarify for you... I was not talking about you wanting to know the child's O2 SATuration Level... I was talking about one of my pet peeves... Every time you say O2 STAT you sound like a moron! ITS SAT short for SATURATION... get it?

~street

[chbare]

Timmy,

Please Let me Clarify for you... I was not talking about you wanting to know the child's O2 SATuration Level... I was talking about one of my pet peeves... Every time you say O2 STAT you sound like a moron! ITS SAT short for SATURATION... get it?

~street

This may or may not even come into the equation; however, Timmy is not from the United States, therefore abbreviations may be different. Even among local and state services, abbreviations can differ. I remember working for a service some years ago that called blood sugars satellite G's. Therefore, I am somewhat hesitant to call somebody out if I am unsure of abbreviation and language differences.

Take care,

chbare.

[ambodriver]

Timmy,

Please Let me Clarify for you... I was not talking about you wanting to know the child's O2 SATuration Level... I was talking about one of my pet peeves... Every time you say O2 STAT you sound like a moron! ITS SAT short for SATURATION... get it?

~street

O2 STATS and SUGAR PRESSURES?

[Arizonaffcep]

I agree with the additional history and assessment considerations. For example, sudden onset stridor is going to have different pathology considerations.

I would most likely not go with salbutamol for an upper airway obstruction problem such as this kiddo. I would want to consider something like racemic epinephrine and ensure we are nebulising this medication properly, because unlike salbutamol, we want inertial impaction and deposition of the aerosol in the upper airway.

I would agree, that at least a loading dose of a steriod will be indicated in this patient.

While not an EMS consideration, this patient may benefit from Heliox therapy.

If we are still looking at croup, I would not consider antimicrobial therapy unless we have other indications of a bacterial infection. We must remember, croup is typically a viral infection.

Take care,

chbare.

Good call!