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My child can't breathe!


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Here is a call I had a week ago.... kinda fun with lots o' pucker factor.

Called for a 7 y/o male with diffuculty breathing. Note; It is 1900hrs

On arrival you find a 7 year old in extremis. Adventitious air entry sounds are heard from the door.

Mother sts, her son awoke with SOB @ approx 0930 this morning. She has been trying to manage it all day, but it seems to be getting worse tonight.

The child does not track you as you enter and introduce yourself.

he is sitting semi-fowlers on the couch, and see-saw breathing with intercostal retractions and tracheal tugging is noted.

(PS tniuqs... no smacking me till the scenario is over!)

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Friggin' heathen... Dwayne

Yes long pucker factor as well. It stands to reason that we do not intubate these people unless we have to, from what I am told, they are very difficult to wean off the ventilator. This child

V/S, put the kid on O2 and get brief medical history from mom (asthma, preemie nicu or picu time) Lung sounds

I already have a treatment plan sitting in the back of my head but I should probably wait for these answers

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V/S,

BP 98/66 P164 Temp 38.2 Sp02 82% BGL 7.1

put the kid on O2

done

get brief medical history from mom (asthma, preemie nicu or picu time)

He is an asthmatic although he only carries a rescue inhaler and has rarely used it. he was in the clinic earlier this week with some SOB, so the Dr sent home a nebulizer to use every morning for a week. No other Hx.

Lung sounds

Lungs don't make sounds

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A

Is the Airway clear?

Patent?

B

Rate, Rhythm, Effort?

Breath sounds on Auscultation?

SP02?

C

Pulse rate?

Blood Pressure?

Cyanosis?

BP?

Capillary refill (core & peripheral?)

Perfusion Status?

Monior?

D

Glucose?

E

General Appearance?

Past History?

Allergies?

Medications?

Oral Intake?

Hydration status?

Have 02 on by now, getting Salbutamol nebuliser ready until we have further information.

EDIT: Based on the further info while I was posting the above.

Holly cow! Silent!

Get some Salbutamol into him.

What’s his weight?

Drawing up some prednisolone and Hydrocortisone ready to push when we have more info.

I’ll also start drawing up RSI drugs as per weight and have more info on respiratory/perfusion status.

Edited by Timmy
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I agree, without further information I’ll assume were under timed critical conditions secondary to severe asthma. If were heading on the down hill cascade then we need to act quickly.

-Need at least IVC X 2, I’d go with OI if we need to be quick.

-Continue with Salbuatmol 5mg and Ipratropium 250mcg.

-Methylprednisolone 1 mg/kg IV

-Aminophylline loading dose of 10mg/kg, if were still not winning we can set this up as an infusion depending on the weight to reflect the infusion rate.

-If were having no luck with the NEB Salb I’m a bit reluctant to give Salb IV because it has limited benefits in timed critical situations and we risk toxicity if we’ve been giving him Nebs then an IV.

-RSI

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No further information on why he was at the docs? You said that he didn't follow you as you walked into the room, how obtunded is he?

Stridor? Did you percuss the thorax? What did you/might you have heard? Do you have him on ETCO2? Before or after we began bagging? Is it the canula sensor? What is the wave form? What is the numerica value?

If you're going to neb him you need to bag it in. I'd be putting epi onboard before I worked an IV unless it's possible for you and your partner to do both at the same time. I think the steroids are going to help, but he needs relief faster than it will bring it. Depending on the results of percussion, the short term, 30-60 second effects of the meds/assisted vents, I'm wondering..again, if we find that he's constricted and not blocked, of maybe a gram of mag sulfate too? Might wanna run that one by the doc...in his condition I have no faith that it's the right thing to do, but something better work or we better pull a rabit out of the hat. I don't have another rabit per se, but I have the mag sulfate guinnea pig..and it may have to do if we're going to avoid intubation.

But based on the above, I'm not confident that this isn't a/or several slowly developing pneumos...I''m really not confident about anything else though, either, so there you have it...

I'm thinking RSI probably won't be necessary with this kid..if we can't open him up in the next few mins he's going to crump and probably be easy enough to intubate....

Dwayne

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Lung Sounds, Capillary Refill, Vital Signs, Skin: color, temperature, & condition, AVPU, A/O?, PMH, Allergies, Medications, HPI, OPRST (if there's pain). Then we can think of ALS treatments but BLS maneuvers should have been started already before your ABCs were done: O2 via NRM or BVM (OPA?)... Not enough information...

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