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My child can't breathe!


mobey

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Yes they do! No really I think one thing obviously missing is lung sounds. Trachea tugging really makes me suspect pneumo.

Tracheal tugging? Where did that come from?

And surely you've heard lung sounds before that were moving so little air that the sounds you could hear returned no useful information? I've rarely, but have, put 'lungs are silent to auscultation" in these situations.

Dwayne

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The lungs thing is my tongue in cheek humor, combined with my dislike of using physiologicaly impossible lingo. I suppose if you threw a lung on the floor it would make a *thud, but otherwise lungs themselves do not "make sound". The air entry sounds are silent R base, faint wheezes in L base, and loud musical wheezes in apex's.

Moving on

On percussion the entire chest is hypereresonant (sp?)

The mother sts the child was perscribed the nebulizer in the AM, due to bouts of morning SOB these last few days. Dr said he suspected allergies that would pass once the season changed.

I did not intend to paint the picture of an obtunded pt, just tuckered out. He does not agnowledge you as you enter the room, but is responsive to voice and meets your gaze when spoken too.

Child is 48lbs

No stridor

EtC02 via nasal cannula is 32. *Question - What does this value tell you about his PC02?

Skin; Pale, cyanotic lips/fingers, diaphoretic

What rate do we want the I.V's at?

I think we all agree on the Mag, I gave 600mg over 10min.

Salbutamol 5mg is running.

Atrovent? Pro's/Con's?

What RSI drugs do you want to have ready? Toolbox includes Fentanyl, Versed, Ketamine, Droperidol, Diazepam, Rocuronium, Succ.

Side note: If we act too quick, and put an asthmatic on a ventilator before exhausting all options, Squint/chbare/Ventmedic are all going to beat us senseless! That's right... even Ventmedic will come back to get in on it!

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The lungs thing is my tongue in cheek humor, combined with my dislike of using physiologicaly impossible lingo. I suppose if you threw a lung on the floor it would make a *thud, but otherwise lungs themselves do not "make sound". The air entry sounds are silent R base, faint wheezes in L base, and loud musical wheezes in apex's...

Oh.....My....God! That may be the gayest thing I've ever heard you say...(he's got a hot wife, he's got a hot wife.....ok..ok... then....I'm better now) But if you insist on anatomically correct terms and you define the entry sounds then don't you also have to define the exit sounds? I'm thinking your friggin' PCRs have got to be miles long...

I'm probably going to be sorry I asked, but no epi? How come? I would have shot the epi while I was prepping the Mag sulfate in 250cc of Saline...(In theory of course..pretty easy to manage this call when I've had two days to think about it.)

But I would have done everything in my power to avoid intubating this munchkin.. and not just cause Vent scares the shit out of me these days, thus my reason for ignoring the RSI stuff before..

Dwayne

Edited to add a missing word..if that will really help in that mess...No other changes.

Edited by DwayneEMTP
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What route for the Epi? Dose?

Now that more 5 mg ventolin is in he is more responsive, and Spo2 has come up to 92.

Someone pls see my last post and take a crack at the questions. That is the reason I posted this.

I'll be back soon for a better post, on the road right now.

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Epi would be 0.5mg SQ of 1:1000, but since he is improving on the ventolin nebs it's not really indicated any more. Atrovent causes smooth muscle relaxation, should help open up this kids lungs some more

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...EtC02 via nasal cannula is 32. *Question - What does this value tell you about his PC02?...

In my opinion, in my experience, it will tell you little to nothing. This is just not a reliable enough sensor and without labs to back it up we can't draw any hard and fast conclusions. What I hate about this sometimes, as with SPO2, is that as this value is near 'normal' then this little man shouldn't have any of the symptoms that you are reporting...but that is obviously not the case...So once again, 'normal' doesn't apply. Yet still it's common to hear medics talk about chasing this number around...

Not sure what you were looking for here brother, but I don't think that you can define the relationship between the two with the data provided. Even if we can trust 32 as an accurate absolute ETCO2 value, (And with Os running, we can't trust that it's even very close) we still need more information not available in the ambulance, at least not any that I'm aware of, to draw an accurate relationship to PCO2.

Or, I'm just talking out of my ass...I probably should have Googled this to see what the newest thinking is as I've not messed with it in over a year now...

Dwayne

God Damn it...I wrote that above, and then did in fact Google it, and found... http://emscapnograph...-in-asthma.html

Concordance between capnography and arterial blood gas measurements of carbon dioxide in acute asthma.

Corbo J, Bijur P, Lahn M, Gallagher EJ. Ann Emerg Med. 2005 Oct;46(4):323-7

In this study, 39 Patients, 37 Classified as "Severe Asthma," received simultaneous measurements of arterial carbon dioxide and end-tidal carbon dioxide. The mean difference between Pa02 and PetCO2 was 1.0 mm Hg. The median Difference was 0 mm Hg. Only 2 patients were outside the 5 mg HG agreement (1-6, 1-12).

"In patients with acute, severe asthma exacerbations, we conclude that concordance between PetCo2 obtained by capnography and PaCo2 measured by arterial gas is high."

Bottom Line for EMS: End tidal CO2 gives a good indication of the arterial blood gas level and can help a paramedic evaluate the severity of an asthmatic's condition.

So, as not to be a bigger pussy than usual, I'm leaving the original and have added the above.

The problem that I have with this is monitoring a person on O2. Either delivered by canula or NRB I've found that I can drag the numeric ETCO2 value all over the place with a change in flow rate and often with relatively small changes in the positioning of...anything. But I'm also guessing that the above quotes come from in hospital testing as well as more highly trained providers, so perhaps I'm not completely off in the ditch....not sure though.

Dwayne

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  • 2 weeks later...

So, we have a tired, gas trapped, cyanotic kid, with tracheal tugging.

From my limited drug kit, i'd hit this kid with the adrenaline straight away then set up the nebs. In my experience, tuckered out and obtunded are not that far apart. 10mcg/kg adrenaline IMI (sorry, i dont do pounds!) followed closely by the 5mg of salbutamol and 250mcg of atrovent. Its the shotgun approach but with minimal air movement theres a chance the nebs wont work but at least we can get some immediate effecct with the adrenaline - stabilise some mast cells, stop some bronchospasm and squeeze up his vasculature before the intrathoracic pressure dumps his preload

I cant see the rest of the posts Mobey, is there a set of OBS on this kid and lung auscultation?

Watch out for a pneumo.

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