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DartmouthDave

Worried Mother!

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I'm not being an ass, you said it was quicker to stick in a drip and infuse some sugar than to put in an LMA in this patient

So naturally my next question is why suggest it if you don't think it's a good idea?

I misread the way the glucose level was presented. I thought I read it at 38 mg/dl. Sorry.

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As usual, I might call something by one name, and youze guyz by another.

What is/are a LMA, and same question on a EDG?

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LMA is the laryngeal mask airway aka lesbo lolly or fanny on a stick; it is what is used at the sub-ALS level (ACP/ICP/SRP/ECP) around the world for airway management.

They were first introduced here in early 2005 and generally speaking perform very well; in fact outside of RSI if a patient is ventilating and oxygenating well via an LMA it is being discouraged that it is swapped for an endotracheal tube in the field.

Equivalent in US EMS would be the King airway which some places have; it pains me greatly that supraglottic airways were included in the EMS Agenda for the Future as an "Advanced EMT" intervention; I can teach a bloody 5 year old the critical thinking and skill require to put in an LMA and it has been a bottom-tier thing here for at least 5 and probably closer to 7 years.

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I'm not being an ass, you said it was quicker to stick in a drip and infuse some sugar than to put in an LMA in this patient

So naturally my next question is why suggest it if you don't think it's a good idea?

Kiwi, QUIT BEING AN ASS. Not everyone uses the same number system for reading BGL, and 38 in common American usage means HYPOGLYCEMIC. Until you plug in and do the conversion to figure it out, you have no way of conceptualizing just how high that "38" is in the numbers you're actually used to.

THAT is why D50 was suggested. It is also still currently used here in my neck of the woods in both the hospital and pre-hospital settings for different patient presentations. BACK OFF, yo!

Thanks.

You also jump way too fast to advanced airway management here. She's breathing at 38, she's satting high 80's, we need to assess for aspiration first before we jump for the damn paralytics. It occurs to me, that if she's in DKA (which this appears to be with acetone breath and sky-high BGL) that the high respiratory rate may be the compensatory mechanism to fight the acidosis... so perhaps we should think about administering bicarb (off the wall guess here, as I don't actually know, but I do know we need to fix the acid-base balance) before we knock out her drive and try to take over...

Was she diagnosed with gestational diabetes, perchance? Folks with that diagnosis often then go on to develop Type II if not carefully watched/managed (it increases your risk substantially). That is my index of suspicion for what is happening here...

As far as baby goes, definitely get IO access and start some fluids... also see if orals can be tolerated... I would go for formula if possible, as H2O isn't well tolerated by infants this young... mom's definitely the priority, but baby isn't far behind with that elevated pulse and skin turgor... dehydration kills babies every day around the world, and kiddo's kidney function is at risk if diaper is dry and baby's that fluid volume depleted.

Bear in mind, if baby's that dehydrated and ends up vomiting, then you have two airways to be concerned about...

Wendy

CO EMT-B

Edit: Darn thing turned two separate posts into one and looked super weird. Fixed that.

Edited by Eydawn

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Kiwi, QUIT BEING AN ASS. Not everyone uses the same number system for reading BGL, and 38 in common American usage means HYPOGLYCEMIC. Until you plug in and do the conversion to figure it out, you have no way of conceptualizing just how high that "38" is in the numbers you're actually used to.

THAT is why D50 was suggested. It is also still currently used here in my neck of the woods in both the hospital and pre-hospital settings for different patient presentations. BACK OFF, yo!

Thanks.

I'm not trying to be an ass and am quite aware that 38mmol/l is about 800mg/dl (doing a quick mental conversion of 40x20) whereas normal is 80-120mg/dl

Several times it was stated that the blood sugar was in mmol/l and that should have fired off some neuronal activity with the bloke to go "what in the bloody hell is that thing I've never seen it before!" before going "all I've ever been taught is mg/dl so it must be the same" because one day he might land himself in hot soup doing that.

I could say to you "ZOMG WTF this bloke's Trop-T is 100!" and you'd probably keel over and die in horror when in fact I meant 100mcg/L which is 0.1mg/L which is normal.

You also jump way too fast to advanced airway management here. She's breathing at 38, she's satting high 80's, we need to assess for aspiration first before we jump for the damn paralytics. It occurs to me, that if she's in DKA (which this appears to be with acetone breath and sky-high BGL) that the high respiratory rate may be the compensatory mechanism to fight the acidosis... so perhaps we should think about administering bicarb (off the wall guess here, as I don't actually know, but I do know we need to fix the acid-base balance) before we knock out her drive and try to take over...

If you're referring to me I was basing my thoughts on the limited information I had at the time. I'd be more than happy to manage her airway with an LMA and would prefer to do this than RSI. A patient who is poorly oxygenated despite adequate ventilation is not the best candidate for RSI because ventilation is a separate physiologic process and not mutually exclusive to oxygenation. You can be ventilating perfectly but if I come along and take out all your Hb then your oxygenation is going to be a bit nunngered because what, about 2% of oxygen is transferred in the blood as dissolved oxygen?

I would certainly consider RSI in this patient if she was poorly oxygenated with an LMA, if her unconsciousness did not rapidly improve and we had suitable resources available. Her SPO2 is 93% at the moment which is quite low. I am more in favour of just taking her to the hospital rather than trying to bugger around tubing her.

You are correct that in DKA the high respiratory rate and increased tidal volume is an attempt by the body to buffer off the excess acid being produced by the beta oxidation of free fatty acids that have been released from the adipose tissue into Actetyl CoA which is then transformed into ATp, NAD+ and FAD(H2)... blah blah blah gluconeogenesis and kreb cycle oh look my eyes are bleeding in disgust at having written something about biochemistry.

As far as baby goes, definitely get IO access and start some fluids... also see if orals can be tolerated... I would go for formula if possible, as H2O isn't well tolerated by infants this young... mom's definitely the priority, but baby isn't far behind with that elevated pulse and skin turgor... dehydration kills babies every day around the world, and kiddo's kidney function is at risk if diaper is dry and baby's that fluid volume depleted.

Bear in mind, if baby's that dehydrated and ends up vomiting, then you have two airways to be concerned about...

I'd really rather not cannulate this baby if we can avoid it; oral fluids as tolerated and if not then I guess it's a drip and 10cc/kg

This is why I am not a paediatrician

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Why do you want to avoid cannulating the kiddo? Just curious.

Wendy

CO EMT-B

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The King Airway is new for FDNY EMS. We BLS EMTs have been trained in it's usage, but I admit I don't know if the New York State DoH Bureau of EMS has approved it for use outside of "Pilot Programs" yet. The Paramedics teaching us have been doing so from at least 2005, but we were still awaiting that Pilot to be approved, at least the last time I checked.

I'll check with friends at our OLMC and find out, and get back to this string re that.

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We have been using the King for a couple of years now. It replaced the dreaded combi tube. Our medics still use D50. Been on a couple of calls where used, one with amazing results the other not so much. In the end they recovered and were able to go home.

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Hello,

Sorry for the slow response.

Mobey,

Her temp is 35.6

Kiwi, Edydawn , et al.....

The patient's BP perks up with the bolus to 90/45 and the heart rate decreases to 135-140. With airway management (LMA, or good BVM) her SpO2 creeps up to 89-90%. You note course crackles in the the RML and LLL.

The second ambualnce has arrived on scene.

The infant is too weak to latch to a bottle.

Their is a PedER 15 minutes away and a AdultER 20 minutes away.

Thank you,

DD

PS... CWilliams 17: Sorry, I typed mmol/dL when I ment to type mmol/L. I can see how that would cause confusion if you are in the US. The solution is simple. You have to change to our way of doing things!! lol =)

Edited by DartmouthDave

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Why do you want to avoid cannulating the kiddo? Just curious.

Because it is less invasive to see if they'll tolerate some oral fluid

The patient's BP perks up with the bolus to 90/45 and the heart rate decreases to 135-140. With airway management (LMA, or good BVM) her SpO2 creeps up to 89-90%. You note course crackles in the the RML and LLL.

Her BP and SPO2 are still way too low for my liking

This presentation to me is unusual; DKA often takes several days to develop and does not typically present with significant coma so I have to balance the fact that she could have been like this for 3 days and is nunngered vs a patient with DKA should not be this unconscious unless there is neurogenic cause for coma; even with a bit of aspiration and some osmotic diuresis

I am struggling here because I am very worried about her oxygenation but are we dealing with a ventilatory problem or an oxygenation issue? Obviously there is some aspiration which will impair ventilation but hell ventilator dependant people in ICU with complete white out pneumonia have SPO2 higher than 90%

I want to RSI this lady but I do not think she is an overly excellent candidate for RSI because if she has aspirated a bunch of gunk into her lungs the problem is mechanical vs physiologic

The limit of my clinical decision making skill has been reached here, it's quicker to get going on a 1 toward hospital than to ring up an Ambulance Service Medical Advisor and then tube her.

The infant is too weak to latch to a bottle.

Then put in a drip and give baby 10cc/kg fluid

Their is a PedER 15 minutes away and a AdultER 20 minutes away.

Lets go to the adult ER; the big people doctors had to study little people too!

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