# Question about a critical Ped



## cdrcems (Jan 9, 2012)

Hello I’m a relatively new medic with only about three year’s experience. I have been reading on here for some time and I have picked up a lot I have been able to use. I would like your opinion on a call I had.  

I was dispatched to a report of a 7 y/o with trouble breathing. The dispatcher didn’t have any other info for me. We were about 6 miles from the address and the BLS eng company was right around the corner. I arrived to find a Halloween block party. There were cars everywhere and we couldn’t get down the street. I looked down and saw a flash light about 6 houses down. This house was decorated and had a smoke machine going. I walked up to see three firefighters looking down at a child lying across her mother’s lap. One of the firemen was holding an adult Duo-neb mask over her face. The child was completely unresponsive breathing about 40/min with retractions. I started asking the mother questions:
Does she have Asthma – yes
Ever been vent depended – No
Allergies /Meds – No/Inhalers prn
Age/Wt. – 7 y/o  32 kg
I sent my partner and a fireman back to draw up .3 epi, 1.5 grams of mag, and spike a bag. I popped a ped mask out for the Duo-neb, placed pt on the cot and we started dodging cars to the truck. We got in and my partner handed me the epi, no response to the stick. Spo2 82, HR 120, RR still about 40, not moving any air at all. My partner gets us moving.  I put a 20 ga in her left ac and again she never moved. I had the fireman pull out the ped bvm and an OPA but told him not to use them yet. Spo2 is now 86. We had about a 20 transport time to the children’s hospital or a 10 min to the closest.  By the time we get out of the maze of homes and cars the mag is going. In just a few min the RR slow and I can hear wheezing. When we get to the outside hospital the spo2 is 99 and she pulls at the mask.

Now that we’re at the ED she’s doing even better.  It was the same song and dance “ hey she should of went to peds, She’s not that bad”.  I laughed at her and the mom hugged us. 

The fireman asked me why I didn’t want him to bag her or place an OPA. I explained that this pt was fighting to breath. If we would have bagged her it would, more than likely, knock out her respiratory drive. Plus the compliance would have poor. I also explained she’s never been intubated before. More and more studies are pointing to poor out comes for children that are intubated. The OPA could have caused vomiting if the gag reflex was intact plus reflex bradycardia and decreased what little metabolism she had left. We got to her right when she was on the fence. She needed drugs to help reverse the swelling. There was an older medic in the room that over head this said I put that child in danger for not focusing on the hypoxia first. He said I was putting the p before the e in EMT-P. I really respect this guy and I was crushed to be honest. Did I? Would any of you guys done anything differently? Thanks for taking the time to read this.


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## Shishkabob (Jan 9, 2012)

I see nothing wrong.


Asthma that bad is like anaphalyxis... Epi is needed and needed now to reverse the course.  If they don't have good tidal volume (and she didn't if you heard no wheezing), no amount of oxygen via NRB is going to help, they aren't doing good gas exchange. 



Don't know if I would have hopped on the mag that quickly, would have given the Epi some time first and continued more duonebs, but everyone has their own.  I've given Mag to one pediatric asthmatic and that is what made the difference, as Epi had little effect.




Tell him working "e before p" is doing cookbook medicine.  You do what works when it's called for.  If that means doing Epi before anything else, that's what you do.


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## Dwindlin (Jan 9, 2012)

Personally I think it sounds like strong work.


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## NYMedic828 (Jan 9, 2012)

The kid lived... im a total newbie to being a medic but last I checked that was a pretty good sign of a job well done...


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## WTEngel (Jan 9, 2012)

I think you did everything correctly except for going to the closest facility instead of the children's hospital. 

The adult ER saying "she's not that bad, should have gone to peds" is completely contrary to common logic! The only pediatric patients that should go to an adult ER are the ones that "are not that bad." Any serious pediatric patient should go directly to a pediatric specialty facility, barring unreasonable delay due to transport. If it would have delayed arrival by more than 20 minutes, then the closest facility might have been a reasonable consideration, but in your case, 10 minutes additional transport is worth it, considering the undeniable benefits of the patient being treated in a pediatric specialty facility.

Bagging would not have helped, the child is having difficulty exhaling, not inhaling. Providing positive pressure ventilation doesn't relieve this. 

Additionally, I can not really understand how the other paramedic feels that continuing the treatment, giving epi and then mag was not focusing on the low SPO2. All of the supplemental oxygen in the world is not going to increase that child's SPO2 until you open the lower airways. 

As someone has already mentioned, you might have been quick on the draw with the mag, but I would rather see you use it like you did on a patient in extremis, than be so afraid to use it you tuck your tail and stop at epi. 

I think it was strong work. I would have been impressed, and when it comes to peds, impressing me is sometimes hard to do.


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## KellyBracket (Jan 9, 2012)

Nice job. Sounds like the environment alone was a challenge.

The question of assisting respirations with bagging is a tricky one. In the ED we don't really worry too much about the CO2 in an asthma patient, and really only care about the sat. I don't think I've ever heard about asthma patients having a hypoxic drive, in the same way that COPD patients can. Generally, in mild/mod asthma attacks, the pCO2 may actually be _low_, due to the tachypnea.

Now, in the ED you should try CPAP or BiPAP as a bridge device, to buy time for the drugs to work, but the mental status has to be there. You're helping out the respiratory muscles for a while, so they don't crap out on you entirely. Without NIV, you could try a BVM in order to assist her respirations as her diaphragm and intercostals are weakening, but I agree that an OPA might trigger vomiting, aspiration. 

Tough to say exactly when a patient "needs" to be intubated for asthma - not too soon, and not too late. You describe her as "completely unresponsive," which is a good reason to control the airway, but it's hard to say without having been there. 

Tough calls to make.

Last edit: All board-certified EM docs have plenty of experience with peds emergencies. If things are getting bad in your rig, get them to _any_ ED fast.


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## NYMedic828 (Jan 9, 2012)

WTEngel said:


> I think you did everything correctly except for going to the closest facility instead of the children's hospital.
> 
> The adult ER saying "she's not that bad, should have gone to peds" is completely contrary to common logic! The only pediatric patients that should go to an adult ER are the ones that "are not that bad." Any serious pediatric patient should go directly to a pediatric specialty facility, barring unreasonable delay due to transport. If it would have delayed arrival by more than 20 minutes, then the closest facility might have been a reasonable consideration, but in your case, 10 minutes additional transport is worth it, considering the undeniable benefits of the patient being treated in a pediatric specialty facility.
> 
> ...



Little side note, is mag particularly dangerous in peds vs adults? I know messing with the electrolyte balance of the body is always risky, but do peds pose any further complications?


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## WTEngel (Jan 9, 2012)

The appropriate dose of mag in a pediatric patient typically doesn't carry more risk than in the adult, at least in my experience. You have the same hemodynamic and metabolic risks in both populations. Always be prepared to provide hemodynamic support in patients you are giving mag to.

Brackett, I would have to respectfully disagree with you. "Plenty of experience" is a rather subjective description. Peds rotations during EM residency vary on quality and quantity of experience. 

The EM residents at UT Southwestern/Parkland who get to rotate at Children's Medical Center in Dallas in the ER have a much different level of experience than those who did residency at a smaller program that does not have access to a high acuity pediatric facility. Even with that great residency experience, they are most likely less capable than their pediatric critical care trained counterparts who work at a peds specialty facility.

Working in pediatric critical care transport I have seen more than one ER physician make critical errors in clinical judgement that have adversely effected patient outcomes. This fact does not make those physicians incompetent providers, it simply is not their area of specialty, and most are happy to admit that fact. That is why they make the decision to transfer those patients by critical care transport team without delay.

I stand by my original post. A pediatric patient going to a pediatric critical care capable specialty facility is the best practice. If this is not possible due to unreasonable delay, then choose a closer facility. The closest facility is not a replacement for the closest appropriate facility.


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## systemet (Jan 10, 2012)

I'll just echo what other's have said - this sounds like a critical ped, and you did an excellent and potentially life-saving job.

It's hard to comment on the treatment without seeing the patient, and I think other people with more experience in this area have already given their input.  For what it's worth, I'd give the mag in this situation.  In the days when I had IV ventolin or aminophylline, this would have been going in too.  Some dexamethasone would be an ok adjunctive therapy, but I think you had more urgent things to do here.

Regarding the other issues:

* OPA: this is to keep the tongue from occluding the pharynx.  If there is no evidence the tongue is occluding the pharynx, then you don't need it.  It carries a substantial risk of inducing aspiration, and it's questionable whether this patient is able to protect their airway.

* BVM: with this low a saturation, it would be tempting to bag.  But, this carries its own risks;  with poor compliance, you're going to divert a fair amount of air into the stomach.  While this is a 7 year old, there's some risk that this may still eventually compromise ventilation.  There's a significant risk that this will result in regurgitation and possible aspiration.  Once you're doing PPV, you may worsen the air-trapping that's occurring, especially if you bag too fast / aggressively (or worse yet, let the firefighter do it -- because they will).  This may compromise venous return and hemodynamics, and may cause pneumothoraces.  [These are relative issues if the kid's so desaturated that we're causing an anoxic brain injury by not bagging, but this doesn't seem to be the case here.  The body can tolerate SpO2's in the high 80's for quite a long time -- the major issue here is that when you're at 85% saturation, the dissociation curve is pretty steep and linear, and it's really easy to end up at 50% saturation quickly]

* Intubation:  this patient can't be preoxygenated, and they're a 7 year old, so even at baseline they'll desaturate rapidly, and they're probably going to be a difficult intubation for most paramedics.  If you make them apneic, you may not be able to ventilate them more effectively than they are currently doing.  If you paralyse them, airway resistance issues may even worsen.  If you can't intubate, you may not be able to ventilate.  This is not a patient you want to try and do a PTTV / needle cric on, as they're already having issues with exhalation.  A surgical cricothyrotomy is not a good issue here.

There's a point where these intervention may become necessary.  But they carry large risks.  Fortunately this means you can afford to be quite aggressive with pharmacotherapy.


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## CANMAN (Jan 10, 2012)

Def agree with WTEngel in going to the peds facility vs. adult ED if it was only a 10 minute drive and you were seeing improvement from your treatment. I would bet the farm she got transferred later on to the peds hospital anyway. I too also work peds critical care at the moment along with 911 and I will often bypass community hospitals when working in the field to get patients to appropriate definitive care.... Typically they are managed more aggressively and have better outcomes. 

I however think you did a great job with getting Mag onboard quickly, and will never bash someone for pulling the trigger on Mag in a timely fashion. We do a huge amount of really sick asthmatics where I work and typically if a child is sick enough to get 1:1,000 they will get Mag at the hospital, along with some steroids. If you had access to Steroids thats the only other thing I might have considered in this child.

At my facility this kid would have gotten the epi 1:1000, Albuterol 7.5mg, Mag 50 to 75mg/kg, and Solu-Medrol 2mg/kg.

Strong work.


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## cdrcems (Jan 11, 2012)

Thanks for input guys. i picked the closest hospital because I knew the charge nurse and i felt a little over my head. The pt did get transported to the peds hospital. The next time i have this call i will keep going I think. Every calls a chance to learn. Once again, thanks and be safe.


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## Aidey (Jan 11, 2012)

I'm with everyone else. The only thing is that once she started to stabilize you could have always diverted to the peds hospital instead.


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## jwk (Jan 11, 2012)

Strong work by the OP regardless.

Those of you advocating for pediatric hospitals must have really quick access to them.  Having a child in extremis, as the OP did initially, means going to the closest ER.  I totally agree with Brackett.  Asthma, whether peds or adult, is kind of bread and butter work for most ER's and ER docs.  It's something seen quite frequently.

Intubation in a 7y/o (not indicated in this case) is not particularly difficult, and in fact, should be easier than most adults unless they have some funky anatomical issues.  This assumes you have pediatric=sized airway goodies on your truck.

Clearly OPA not indicated, and even if you had some obstruction, the better choice in this case would be a simple jaw thrust.


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## CANMAN (Jan 12, 2012)

jwk said:


> Strong work by the OP regardless.
> 
> Those of you advocating for pediatric hospitals must have really quick access to them.  Having a child in extremis, as the OP did initially, means going to the closest ER.  I totally agree with Brackett.  Asthma, whether peds or adult, is kind of bread and butter work for most ER's and ER docs.  It's something seen quite frequently.
> 
> ...



"Asthma, whether peds or adult, is kind of bread and butter work for most ER's and ER docs.  It's something seen quite frequently."

Seen quite frequently yes, pediatric asthma managed CORRECTLY and AGRESSIVELY by adult physicians is very rare so I disagree with this post. Working in a transport program with volume above 5,500 transport a year with a large portion of those being pediatric asthma cases very under managed by the outside hospital has given me this stand. It's almost comical to walk in on transports and see a kid on 5mg Albuterol over an hour and 25mg/kg mag dosages and the MD's struggle to understand why the child isn't doing better......


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## systemet (Jan 12, 2012)

CANMAN13 said:


> "Asthma, whether peds or adult, is kind of bread and butter work for most ER's and ER docs.  It's something seen quite frequently."
> 
> Seen quite frequently yes, pediatric asthma managed CORRECTLY and AGRESSIVELY by adult physicians is very rare so I disagree with this post. Working in a transport program with volume above 5,500 transport a year with a large portion of those being pediatric asthma cases very under managed by the outside hospital has given me this stand. It's almost comical to walk in on transports and see a kid on 5mg Albuterol over an hour and 25mg/kg mag dosages and the MD's struggle to understand why the child isn't doing better......



Quick question -- is this going into urban / suburban centers and dealing with patients managed by EM docs.  Or is this flying into very rural areas dealing with FM guys who are primarily doing clinic work and covering a small ER as needed?


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## WTEngel (Jan 12, 2012)

I have to echo what canman is saying. I work in a critical care transport discipline that only transports pediatric patients. We moved over 5,000 sick or injured children last year, from both rural and urban facilities. We were one of the busiest in the nation.

Pediatric patients are commonly under-managed or inappropriately managed at both rural and urban facilities. I would have to say I see this more at urban facilities, simply because their volume is higher, which leads to more pediatric encounters, ultimately resulting in more opportunity to make clinical errors. 

I mean no offense to anyone when I say this, as it is not your area of expertise, but what you think may be appropriate treatment by the EM physician at an "adult" ER may very well not be appropriate. It is hard to tell the difference if you don't work peds as a specialist. 

It is completely counter-intuitive to say divert to the peds facility for the patient who is not in extremis, and go to the adult facility for the patient who really needs peds specialty care. It is like one step forward and two steps back. In this case, the benefit of peds specialty care, patient improvement not withstanding, justifies the additional 10 minutes, IMHO. 

Closest facility is not a replacement for closest appropriate facility.


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## MedicPatriot (Jan 12, 2012)

Good job. Epi was most important IMHO. I probably would have used BVM personally but I think the epi was the main treatment that needed to be done. It saved her.


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## Commonsavage (Jan 12, 2012)

*Strong work*

Ya dun good, as my Uncle the perfesser would have said.
A coupla thoughts:  I agree with the doc about applying some positive pressure assist on the neb, until the meds take effect.  Rather than an OPA, I would have used an NPA if bagging was difficult.  Otherwise, good positioning means a lot.
So, once again, good job.


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## CANMAN (Jan 13, 2012)

WTEngel and I are clearly on the same page, well stated my friend. Systemnet my program is almost exactly like Engel's it sounds like. Both urban and rural facilities we have interaction with on a regular basis, with the rural ones being more on flight. Pretty much like he said, what you as a field provider or an Adult EM doc finds as appropriate and aggressive treatment is usually not the case for peds speciality team members. It's all in what you are farmiliar with obviously, but typically in my area we see children that sit in the community ED for hours awaiting transfer to the Childrens Hospital when they could have been brought here to start with, often times with very little delay in transport time. Of course some of these patients are brought in POV but never the less the caliber care they are getting is often decided on a coin toss. Sometimes their management is ok, and other times they are under treated or mismanaged for hours which obviously does not benefit them. 

Either way I think we have established that the OP did a good job and the transport decision varies from provider to provider.


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## Sublime (Jan 29, 2012)

Not trying to jack this thread but I have a question, and I think the OP has already found the answers he was looking for. 

I am a new medic, and was never taught about the use of mag sulfate in asthma/severe respiratory distress. I can research how that works and why to use it in those situations on my own... but my question is, why would you use Mag instead of Solu-Medrol? Is mag a better option?


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## Handsome Robb (Jan 31, 2012)

Sublime said:


> Not trying to jack this thread but I have a question, and I think the OP has already found the answers he was looking for.
> 
> I am a new medic, and was never taught about the use of mag sulfate in asthma/severe respiratory distress. I can research how that works and why to use it in those situations on my own... but my question is, why would you use Mag instead of Solu-Medrol? Is mag a better option?




Mag will relax the smooth muscles of the brochioles thus causing bronchodilation. As for mag vs. methylprednisolone, mag is going to act much faster. Nearly immediate onset vs. 60 minutes. Mag acts at the neuromuscular junction, limiting the release of acetylcholine. ***I think. That was my understanding of it, and a very, very simple understanding of it.***

That's my understanding of it. Corticosteroids aren't preferred for an emergent pt for the simple fact that the onset is too slow. They didn't talk about mag in your program??

Back to the OP, the kid is alive that's all that matters. 

It sounds like CPAP may have been a good option if it was available since the kid did have spontaneous respirations after some treatments were in. If no CPAP, BVM with a bit of peep? 

Sorry I skimmed, didn't see if it was mentioned already.

Either way you got the kid to the hospital and delivered him in, what sounds like, better shape than you found him


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## Sublime (Jan 31, 2012)

NVRob said:


> Mag will relax the smooth muscles of the brochioles thus causing bronchodilation. As for mag vs. methylprednisolone, mag is going to act much faster. Nearly immediate onset vs. 60 minutes. Mag acts at the neuromuscular junction, limiting the release of acetylcholine. ***I think. That was my understanding of it, and a very, very simple understanding of it.***
> 
> That's my understanding of it. Corticosteroids aren't preferred for an emergent pt for the simple fact that the onset is too slow. They didn't talk about mag in your program??
> 
> ...



Thanks for clearing that up, makes sense. We learned about the use of Mag for treatment of torsades and seizures in pregnant patients, never for bronchodilation.


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