Pediatric scenario

TXmed

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PART 1

You're a CCT flight crew dispatched to a sending facility ER for a transfer to a pediatric ICU. Radio report details 2yr old pediatric with sepsis & pneumonia. Intubated, GCS of 3.

You arrive to find patient under sterile drapes with a ER physician placing a left IJ central line. You see a radial art-line with no waveform and no readings. Patients physician details report of patient presented to ER 3 hours prior lethargic and obvious trouble breathing. Anesthesia called and patient intubated with propofol and rocuronium 90 min ago. Patients lactate is 8, Chest x-ray revealed small amounts of infiltrates but "nothing too significant". Patient has received 2 different doses of D25 due to BGL dropping to below 60. Patient has a history of sickle cell and currently takes no medications. Patients ABG reveals PH of 6.8, patients potassium 3.7 and hemoglobin of 3. They have been unable to obtain a BP for the past hour despite efforts, SPO2 periodically flashes 90%+. Patient has received 430ml of NS. [Despite asking for paperwork you are not provided and are not shown any labs, physician just repeats labs already verbalized and has no knowledge of any other values not given]. Vent settings = SIMV(pressure) RR30 PIP 17 PEEP 3 TV displays between 15 - 630ml. Adult ventilator circuit used.

Assessment reveals 2 year old GCS of 3 with no infusions running. 4.0 ET tube breath sounds are present yet shallow. Patient is cold. Patients abdomen is distended. NG tube in place and on suction.
HR=140-150
ETCO2= 71 good waveform.
RR=30
Unable to obtain NIBP , arterial BP or SPO2 despite numerous attempts.

You attempt to place patient on your vent with settings of AC(P) RR30 PIP 23 PEEP 5 Ti 0.7. After 5 seconds patients ETCO2 drops to below 20, patients HR increases to above 160 then drops to below 100. Patient is pulled off and placed back on hospital vent. Another attempt tried with AC(V) RR 30 TV 50 PEEP 5 Ti 0.7. Same thing happens.

OK fellas lets hear yalls treatment plan.
 

VFlutter

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Wow, sounds like a cluster. Not really sure where to start. Do not pass go, straight to ECMO?

This kid is obviously in extremis. Seems to be in severe shock with profound acidosis and a component of hypercapnia. So not perfusing and not ventilating. Patient is cold, are they mottled? Any palpable pulses? Is the Arterial line improperly placed or are they that vasoconstricted? Start an Epi drip and request blood ASAP.

What led up to this event? Possibility of toxic exposure? Had sickle cell crisis before? Could very well be a Splenic Sequestration and/or Vaso-occlusive crisis. Again needs blood.Get full labs if able.

The vent issues are perplexing but I would probably try to get a blood pressure compatible with life before messing with it. Although the hypercapnia is not helping the situation the patient probably can not tolerate abrupt changes and may arrest. They are somewhat stable on the hospital vent at the moment. Are they using Adult vent tubing and ETC02 monitor? How big is this kid?

Can the MD place a femoral arterial line?
 
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E tank

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Well, think it safe to say the patient is under resuscitated. You say he's cold, he's anemic, he's hypoglycemic. Two year olds have pot bellies but you're mentioning the distention implies its more than just that. SC exacerbation?

The kid needs more volume in the way of packed cells on a warmer. I'd start with 10 per kilo bolus on a warmer and feel for pulses. If I couldn't feel a pulse in the groin after that, I'd give another 10. ABX, glucose, pick another crystalloid than NS, support calcium etc....Epi after the blood package and go...

Addendum..I wouldn't put too much effort in screwing around with an a line or hanging my hat on an NIBP. If I could feel decent pulses in the groin ( or periphery) I'd be happy with that. Obviously with epi running you'd need more than pulses, but presumably the epi would help with measuring a bp.
 
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Peak

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Do I trust anything that I have been told? I'd be tempted to start from the top, although I'll probably be hurting some feelings.

Confirm tube placement by direct laparoscopy. Ensure that tube size is appropriate. Request chest xray for depth confirmation. Advance/withdraw as needed; exchange over wire if correct placement but too small of a diameter. An 11 kg kid should not be drawing 650 mL of volume so I wonder if the tube is undersized (although a 4.0 should be fine) or if there is a leak somewhere in the setup.

I would leave him on the adult vent until his blood pressure is managed, though it certainly needs to be fixed.

Place a femoral A line and large bore femoral venous catheter (18 or 20). Run my own labs: H&H, BMP, ABG. If his Hgb is actually 3 I would plan on 40 mL/kg of PRBCs, assess for improvement in condition after every 10 mL/kg. Recheck H&H after first 20 mL/kg, if he is substantially improved we can give the reset en route. I wouldn't be convinced that an elevated lactate means that he is septic, if he is that anemic he can raise it just by not being able to perfuse, although this certainly does not preclude the possibility of infectious etiology. If blood pressure is not improving with PRBCs start pressors. While epi is preferred for 'cold shock' I wonder if he is hypothermic from having no temperature regulation at the facility after being given roc and just continued to decompensate from there, I don't necessarily thing Levo should be excluded as the first line pressor; epi would probably benefit his respiratory status more. 1mEq/kg of bicarb, even if we plan to have him breath off the CO2 is curve is way off and I don't think he is going to have much left in reserve. Administer a stress dose steroid preferably 24 mg solucortef but weight based dose of solumedrol or dex will suffice. Place an OG and put on suction.

The roc and propofol should have worn off, should he improve I would want to have a dissociate and paralytic ready. I would plan on 1 mg/kg of ketamine and 1.2 mg/kg of roc, repeat dosing PRN at 0.5 and 0.6 mg/kg respectively. I also suspect that this will help with vent compliance provided that we have addressed his blood pressure.

Head to toe exam, does he have any other signs of injury or infectious source? Any other skin abnormalities (mottling, hives, etc)? Have they ran a UA? Did they do a KUB? I wouldn't use my time getting a urine sample but it would be great to know. eFAST exam, I would be particularly interested in a pericardial effusion related to potentially being dilute, make sure he doesn't have a hemo/pneumo, and doesn't have a belly bleed. What was his white count? Have they done anything to correct his temp before we got there? We would certainly need to start some temp correction. Give D10 1/2 NS with 20 K at 42 mL/hr.

I think that your vent settings are appropriate, and provided that BP has been managed he will do much better. If I suspected an asthma/RAD component I would give an inline duo and then start continuous inline albuterol; consider IV mag (I would start low given his pressures, but would give up to the full 75mg/kg over an hour), continuous terb. Has the facility given ABX?


This case is eerily familiar to a late diagnosis ALL patient I had before. I suspect that in both cases the kid should have been in the PICU long before they presented to the ED.
 

Remi

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Basic resuscitation, pretty much like everyone has already said. Start back at the ABC's:

A - The patient is intubated with a good C02 waveform, as long as the ETT is at the appropriate depth that's basically all you need to know.
B - Listen to breath sounds. He is under ventilated and that needs to be addressed. I would try him again on my vent with VCV at a much higher minute volume and PEEP of 5.
C - 100cc of PRBC's and 200cc of IVF to start and IVF at 50ml/hr along with 10 mcg of epi IV. Repeat the PRBC's and epi until you can feel a pulse and/or get a decent BP.
D - Warm him. Glucose, steroids, broad spectrum antibiotics.

An arterial line would be nice, of course, but you don't need it. So would frequent ABG's until the kid stabilizes. But color and pulses are all you really need to know whether you are heading in the right direction.

I wouldn't necessarily wait until the kid is "stable" to leave the facility, but I'd want to know that we are at least not getting worse. Once he's doing OK on my vent and we're starting to get him volume resuscitated it's time to get him moving to someplace that can offer expertise and resources I don't have.
 

VentMonkey

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@TXmed I’m taking the “observe, and take notes” angle on this one, TBCH.

@Peak what is your background if you don’t mind providing such for the group?
 

Peak

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@VentMonkey

Went zero to hero out of highschool, got picked up on a urban interface fire department that ran our own ALS bus and I was about 50/50 between the ambulance and the engine. After a couple of years I realized that I liked making money, and unless I got on the massive urban department that wasn't going to happen (and they only ran BLS). Went to nursing school, worked in the section of emergency medicine for the local major children's hospital doing nursing and EMS outreach (I'm much less of an *** in real life). Got tired of the politics and went to a regional specialty hospital that does adult oncology drug development, high risk OB, and fetology/neonatology/pediatrics (specifically congenital heart defects, though we do general high risk peds stuff as well). I am still out in the field a bit, I'm part of a group providing ALS care for kids (and the adults that are with them) doing camps and make a wish kind of stuff out in the mountains.
 
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TXmed

TXmed

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So the best i could tell was since they were using adult vent tubing, and they were on pressure control, the vent could not sense how much volume it was giving. Too much deadspace for too little volume, so sometimes it wasnt sensing any air return and i guess miss calculating when it did. The patient didnt have an air leak, i checked.

Ill post part 2 when i get a chance.
 

E tank

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So the best i could tell was since they were using adult vent tubing, and they were on pressure control, the vent could not sense how much volume it was giving. Too much deadspace for too little volume, so sometimes it wasnt sensing any air return and i guess miss calculating when it did. The patient didnt have an air leak, i checked.

Ill post part 2 when i get a chance.
The problem with putting an 11 kg patient on an adult ventilator is that those machines, unless they're high end ped's/ adult vents, can't give reliable pressures and volumes with such small settings, especially with an adult circuit, which dynamically change their volume over the respiratory phase.

But, they don't present any more dead space than a peds set up would.
 

CWATT

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@VFlutter — why an Epi drip? They seem to be compensating well with a HR of 140-150. So if C/O = SV x HR and HR is good, then why crank it up further versus focusing on fluid replacement &/or preload? I would think something more cardiogenically stable like Norepi or Phenylephrine would be more suitable, but call me out if I’m wrong on this. ...or perhaps even Antidiuretic Hormone (ADH) / Vasopressin. My thought here is if his SpO2 is around 90% as the probe insicates, I wouldn’t want to cause any more pulmonary shunt vis a vis pulmonary vasoconstriction.

@E tank — if all we have is an LTV1200 and adult vent circuit, what can we do here to successfully get this patient on the machine? Settings/tips & tricks?

@TXmed — I noticed the ‘scenario’ used a TV of 50ml (my protocols call for 6ml/kg starting volume, so 66ml), but there doesn’t seem to be any inclusion of HME vol (37ml adult, 11ml peds), tube-extender (30ml adult, 10ml peds), or inline suction (?ml) dead-space. Were these volumes added to your TV? I’m fairly confident that if they weren’t, the 50ml TV was mostly moving air throughout the respiratory limb of the circuit and not the lungs, hence the low ETCO2 value. (Again, someone call me out on this if I’m wrong).
 

VFlutter

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@VFlutter — why an Epi drip? They seem to be compensating well with a HR of 140-150. So if C/O = SV x HR and HR is good, then why crank it up further versus focusing on fluid replacement &/or preload? I would think something more cardiogenically stable like Norepi or Phenylephrine would be more suitable, but call me out if I’m wrong on this. ...or perhaps even Antidiuretic Hormone (ADH) / Vasopressin. My thought here is if his SpO2 is around 90% as the probe insicates, I wouldn’t want to cause any more pulmonary shunt vis a vis pulmonary vasoconstriction.
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With a lactate of 8 and pH of 6.8 they are in a severe uncompensated shock. We are unable to get a blood pressure so I am assuming they are hypotensive and not perfusing.

430ml of fluid for a 11kg is around 40ml/kg which is probably more than enough considering this kid is severely anemic. He needs blood, not more fluid.

I think pressors are necessary until we can establish what this kids pressure actually is and make sure he isn't massively vasodilated. Epi is our first line pressor for peds and has shown to have better outcomes. Vasopressin is great for severely acidotic patients but isn't a first line.

Probably doesn't matter what his saturation is he ha no hemoglobin

I am still thinking this is Splenic Sequestration.
 
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CWATT

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He needs blood, not more fluid.
I used the word “fluid” in attempt to keep the door open by not saying “saline” or “blood” allowing for whatever you have available to you at the time (not every sending facility is going to have blood available), but I know some people use fluid and saline interchangably, so I’ll own that misunderstanding.
 

E tank

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@VFlutter — why an Epi drip? They seem to be compensating well with a HR of 140-150. So if C/O = SV x HR and HR is good, then why crank it up further versus focusing on fluid replacement &/or preload? I would think something more cardiogenically stable like Norepi or Phenylephrine would be more suitable, but call me out if I’m wrong on this. ...or perhaps even Antidiuretic Hormone (ADH) / Vasopressin. My thought here is if his SpO2 is around 90% as the probe insicates, I wouldn’t want to cause any more pulmonary shunt vis a vis pulmonary vasoconstriction.

@E tank — if all we have is an LTV1200 and adult vent circuit, what can we do here to successfully get this patient on the machine? Settings/tips & tricks?

@TXmed — I noticed the ‘scenario’ used a TV of 50ml (my protocols call for 6ml/kg starting volume, so 66ml), but there doesn’t seem to be any inclusion of HME vol (37ml adult, 11ml peds), tube-extender (30ml adult, 10ml peds), or inline suction (?ml) dead-space. Were these volumes added to your TV? I’m fairly confident that if they weren’t, the 50ml TV was mostly moving air throughout the respiratory limb of the circuit and not the lungs, hence the low ETCO2 value. (Again, someone call me out on this if I’m wrong).
I wouldn't start an inopressor until volume/blood is replaced. 60/kg of crystalloid and a hgb of18-21 are reasonable targets for getting this patient out of there. Dopamine/epi are common in peds CC primarily because the small one's CO (and therefore O2 delivery) is HR dependent. You won't shunt with epi. A shunt (and fall in oxygenation) will occur when blood flow exceeds the capacity of the alveoli to exchange gases (V/Q falls).

As far as the ventilator goes, all that you can do is limp the kid along with what you have or hand ventilate.
 
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TXmed

TXmed

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@CWATT a 50ml TV wouldnt be too low for this kid do to the hemodynamics, i think it comes out to just above 4ml/kg which some protocols recommend for hemodynamically unstable patients.
 

E tank

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For what it's worth, something else that hasn't been mentioned is determining if there is a coagulopathy present or not. May not be relevant for the transport crew, but on of the the first thing a peds ICU would do on admission is send coags.

Depending on the sending facility, FFP/cryo could be sent with, but it doesn't sound like they were that sophisticated.
 

CWATT

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...the small one's CO (and therefore O2 delivery) is HR dependent.
Good to know, thank you. That said, isn’t 140-150 indicative of appropriate cardiac compensation for a 2yr-old? If you’re running Epi or Dopamine to try to inc C/O, what’s your upper HR limit?
 
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TXmed

TXmed

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PART 2


Just a lab refresher PH 6.8, Potassium 3.7, Lactate 8, hemoglobin 3,

So you aks the physician for an epi drip (several times) and she is adamantly against it, but agrees to a levophed drip, which you start at 0.1mcg/kg/min. You also give a 50ml NS bolus. You also begin to infuse PRBC’s at a dose of 10ml/kg with orders to give a 2nd dose if necessary (this takes time as you have to syringe push it through the IJ). In an effort to speed you along the physician marches in the room, demands the RT bag the patient (I guess to show you to do it during transport) the patient then drops ETCO2 <15, drops their HR <60, and no longer has pulses. The physician orders Atropine to be given by the ER RN, which they do. You give another 50ml fluid bolus. The patients pulses return. You place the patient on your ventilator AC (P) RR=24, PIP = 17, TV= 40-50, PEEP = 5, TI= 0.7.

After all of this, a reassessment reveals a HR = 140, ETCO2=42-44, BP now reads 60/32 (NIBP). Prior to moving the patient to the aircraft you get a finger stick BGL which reads 127. You then move the patient to the aircraft and begin transport. You begin to administer another 10ml/kg bolus of PRBC’s. After 10 minutes the patients ETCO2 drops to 15 and the patients ECG shows periods (10-15seconds) of sustained V-tach. The BP no longer reads. And you are unable to feel pulses (which have been difficult anyways).

What is your treatment?
 

VFlutter

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CPR, Calcium, bicarb, start Epi drip
 

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