Playtime Peculiarity

[uhbt420]

BP 90/40 << not good, even at 100/60 it could use some improvment
RR 8 << very not good, get ready to ventilate
PR 40 << is tihs pulse rate? if so she meets the criteria for chest comprs
SPO2 93% << not awful but maybe have some 02 ready. at least the resps aren't making her too hypoxic
BGL 2.5mmol/l (~50mg/dl) << too low, correct w/ IV glucose

at this point i would be doing chest comps/ventilation, also suction the airway and drop a king

IYou are 90 minutes by road from a paediatric intensive care facility and the local hospital is having thier Christmas party so they are closed.

that simplifies things...

 

[MrBrown]

It's not appendicitis.

Since when does a heart rate of 40 qualify for CPR? Is that a crank pipe in your back pocket mate?

While correcting the hypoglycaemia won't fix the problem it will prevent secondary brain injury. 100ml of 10% glucose it is then.

The bradycardia is a manifestation of the CNS depression that made the child unconscious in the first place. Bradycardia in children is rare, usually caused by hypoxia, complex to manage and not something Brown would be concerned about to be honest provided perfusion and oxygenation remain adequate in the short term/

What blood tests do you want?

There were no commercial cleaning products like bleach in the bathroom.

Brown will post the answer if y'all are stuck

 

[abckidsmom]

It's not appendicitis.

Since when does a heart rate of 40 qualify for CPR? Is that a crank pipe in your back pocket mate?

While correcting the hypoglycaemia won't fix the problem it will prevent secondary brain injury. 100ml of 10% glucose it is then.

The bradycardia is a manifestation of the CNS depression that made the child unconscious in the first place. Bradycardia in children is rare, usually caused by hypoxia, complex to manage and not something Brown would be concerned about to be honest provided perfusion and oxygenation remain adequate in the short term/

What blood tests do you want?

There were no commercial cleaning products like bleach in the bathroom.

Brown will post the answer if y'all are stuck

Completely stuck. I've been watching all this time, and didn't even have a relevant question to add to the conversation.

Shock her! It's bound to help, right?

 

[jrm818]

It's not appendicitis.

The bradycardia is a manifestation of the CNS depression that made the child unconscious in the first place. Bradycardia in children is rare, usually caused by hypoxia, complex to manage and not something Brown would be concerned about to be honest provided perfusion and oxygenation remain adequate in the short term/

Is she perfusing? Nice warm extremities, or cold and pale?

side note for my benefit...what would be the potential management if oxygenation or perfusion fell perilously despite good airway management.

Also, was she acting pretty normally before her seizure? Was this totally out of the blue?


What blood tests do you want?

way out of my league here, but I suppose a good learning experience.

Start with CBC and BMP, I don't know what else would be called for. I can't think what this could be besides toxicological, infectious, or mechanical so (raised ICP from something - bleed, hydrocephalus) Head CT would be nice too I think. If you hadn't told us it wasn't infection I'd be wondering about a LP as well.


There were no commercial cleaning products like bleach in the bathroom.

Brown will post the answer if y'all are stuck

not yet! That would ruin the challenge. Much more educational I think if you hold off a bit.

10 characters

 

[Pseudonymous]

Since when does a heart rate of 40 qualify for CPR?

Here, you start chest compressions on a child if the patient is:
A. not breathing
and B. has a heart rate of <60.

So a heart rate of 40 would indicate a need for chest compressions, but since the patient is breathing, we would not start CPR.

 

[abckidsmom]

Here, you start chest compressions on a child if the patient is:
A. not breathing
and B. has a heart rate of <60.

So a heart rate of 40 would indicate a need for chest compressions, but since the patient is breathing, we would not start CPR.

She has a blood pressure, though. You might be mistaking a child for a neonate. I can't think of a category of person that would need chest compressions for a rate less than 60 other than a neonate.

 

[jrm818]

I think the BP of 90/40 is a better reason not to start compressing this girl. I have a hard time thinking that compressions unsynchronized with her heartbeat are going to be any benefit.

EDIT: Darn, scooped! Well, I agree

 

[Veneficus]

I think I would estimate the developmental age of the child rather than a a number to determine if cpr was needed.

I also believe in treating patients, not numbers.

If this kid is 7+

Systolic 70+2(age in years) =84

Diastolic: systolic - 35-45 = 39

So the original vitals demonstrate average blood pressure by an acceptable form of clinical estimate that is within the normal range of a 7 year old even at a bradycardic rate.

Why again are we considering CPR?

 

[Pseudonymous]

She has a blood pressure, though. You might be mistaking a child for a neonate. I can't think of a category of person that would need chest compressions for a rate less than 60 other than a neonate.

I think the BP of 90/40 is a better reason not to start compressing this girl. I have a hard time thinking that compressions unsynchronized with her heartbeat are going to be any benefit.

EDIT: Darn, scooped! Well, I agree

I think I would estimate the developmental age of the child rather than a a number to determine if cpr was needed.

I also believe in treating patients, not numbers.

If this kid is 7+

Systolic 70+2(age in years) =84

Diastolic: systolic - 35-45 = 39

So the original vitals demonstrate average blood pressure by an acceptable form of clinical estimate that is within the normal range of a 7 year old even at a bradycardic rate.

Why again are we considering CPR?

Someone posted this:

BP 90/40 << not good, even at 100/60 it could use some improvment
RR 8 << very not good, get ready to ventilate
PR 40 << is tihs pulse rate? if so she meets the criteria for chest comprs
SPO2 93% << not awful but maybe have some 02 ready. at least the resps aren't making her too hypoxic
BGL 2.5mmol/l (~50mg/dl) << too low, correct w/ IV glucose

at this point i would be doing chest comps/ventilation, also suction the airway and drop a king


that simplifies things...

So Brown posted THIS:

Since when does a heart rate of 40 qualify for CPR?

I was just saying that in my area, a heart rate of 40 in a child THAT young, would indicate the need for chest compressions if the patient was also not breathing. But this isn't an appropriate scenario for CPR (For multiple obvious reasons). I was simply pointing out that a heart rate of 40 CAN qualify for CPR in some places. Even if it's some crazy, improbable situation.

 

[MrBrown]

Is she perfusing? Nice warm extremities, or cold and pale?

Unless she is in cardiac arrest or dead (not sure if the two are that much different lol) then yes, the question is whether or not said perfusion is adequate to provide adequate neurologic, cardiac, renal and hepatic function.

Limbs and other bits and pieces like the stomach and various odenums can go many hours without adequate perfusion before they die. The heart, brain, liver and kidneys cannot and begin to die quickly which makes patients crook and various medicinos nervous.

Her perfusion is adequate for now, obviously there is something causing decreased respiration and cardiac output so we should be supporting them with the goal of avoiding any secondary injury as we are unable to correct whatever underlying problem caused her to get into this mess.

side note for my benefit...what would be the potential management if oxygenation or perfusion fell perilously despite good airway management.

Perfusion is a marker of cardiac output not ventilation and oxygenation. Potentially if she began to become shocked then we could look at inotropic support and flogging the ticker along with an adrenaline drip however a Paediatric emergency or intensive care consultant Brown is not however in this case its more about supporting the pump to move fluid than lack of fluid itself (cardiogenic cause vs hypovolaemic). What has caused this problem does have some vasodialatory effect so then you could look at things like levophed, noradrenaline and dopamine. Brown would want to have a chat to the little people doctor types first on the telephone machine.

What size orange "DOCTOR" helicopter jumpsuit does Arizona Robbins take again?

Good airway management as far as Brown is concerned in this case would be for the first crew on scene to liberally suction/decontaminate the airway, place an LMA and ensure adequate artifical ventilation. At the Intensive Care (ALS) level or if those funny sky cowboys rocked up out the stratus Brown would automatically be intubating, using RSI if required.

Invasive oxygenation techniques are the realm of those white coated people at the place known for its gaggle of Doctors.

Also, was she acting pretty normally before her seizure? Was this totally out of the blue?

No, she has Brown as a dad so how can she have been normal?

There is no known PMHx

Start with CBC and BMP, I don't know what else would be called for. I can't think what this could be besides toxicological, infectious, or mechanical so (raised ICP from something - bleed, hydrocephalus) Head CT would be nice too I think. If you hadn't told us it wasn't infection I'd be wondering about a LP as well.

CBC is normal as is the head CT .... man giving up our coffee machine for a portable CT was totally worth it

*Brown looks at his shaking hand ....

If there was a significant serum Osm gap would that help any?

Here, you start chest compressions on a child if the patient is:
A. not breathing
and B. has a heart rate of <60.

So a heart rate of 40 would indicate a need for chest compressions, but since the patient is breathing, we would not start CPR.

Either you are thinking of a newborn/neonate .... or is that a crank pipe in your medical directors back pocket?

 

[Pseudonymous]

Ah, upon further investigation, that <60 pulse for children if they are not breathing thing is in fact, not in our protocols. Although, it's still in the current American Heart Association CPR course for Healthcare providers. And in that course, if there is a child age 1 to puberty, and they are not breathing, and have a heart rate of <60, you are instructed to start CPR.

I was confused, since I took my AHA CPR course IN my EMT-B class. But I crosschecked my American Heart association BLS book, against my state's protocols and it revealed that my protocols agree with the rest of you.

 

[jrm818]

Unless she is in cardiac arrest or dead (not sure if the two are that much different lol)

"Whoo-hoo-hoo, look who knows so much. It just so happens that your friend here is only MOSTLY dead. There's a big difference between mostly dead and all dead. Mostly dead is slightly alive. With all dead, well, with all dead there's usually only one thing you can do."

CBC is normal as is the head CT .... man giving up our coffee machine for a portable CT was totally worth it

*Brown looks at his shaking hand ....


you're shaking? better hop in the scanner yourself! Don't worry, the rep. told me they're perfectly safe.

If there was a significant serum Osm gap would that help any?

that depends. How much hand sanitizer is left in the bottle in the bathroom?

10 characters

 

[Sam Adams]

Two quick questions and I'll get onto my rambling stream of thoughts. What are her pupils like? I don't think we've received a solid answer yet. Did her hypoglycemia resolve with the administration of Dextrose?

Now: What causes hypoglycemia in an apparently healthy child? growth on the pancreas stimulating an over abundance of insulin and an over abundance of and secretion of pancreatic digestive enzymes creating said disgusting emesis? Further, the release of those enzymes is controlled by parasympathetic nervous system and there appear to be other systemic parasympathetic s/s's....

 

[MrBrown]

Brown does not trust sales reps ...

Nobody can find, and is unsure, if there was hand sanatiser in the bathroom

 

[MrBrown]

Two quick questions and I'll get onto my rambling stream of thoughts. What are her pupils like? I don't think we've received a solid answer yet. Did her hypoglycemia resolve with the administration of Dextrose?

There is no evidence of opiate ingestion or raised ICP

100ml of 10% dextrose has brought her BGL up to 5mmol (~100mg/dl) however as previously said, the hypoglycameia is a secondary problem and will not effect her

Now: What causes hypoglycemia in an apparently healthy child? growth on the pancreas stimulating an over abundance of insulin and an over abundance of and secretion of pancreatic digestive enzymes creating said disgusting emesis? Further, the release of those enzymes is controlled by parasympathetic nervous system and there appear to be other systemic parasympathetic s/s's....

Hypogyclaemia in this case is secondary to the underyling problem and not a factor in the onset of symptoms

 

[jrm818]

Brown does not trust sales reps ...

Nobody can find, and is unsure, if there was hand sanatiser in the bathroom

Pending further information I'm thinking there was and it can't be found now because it's all in her belly. Google tells me her blood level would have to be pretty high to cause cardiovascular collapse, but she's little so I think it's plausible.

 

[Handsome Robb]

Brown does not trust sales reps ...

Nobody can find, and is unsure, if there was hand sanatiser in the bathroom

h34r:

 

[Sandog]

How about an electrolyte check, how is Na/K?

 

[MrBrown]

How about an electrolyte check, how is Na/K?

Ca and Mg are a bit low .... Na/K seem OK

 

[abckidsmom]

Embolus to the mesentaric artery causing acute bowel infarction with profound vagal stimulation!