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Case #44 13 Y/o With Resp. Distress.. Uh Oh...


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#1 Mike MacKinnon

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Posted 06 October 2008 - 07:10 PM

The Story:

You are kicked out on sat. at 6 pm for a 13 y/o girl who is reported to have resp. distress. This is a small town which is about 45 min by air from the nearest ER.

On Arrival:

You arrive on the scene of a playground where there is a 13 y/o girl surrounded by the volunteer FD people eagerly waiting for you to arrive.

There is a 13 y/o sitting up on the ground with a NRM mask of 12 L O2 on. She looks anxious and her eyes are darting back and forth. Her parents are there and look very concerned.

You are told she was just hanging around with her friends when she just had to sit down because she felt dizzy. Her mom was there and came over and decided to call 911.


Assessment:

On auscultation you hear biphasic stridor
She is tachypneic and has an SPO2 of 92% HR: 108 and BP 100/64

You notice her face is a little puffy and you can see JVD

History:

She was diagnosed 2 years ago with T-cell leukemia on the basis of blood smear and bone marrow aspiration of a small mediastinal bump which was treated and she has been in remission ever since.

Her mom tells you she has been displaying increasing symptoms of SOB over the past 6 days and they have an appointment in the city with her paeds oncologist about it.

Today she is "significantly" worse now than it has been.

Where to start?
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#2 GravyMedic

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Posted 07 October 2008 - 03:19 AM

Got real busy.

Gonna have next case up this weekend.


OK, well I'll cover the bases. ABC's, IV's x 2, Vitals, EKG's, Labs, Radiology, consider decompression or pericardiocentesis...
PmHX? Is the pt c/o shortness or breath? Lung sounds? Murmurs? Abd pain? S/S of DVT's?

Great case so far!
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#3 fiznat

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Posted 07 October 2008 - 04:02 PM

Promises Promises

haha, looking forward to it.
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#4 EDMEDIC

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Posted 12 October 2008 - 01:13 PM

Looking forward to the case. Hey, I believe GravyMedic may have a first in the forum here..sounds like telemedicine....LOL.be safe, Brian
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Brian EMT-P/CC
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#5 Joe Percer

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Posted 12 October 2008 - 08:53 PM

Okay start with the basics:

IV Access x 2
12 - lead ECG
Skin color / temp / diaphoresis?
any allergies?
meds?
increase O2 to 15 lpm
how is the child's resp effort? accessory muscle usage?

My first impression with the facial puffiness & inspiratory stridor is to look for any sort of laryngeal edema. If that's present, it's time to think about isolating the airway.

Let's see how it goes... First time posting in a case presentation.
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#6 mmssnb

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Posted 12 October 2008 - 10:39 PM

Any tracheal deviation or compression?
How is her voice? Is she able to speak clearly? Does she have any vocal cord parylsis?
Did she receive chemo or radiation treatment for her leukemia?
I am thinking she has a medistinal mass again.
Initial treatments have been covered by others already
I'm thinking intubate to control airway and transport to nearest place for x-rays and CT of neck/chest.
Of course, this is just the start of the case, so I'm sure there is going to be much more to prove me wrong..
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#7 flychicko8

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Posted 12 October 2008 - 10:42 PM


This is my first posting as a NEW flight nurse....so please be gentle.....
I agree: 2 IV's, 12 lead EKG but I'm thinking that this kiddo is only 92% on a NRB....12 liters.....maybe we need to increase that O2 to 15 liters and get ready to secure an airway....quick. What allergies,meds,SAMPLE...what she look like sitting there? Accessory muscle usage? She's at a playground....what was she doing before she got to this point? Lotsa' questions at this point!! Thanks for the posts, Mike! I've learned alot so far. Can't wait to see what comes around the corner!!!
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#8 BackcountryMedic

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Posted 12 October 2008 - 10:54 PM

I can't believe this will end up being as simple as an anaphylaxis Rx. Stidor, face swelling, resp distress - could it all be that simple? I hear hoof beats - is it a horse or a zebra?

Percer has a very aggressive plan so far (IVx2?), and I could only hope he was my partner.

The onset - if it is anaphylaxis - is a little slow for an injection (bee sting) type reaction. Is she talk a new medication that would cause her to develop this new allergy? Or, maybe she did just get popped by a bee, and some weird underlying illness as been going on for a few weeks too. And, what does the T-cell leukemia have to do with anything, other then immune system problems. Very trick Mike. I'll get the Epi, benedryl, solu-medrol, and albuterol out, but I need more info.

For now:
Watch that airway and breathing.
Dig more into the history, last meal, meds, allergies. Any toxin exposures?
Any hives?

I look forward to more.
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#9 Flightgypsy

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Posted 12 October 2008 - 11:24 PM

I agree it sounds like the mediastinal mass is back and impinging on the airway and the SVC and other vascular structures. She also has SVC syndrome so the major vessels are being impacted. I would not be laying this girl flat, sedating and paralyzing her and messing with her airway unless she was dying. The anatomy is probably distorted and this is most likely going to be a difficult intubation from a lower airway standpoint. A surgical airway would probably not be of much benefit as the obstruction is probably too low. Laying her flat may totally obstruct her airway depending on where the mass is and it may also impede blood flow in the area making the situation even more "puckering".

Priority with this pt and her family is to keep calm and keep them calm especially the patient...lots of reassurance.
So for me for now I would start with the IV's and increase the O2.
If she becomes really anxious and it is increasing her respiratory distress I would give very tiny amounts of sedation or even just a touch of fentanyl to calm her otherwise just keep her as calm as possible.
Transport in a position that she is comfortable with and fly as low as possible.
Have the RSI ready to go only if she is about to code on you and have a cric kit ready even if possibly limited chance of success. (always be prepared, right?)
I think some steroids would be ideal in this situation but we don't carry them.
I don't think racemic epinephrine or atrovent would help much in this case but if she was starting to get worse I would definitely try that before thinking about intubation.
Basically intubation would be absolutely a last resort and only if she was near death.

"In the presence of severe symptoms of
cardiorespiratory compression such as, positional
dyspnoea, orthopnoea, stridor, syncope, and superior
venacava syndrome (SVCS), administration of GA may
be fatal.4,5,6 The profound hypoxia may also be due to
compression of great vessels in the presence of patent
airway.1,7,8 In high risk patients with mediastinal mass,
irreversible cardiorespiratory collapse can occur with the
use of sedative premedication, induction of anaesthesia,
with the use of muscle relaxants,2 initiation of intermittent
positive pressure ventilation (IPPV),9 simply by making
the patient supine,1 change of posture,7 and tumour
resection or manipulation.1,10 It is also possible that
tracheobronchomalacia i.e., softening of tracheal wall,
due to prolonged compression by mediastinal mass,
may potentiate the airway collapse, with the onset of
relaxation produced by anaesthesia or commonly after
tracheal extubation or emergence.2,11 Therefore, airway
management in patients with large mediastinal masses
with or without the evidence of airway obstruction poses
a difficult challenge to the anaesthesiologists."

Quoted from here.

Just my thoughts and the zebra is probably going to trample me but I gave it a shot.

Cheers.
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#10 fire_911medic

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Posted 12 October 2008 - 11:50 PM

Okay, time to play here. First thought going through my head is lymphedema. With a prior history of leukemia, chances are she underwent chemo and radiation and this caused problems with the lymph system causing the edema resulting in the JVD and stridor. It's sometimes not seen for a few years following treatment and can cause fluid collection in the head, neck or chest area (not just extremities) . Common in breast cancer survivors (the girl had a mediastinal mass so not that far off) also can have onset around puberty and well 13 fits the bill pretty well. Just a fun thought, flying this girl in and of itself could present problems as sometimes flight can aggravate the problem.

Now what am I going to do for her? If she is having fluid overload issues, I'm not sure I really want to add to that problem, so I'll be conservative with fluids, but I definitely want some IV access. Does she look like she's going to poop out any time in the near future breathing? If so, I'm gonna prepare to be aggressive with the airway and intubate. Otherwise, I'm going to attempt to avoid it if I can. In the mean time, kick her up to 15 L and see if that doesn't help the situation. For breathing, let's try a little albuterol and see where that gets us.

If this is what is this girl's problem, she's in for a tough road. If not, oh man, I'm about to have hoof prints all over me and I am trampled. I already see myself curling up into a little ball and waiting.
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When once you have tasted flight, you will forever walk the earth with your eyes turned skyward, for there you have been, and there you will always want to be. ~~~Leonardo DaVinci

#11 BrianACNP

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Posted 13 October 2008 - 12:49 AM

The Story:

You are kicked out on sat. at 6 pm for a 13 y/o girl who is reported to have resp. distress. This is a small town which is about 45 min by air from the nearest ER.

On Arrival:

You arrive on the scene of a playground where there is a 13 y/o girl surrounded by the volunteer FD people eagerly waiting for you to arrive.

There is a 13 y/o sitting up on the ground with a NRM mask of 12 L O2 on. She looks anxious and her eyes are darting back and forth. Her parents are there and look very concerned.

You are told she was just hanging around with her friends when she just had to sit down because she felt dizzy. Her mom was there and came over and decided to call 911.
Assessment:

On auscultation you hear biphasic stridor
She is tachypneic and has an SPO2 of 92% HR: 108 and BP 100/64

You notice her face is a little puffy and you can see JVD

History:

She was diagnosed 2 years ago with T-cell leukemia on the basis of blood smear and bone marrow aspiration of a small mediastinal bump which was treated and she has been in remission ever since.

Her mom tells you she has been displaying increasing symptoms of SOB over the past 6 days and they have an appointment in the city with her paeds oncologist about it.

Today she is "significantly" worse now than it has been.

Where to start?


Mike -

How was her "mediastinal bump" treated? Chemo? Radiation?

Sounds an awful lot like SVC syndrome...my grandmother-in-law had it before she passed....classic w/ the progressive SOB, facial puffiness and JVD.


Brian
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#12 fire_911medic

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Posted 13 October 2008 - 01:50 AM

I think I feel the zebra's hooves running me over.....
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When once you have tasted flight, you will forever walk the earth with your eyes turned skyward, for there you have been, and there you will always want to be. ~~~Leonardo DaVinci

#13 EDMEDIC

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Posted 13 October 2008 - 02:15 AM

OK then! Increasing FiO2 and getting some PIV access all a good idea. I think a mediastinal mass is a good possibility..and a major pucker factor when I consider having to intubate this child. Some judicious sedation ( minimal /c some Ativan or fentanyl) is also a good idea. What does her capnography waveform and EtCo2 look like? is she febrile,any erythema or hives or cyanosis present. Can she speak? I wouldn't put her supine unless she really needs to be intubated rapidly, and even then I'd put her head back up. Looking for the zebra as well...just some initial thoughts ..my .02, Brian
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" you don't know what you don't know"

#14 mjcfrn

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Posted 13 October 2008 - 02:16 AM

Concur that it sounds like SVC syndrome. Bacterial tracheitis ran thru my head briefly, but would not account for the JVD, and I think it would onset faster than gradually over 6 days.

So, what's her resp rate and WOB? The stridor is only auscultable (thru the stethescope) and not audible (without a stethescope)? If it takes a stethescope to hear it, then it's not that bad, and I just want to fly fast before it worsens.

I do not want to tube this kid unless she becomes intractably apneic. If she's coping well upright, let her keep sitting upright. If the NRB bag is collapsing, agree with increasing the flow; otherwise, I don't think it would help. (although please correct me if I'm wrong) We may have to settle for 92% sats. Agree that the intubation/cric stuff needs to stay handy, if for no other reason than to ward off evil apnea spirits.

I'd like to consider racemic epi neb, to see if airway edema is responsive to it.

I haven't seen enough SVC syndrome to know if steroids are indicated, but it seems like it would be. Would love some discussion on steroids at the appropriate time by the great gods of case presentation.

Would like to take her to the center where her oncologist is, assuming the appropriate emergency / anesthesia / critical care services are available in said facility.





Ok, ready to be trampled by the zebra herd (or are they gazelles?)
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#15 Gila

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Posted 13 October 2008 - 03:07 AM

Let me work a couple of concepts out? She was diagnosed with T-cell leukemia? Since she is a little one, I assume we are talking about T-cell ALL? If this is the case, an enlarged thymus can be associated with this condition. This could lead to what we see. I suspect this patient is on the verge of rapidly de-compensating. I suspect we could have a difficult time securing the airway.

A few other questions:

Allergies to anything?
Was she stung or bitten by anything?
Currently taking any medications?
Any new medications or changes in her medication routine?
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#16 fiznat

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Posted 14 October 2008 - 03:25 PM

This reads like an acute onset of symptoms. A problem that's been kind-of hovering for six days and just now hits her hard? How come? I would imagine something like SVC syndrome would have a much slower onset of symptoms as the obstruction gradually becomes more and more systemically significant. I'm no expert on these pathologies though, so perhaps this kind of assessment is of little value.

I would be thinking about allergic rxn/anaphylaxis first, but in any case get the routine ALS stuff done. IV/Monitor/O2/GetTheRestOfTheStory.
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#17 rfdsdoc

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Posted 14 October 2008 - 09:03 PM

Hey folks

Challenging case to say the least.

The child is alert and conscious , maintaining her airway currently.

I would be tempted to start a neb of epinephrine to try to temporarily relieve the airway obstruction and get moving to definitive care as soon as possible.

I agree SVC syndrome sounds the go but it could be a lot of other things as others have mentioned : anaphylaxis, angioedema, croup, epiglottitis,inhaled foreign body.

A neb of epinephrine should help in croup, anaphylaxis, angioedema and even ( to a degree) tumour affecting the airway.

I would be loathe to try to do anymore to make her anxious or upset as that may precipitate complete airway loss in cases of croup, epiglottis, foreign body and tumour obstruction. If the neb had improved the stridor I would try inserting an IVC whilst giving her a second neb. IV or IMI epinephrine ready to be given for signs of deterioration in the case it is anaphylaxis.

First do no harm and certainly setup all your resus gear and airway gear but get going and try to treat along the way rather than stay and play.

And start rehearsing the paediatric surgical airway plan you are going to need
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#18 Mike MacKinnon

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Posted 14 October 2008 - 10:34 PM

Good start and welcome!!

Okay start with the basics:

IV Access x 2
12 - lead ECG
Skin color / temp / diaphoresis?
any allergies?
meds?
increase O2 to 15 lpm
how is the child's resp effort? accessory muscle usage?

My first impression with the facial puffiness & inspiratory stridor is to look for any sort of laryngeal edema. If that's present, it's time to think about isolating the airway.

Let's see how it goes... First time posting in a case presentation.


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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#19 Mike MacKinnon

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Posted 14 October 2008 - 10:36 PM

Welcome!

Pay it forward. I love doing these because i learn so MUCH from the people who answer. Its amazing really. Do the same for new people and then we all benefit!

allergic to peanut butter
Lots of accessory muscle use

She was just "playing" mom says.


This is my first posting as a NEW flight nurse....so please be gentle.....
I agree: 2 IV's, 12 lead EKG but I'm thinking that this kiddo is only 92% on a NRB....12 liters.....maybe we need to increase that O2 to 15 liters and get ready to secure an airway....quick. What allergies,meds,SAMPLE...what she look like sitting there? Accessory muscle usage? She's at a playground....what was she doing before she got to this point? Lotsa' questions at this point!! Thanks for the posts, Mike! I've learned alot so far. Can't wait to see what comes around the corner!!!


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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain

#20 Mike MacKinnon

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Posted 14 October 2008 - 10:38 PM

[quote]Any tracheal deviation or compression?[/quote]

Nadda

[quote]How is her voice? Is she able to speak clearly? Does she have any vocal cord parylsis?[/quote]

Nope all good

[quote]Did she receive chemo or radiation treatment for her leukemia?[/quote]

IV chemo

[quote]I am thinking she has a medistinal mass again.[/quote]

How can you know?
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Mike MacKinnon MSN CRNA
WWW.NURSE-ANESTHESIA.ORG

"What gets us into trouble is not what we don't know
It's what we know for sure that just ain't so" - Mark Twain