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Case #46 My Baby Is Having Trouble Feeding


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#21 STPEMTP

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Posted 05 December 2008 - 10:27 PM

[quote name='Flightgypsy' date='Dec 2 2008, 04:58 PM' post='14820']
Start the PGE1 at 0.1mcg/kg/min if it is available.
Insert an OGT to improve respiratory status.
Check chemstick (heelstick) and give dextrose as necessary. This baby will be chewing through the glucose.
Maintain the baby's temperature to decrease the stress on him and decrease his glucose requirements.
Start dopamine or epinephrine drip if needed for BP.
If possible do at least a capillary I-stat and may need to give some bicarb (discuss with MD first) for extreme acidosis not responding to fluid.
Give Ca gluconate per I-stat results.
Be cautious with the fluid - if he is responding repeat the boluses but if it is making his respiratory status worse (grunting, worse sats) then just use maintenance fluids. Use smaller volumes 5-10mls/kg and reassess with each bolus. He may even need some lasix instead of fluid to help his respiratory status.


Infant warmer has arrived and pt placed under that to maintain temp.
2 boluses have been given now. Lungs are still clear, perfusion improving to about 3-4 sec cap refill.
Respiratory status is not improving, however it is not getting worse.
MD has now decided to intubate patient.
Pharmacy called, PGE1 requested......... unavailable.
RSI performed using atropine, etomidate, and anectine.
Tube placed successfully and confirmed via L/S, colormetric end tidal CO2 detector.
OGT placed. no significant change in ventilation resistance noted.
Child now "perking up" and spontaneously moving around on warmer. opening eyes spontaneously...... GCS scoring now E4 M5 V1(tube)
Versed given for sedation (0.15mg if I remember correctly)
R leg now severly swollen, IO assumed to be infiltrated and capped (as if this kid didn't have enough problems right now.....)
Reattempt at PIV access, still unable to get successful access.
EZ-IO placed in L tibia, no marrow returned, fluid infuses well without obvious swelling of L leg.
No Istat available, unable to obtain blood from heel stick. No more attempts at heel stick after loss of 1st IO

Vitals now
HR 150's Sinus tach with normal axis
RR: 40 on 2lpm
BP: not obtained
Cap Refill: 3 secs.....
SAO2: When able to get good waveform 85-92%
The kid looks purple

What, if anything, do you want to do prior to transport?

MD asking if we are able to transport pt. Estimate transport time of 90 mins to nearest peds hospital with peds cardiology.
Nearest pediatric speciality team at receiving facility..........
Only method to secure pt to stretcher is via Pedi-mate, no transport isolette.
No transport vent approved for use in neonatal pt's
Single 3 channel pump available.
estimate 10-20 minutes to obtain additional EMS personnel to assist with transport if desired.

Do you attempt to transport?
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#22 Flightgypsy

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Posted 05 December 2008 - 11:40 PM

It sounds like a good job has been done of stabilizing this child.

You said the baby was now intubated but you have RR "40 on 2lpm". What % O2 are we on?

I am ok with those VS. 150 HR on a neonate is not necessarily sinus tach. Capillary refill time is a little delayed but not being there it could also be due to environmental temperature. I would hold off on more fluids at the moment but not hesitate to give further 5-10ml/kg fluid boluses if needed. This infant was probably slightly dehydrated from a couple of days of poor feeding so was able to tolerate initial boluses. We have a decent respiratory status at the moment and I would be hesitant to jeopardize it now with fluid overload.

The one thing I would be checking even if you are unable to obtain any other labs is a heelstick for a glucose level. Get some antibiotics started or take some with you to start on the transport at least. As long as you are comfortable that the second IO is really working I would wait and try for PIV access en route. Remember the feet and scalp are possible sites as well.

I would get a quick chest x-ray for tube placement and a look at the heart size and shape which may also help decide if we are dealing with a septic shock pt or a CHD. Otherwise I would package the baby on the pedimate with a warmer pad underneath and towel rolls beside the head and taped to secure the ETT. I would insert a rectal continuous temperature probe.

Continue to try and get a BP if possible. How are the pulses? Start inotropic support as necessary. They may need it to balance out their shunting. I am used to starting Dopamine first and then adding Epinephrine if needed. The choice of inotropes may be Physician preference. Start maintenance fluids on the pump (D5 and 1/4NS). I would add Fentanyl to the sedation regime and use less versed for sedation. Most infants tolerate intubation ok with less sedation than we need for an adult. I am not saying don't sedate them just am concerned about the lack of a BP and would use the least amount of versed as possible.

We have no PGE1 and although the baby is semi-stable I would not be ruling out a DDL so our best option is to get the baby to a tertiary pediatric cardiac facility as fast as we can.

Depends what ventilator you have whether or not you put them on it. Technically the LTV is not meant for under 5 kg but it will work fine when they are in a pressure control mode. We have used it many times for kids under 5 kg both in the PICU and in transport. I am not that familiar with a lot of the other transport ventilators around so would not recommend using them if not approved.

So I personally would be comfortable with my current equipment to transport the pt as possibly their only chance of survival may be getting PGE1 and/or a cath lab. Basically which is the fastest and safest way to get this kid to the tertiary center.

Waiting for the specialty team to arrive from the tertiary center may be an option if you don't have an appropriate ventilator. The question is are they aleady in-house or do they have a 30 min response to the hospital time. If it is only going to take about 90 mins for them to get to our side it may be ok as they could bring PGE1 and an appropriate ventilator, isolette and expertise with them. If it is going to take them an hour and a half to get here then it may be better to just transport the kid and get them to the PGE1/cath lab in about 90 mins versus ~2 hours if you wait for the team.

Are you saying it will require an extra 10-20 mins plus the 90 mins flight time to transport as we need the additional personal to transport or are they just a luxury item that we can still transport faster without them? I would definitely be discussing the various options with the receiving physician at the tertiary center and see what he would like done about transporting. If he recommends getting the specialty team there then I would probably stay with the infant and guide care until they arrive.

Also what do you mean by the kid looks purple? Do you mean a gray/dusky color or do you mean like purpura fulminans?

A couple of other things on assessment: How are the fontanels? Can you palpate the liver below the costal margin? On either side of the abdomen? (An xray may also show if they have situs inversus or situs ambiguous as well). If you press on the liver does it improve his pulses?

Waiting for more.
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#23 rfdsdoc

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Posted 06 December 2008 - 01:54 AM

Good case discussion going on.

I can tell you now you would be on a hiding to nothing by trying to rapidly transport this baby without proper gear, transport drugs and skill.

TO use the scoop and run strategy in a critically ill baby who has not suffered trauma is in my view somewhat of a reckless attitude.

It would be better to stay and wait for specialist transport team to arrive. They could bring the PGE1 to you rather than you risking the baby inflight.

Using a non dedicated adult portable ventilator on a baby is taking too much of a gamble for uncertain benefit. Sure you can do it and I have transported a 6 week old on the Oxylog 3000 using PCV but that was with a #1 LMA as the airway!! Kid discharged 5 days later doing well post resp arrest from RTI. I spoke to one paediatric anaesthetist about this and he said sure you can do it but if it was his baby he would not take the risk when there are other resources and backup to call upon.

You only got one vascular access point at this moment.

Sure if the baby was bleeding to death after a MVA, scoop and run. But this critical medical illness needs further stabilisation at the facility prior to transport. NETS teams often spend 4hrs+ stabilising before moving a baby who is critically unwell. there is a good reason for that time spent.

Regards
Minh
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Minh Le Cong
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RFDS Cairns base , Queensland, Australia

#24 Flightgypsy

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Posted 06 December 2008 - 03:29 AM

Actually in this case if it is a ductal dependant lesion like it is sounding like (without the extra information requested) the baby's best chance of survival is getting them either PGE1 or to a cardiac cath lab as fast as you can. This hospital has neither and since the patient has now been semi-stabilized probably to the best it is going to get without either of the above treatments there is nothing more except for a possible central line which you can go for an umbilical vein catheter in this infant IF there is someone there able to insert one. I would definitely prefer to have more and better vascular access but how much time has already been wasted trying to get IV's. Have they even tried for a central line yet? Are the local Doctors even comfortable inserting one into an infant this size? All the other treatments can be done en route to definitive care. Infants with ductal dependant lesions die without PGE1 or cath lab/surgical intervention. I know of an infant who presented at a local hospital and they waited for the specialty team to get there by ground 4+ hours instead of sending them with the local flight team (60 min flight time). The hospital also had PGE1 available which the local flight team could have started prior to transporting. This infant died as a result of the delay in receiving PGE1 or surgery. Time is CRITICAL in DDLs. It is not a reckless attitude when you understand what you are dealing with.

If it is going to take longer to get the specialty team to the infant than to get the infant to the specialty hospital and said treatments then I would be heading out the door as fast as I can. This is also provided you have a ventilator appropriate for an infant. The LTV is used frequently at a large tertiary childrens hospital in the PICU where I worked for infants less than 5 kg. Infants even go home on this particular ventilator so I feel comfortable using it on this size infant and have done so a number of times with no adverse effects. They were all intubated or trached babies too. I did not recommend any other ventilator as I don't know their capabilities. I also recommended having a very in depth discussion with the receiving doctor to see what he wants to do.

I do agree that scoop and run is not always the best option for critically ill infants but this particular possible diagnosis is just not going to get better the longer you stay and play it is going to get worse. By the time you realize that you may be too late. If the x-ray and other assessments lead me to think that this is not a CHD infant then I would be happier to take more time doing interventions prior to transport.
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#25 rfdsdoc

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Posted 06 December 2008 - 07:21 AM

Good points open to debate, FlightGypsy.

What of the stresses of flight in either a fixed wing or rotary unit on this baby? You have no transport cot so I guess plan to just secure them to an adult stretcher as best as you can. Not very secure and really risks the airway being lost particularly with takeoff for a rotary aircraft. I learnt that the hard way when I moved that 6 week old and that was with a transport cot. temperature control? You were going to use just blankets?

I agree ..I think we all agree this baby needs PGE1 to stabilise for transport. You even cite that in the case you mention where the baby died even though the PGE1 was available.

Lesson from that is that it is often better to get expert help early, stabilise as best as you can before committing yourself to a hypoxic, dry, cold, vibrating environment ( all the things that will worsen such a baby).

I say bring the PGE1 and expert help to the baby. Even if things went lethally wrong with that decision, I could live with having taken such an action. But if I had chosen to put a partially stabilised baby onto an aircraft with no transport cot, no neonatal ventilator, with full knowledge that the aeromedical environment will worsen their physiology as they are not as well prepared for the transport as they could be....sure if you are happy to explain that to the coroner.

I think we both agree either action is taking a gamble. We cannot say with any scientific rigour which action would be even remotely superior.

If you are confident of your diagnosis and you know how to stabilise the condition further but do not have the drug/gear to do so, one can strongly argue that bringing that drug/resources to the patient is a more elegant solution than risking worsening the physiology by air transport.
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Minh Le Cong
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RFDS Cairns base , Queensland, Australia

#26 FlyingScot

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Posted 06 December 2008 - 05:11 PM

I'm going to have to side with Mihn on this one Gypsy. Currently you have acceptable vital signs and are in a stable environment. For arguments sake lets say that the time for you to get to the hospital is 90 minutes and the time for the specialty team to get to your location is also 90 minutes. In effect you are achieving the same thing. The specialty team brings the hospital's expertise to the bedside so in essence, short of surgery, the infant would be receiving the same level of care in the same time frame but without the risk of transporting utilizing equipment not approved for infants and with a crew that has only a rudimentary knowledge of the disease process and treatment. With the information we have at hand this baby does not need IMMEDIATE surgery (as in go to the OR in the next 5 minutes or die). Although he is "purple" his saturations are 85-92 which is entirely acceptable and may in fact be too high depending on what type of defect we have. On a side note, I'm not entirely sure how he can have these types of sats and have such extreme cyanosis, but it depends on where the pulse ox probe is and we weren't given that info. At any rate, a Pedimate is only approved for >=5 kg. Can you make it work...sure you can make it seem secure but there's a reason they test these things and my guess is that they were proven to not adequately sure infants under 5 kg. You've been trained to use this piece of equipment and you would be actively choosing to use it incorrectly. Imagine the legal ramifications of that. This infant is still a neonate and this patient population is particularly susceptible to cold stress. You will not be able to keep him warm with blankets ( do HEMS programs even carry Transwarmers) in a cold helicopter plus you will not be able to continuously monitor him for things like increasing respiratory distress without removing the blankets. A cold stressed baby is an acidotic baby which will worsen his respiratory status significantly. He needs an isolette...period. Now to the ventilator. Again, they are not approved for infants <5 kg...that should be enough right there. It doesn't matter that you've seen it done before. I've seen it done too and while the infant's saturations stayed the same the etCO2 went through the roof which if we only had a sat probe on (probably your only means of monitoring in this situation) we would have never known. The ventilatory management of this child will be a delicate balancing act and should not be taken lightly and definitely not on the basis of "well I've seen it done before". Even if you decided not to use the vent and instead hand-bag. Do you have a CPAP bag with a manometer because a Laerdal type won't work. If you do is there someone skilled at using it? It's not as easy as it looks. Are there enough crew members so that one person can act as the "vent" for the entire trip back?
So let me turn this around. Say there is a neo/peds specialty team at a rural hospital out in the boondocks. The patient they were originally transporting has improved and is going to stay there but there is an adult with an acute MI who needs to go to the Big City Hospital where incidentally the Big Children's Hospital is. The adult team is delayed but the referral doc notices that the pedi team has a cot, pumps and an LP12 just like the adult team. Plus the pedi team's nurse has worked in an adult (community hospital) ER in the past and is familiar with clot-busting drugs although not while actually transporting the patient. She's pretty rusty on her adult EKGs but has ACLS (although hasn't participated in an adult code for awhile) as do the rest of the crew. The nurse can look up the drugs as a refresher on her PDA and she can also look up the signs and symptoms of an MI but doesn't really know much about the differences in treatment of a right inferior vs left anterior etc. Oh, this patient is also very unstable with a BP in the toilet and is intubated but only one PIV. He needs to get to a cath lab quickly. Do you think this would be an appropriate transport for them to take?
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#27 MSDeltaFlt

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Posted 06 December 2008 - 05:37 PM

OK, I needed to make sure we were on the same page with the poss Dx. Great that we tubed the kid. STEMTP, no we don't leave just yet. Since this child is this sick, it also means junior's brittle. Let's not put the cart before the horse.

We're not flying due to icing conditions, so make sure you can ensure euthermia on the truck. This means it will be a very slow transport. You need to get all of your ducks in a row. The crew does not make the decision on when to transport. The pt does. Either the pt will be stable enough that you can afford to move for transport or the pt will be so critical that you can't afford not to move for transport. Either way the pt will decide that for us. We need to be attentive. Let's make sure the truck is nice and warm. Let's wait until some more crews show up so we can move him nice and slow.

There's no BP mentioned. Was that NIBP? Can we get a manual? If we can't get any BP whatsoever, along with cap refill, where do we feel pulses? Where do we NOT feel pulses? The fact that he's moving around on the warmer and moving extremities means he's got arterial blood flowing down those extremities. The question is, just how far down them?

You said that ETT was confirmed with L/S and EtCO2 waveform. That's all good and all, but, since we have a probable PDA and BP's not doing so hot, CO will be off. Meaning EtCO2 will be off. Can we get some temp corrected ABG's? He might have a metabolic, or even an Anion Gap, acidosis. Nothing will work in an acidic medium. Vasopressors will exacerbate the condition. We all know this.

Let's not forget that junior's brittle and the cart goes behind the horse.

Humbly written.
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Mike Hester, RRT/NRP/FP-C
Courage is resistance to fear, mastery of fear - not absence of fear -- Mark Twain

#28 Flightgypsy

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Posted 07 December 2008 - 10:11 AM

Argh, I just deleted my whole long-winded post (I am sure much to y'alls relief!). So I will try a short (er) version.

Good debate all.

Minh, I agree we agree that both options are a gamble! If the difference in time between waiting for a specialty team versus the Flight crews ETA to the tertiary hospital is significantly longer to wait for the team than I still advocate transporting. I personally would feel comfortable doing so but would not fault anyone with a lower comfort level for not. If I wasn't convinced it was a time critical DDL (still waiting on further info to be convinced or not) or if I knew that the peds team will arrive about the same time as I could get him to the other hospital, I would be more than happy to wait for a specialty team to arrive with their equipment/drugs etc. Perhaps the reason we are on this transport is because the specialty team is not available or has a long ETA. I would rather explain to the coroner why the baby died en route than explain to the family that their baby died because we were waiting for the optimal equipment to arrive when perhaps they could have survived if they had gotten the life-saving drugs in time by transporting them. I am advocating for whichever option gives the baby the best chance of survival whether it is waiting for a specialty team or transporting myself.

My feeling is that if this is a DDL, this baby is pretty much as stable as he is going to get without PGE. While he is fairly stable is the optimal time to transport him rather than wait until he deteriorates again and the longer we wait the more likely he is to deteriorate. We may not have the optimal or ideal equipment but we can mitigate to a large degree the stresses of transport. If we don't have equipment available to transport infants why are we even accepting the request?

No, I did not suggest securing them to an adult cot as best we can. We are told we have the Pedi-mate. Yes, it is only recommended for infants 4.5kg and greater and is not the ideal method of transport but it can be safely done. The transport environment and equipment is often less than ideal. All patients on inotropic support should ideally have arterial and central lines but in my area at least that is a rarity. If you package the infant with blanket rolls around him and towel rolls beside his head (and taped like with spinal immobilization) the infant and the tube are secure. I would be curious to know if they have even tested the pedi-mate in the less than 4.5kg age group as the majority of these infants are transported in isolettes.
The baby I mentioned died despite PGE being available because they (the hospital) chose to wait 4+ hours for the specialty team to arrive and assume care. Waiting for expert help to arrive versus using the local flight team (5 mins away + 1 hr flight time to receiving facility + possiblilty of getting PGE started prior to transport) was poor decision making that cost that infant his life.

I also recommended a warming device with continuous rectal temperature monitoring. We carry the porta warmer (chemically activated re-usable gel pad) that also acts as a cushioning/padding device. I have not had any problems maintaining an infant's temperature with this method even without an isolette. I have also found that this often keeps them warm enough that I can use less blankets and have better access to the infant.

I don't have a problem using the LTV ventilator for this size infant. If the ventilator available is not an LTV then I would definitely not recommend bagging (and yes, I personally am skilled with anesthesia bags) this baby for an entire transport even with an anesthesia bag and manometer. Have you ever used insulin/glucose for treating hyperkalemia? It is only FDA approved for use in diabetic conditions. So does that mean you will never use it for hyperkalemia despite knowing how it works and how to give it in this situation because it is not FDA approved for that use.

We always use continuous ETCO2 monitoring on all our intubated pts and also have sidestream ETCO2 monitoring capabilites.

The question was would you transport this infant and basically if a specialty team is going to take significantly longer to arrive than for me to get the baby to the receiving hospital and the receiving physician agrees with the plan, than yes, I personally would transport. Now if you have a team that is totally out of their comfort zone with infants or peds and does not have an appropriate ventilator than I would not recommend transporting.

Have to get to bed now.
Keep safe all.
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#29 rfdsdoc

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Posted 07 December 2008 - 11:37 AM

Hey folks

I guess we disagree, Flight Gypsy. If its a choice between the baby dying during rapid transport or dying at the referring hospital, well I choose the hospital. I am going to wait for backup with proper gear and PGE1. The case you cite is tragic and I sympathise with your viewpoint on that one but still think that you will never know if doing something else would have made a difference.

IN this case, You suggest transporting a baby with a DDL with no PGE1 support for 90+minutes. You have just stabilised the baby partially and now you want to stress it out more by trying rapid transport using adult gear, one IV access, no blood work, no ABGs.

I can hear the theme music to Top Gun starting.... :rolleyes:

I agree with your last line : keep safe. The last 3 months have disturbed me.
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Minh Le Cong
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RFDS Cairns base , Queensland, Australia

#30 Flightgypsy

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Posted 07 December 2008 - 09:23 PM

No problem rfds, I respect your opinion and agree to disagree. I would actually be shocked if everyone on this forum agreed on everything. We all come from different backgrounds, experiences and knowledge bases which are what we use to make the hard decisions. Actually put 3 doctors (especially if from different specialties) in one room with a sick patient and you will probably get 3 different treatment plans some totally opposing each other. I have seen it happen many times.

Sometimes we have to make very hard judgement calls (especially in the transport environment) and like you said often there is not one plan that is completely superior to another. Ultimately it is up to the individual to make a tough decision based on their best judgement and in the end they are the ones that have to live with it. I have found in even minor treatment plans everyone has a different opinion and comfort level (e.g. what dose of Fentanyl to give, should an intubation have been done or not, etc.). Majority of the time there is not a clear cut right or wrong answer but I think being open to different opinions and ideas often helps us get a different perspective and allows us to become a better well-rounded providers. I often take others feedback and opinions, do my own research and decide whether or not to change my own opinion/practice or perhaps have my own knowledge reinforced with evidence based practice and research to back it up.

Anyway, interested to hear the rest of the story from STPEMTP and the decisions they made with the outcomes.

Cheers
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#31 mjcfrn

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Posted 09 December 2008 - 12:46 AM

Perhaps I was bit too definitive in my statement. What I should have said is an EKG would be useless unless somebody in this small rural facility is skilled in interpreting neonatal EKGS particularly when a defect is suspected. Really it isn't going to give you enough information to make an absolute diagnosis and/or change your plan of care so why waste the time? Seriously, if you got an EKG on this kid and it showed an abnormal axis what would you do differently than has already been discussed? Would you know exactly what it meant? I'm not trying to bust your chops it's just we don't have the luxury of loads of time to perform tests that ultimately won't change anything. Even tertiary pediatric centers don't routinely use them. Regardless of what the defect is the treatment is the same.


I completely agree that it wouldn't change the initial treatment. I wouldn't take the time to it personally for all the reasons you cite. But usually there are plenty of hands to help in the referring ED (or nursery). While I'm trying the PIV, giving the PGE, checking pre/postductal sats, 4limb NIBPs, etc, I can often delegate doing an EKG to a tech, RT, EMT or RN who is anxious/eager to help. The referring hospital can fax it to the pedi cardiologist at the tertiary canter who can plan his/her care - have the cath lab personnel called in or be set-up for an anticipated procedure, have pedi CVTS on standby, ECMO on standby, etc. He/she has the number of the transport team and can call me if there is some finding that will influence what I do. (And yes they have taught us some interpretation of neo and pedi EKGs) Now, obviously the pedi cardiologists would rather have an echo and would not ordinarily use an EKG for CHD dx, but in some circumstances it is diagnostic info that is available without delaying care.

Like so much we have already discussed, it is specific to the particular patient/personnel/resources of the referring and receiving hospitals as well as the particular transport team members.
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#32 mjcfrn

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Posted 09 December 2008 - 02:01 AM

...I know of an infant who presented at a local hospital and they waited for the specialty team to get there by ground 4+ hours instead of sending them with the local flight team (60 min flight time). The hospital also had PGE1 available which the local flight team could have started prior to transporting. This infant died as a result of the delay in receiving PGE1 or surgery. Time is CRITICAL in DDLs.... I also recommended having a very in depth discussion with the receiving doctor to see what he wants to do.


One option would have been for the referring hospital to have started the PGE1 while awaiting the specialty team. I wondered if this was considered. Four hours is a very long time - spec team doesn't fly?

...You said that ETT was confirmed with L/S and EtCO2 waveform. That's all good and all, but, since we have a probable PDA and BP's not doing so hot, CO will be off. Meaning EtCO2 will be off. Can we get some temp corrected ABG's? He might have a metabolic, or even an Anion Gap, acidosis. Nothing will work in an acidic medium. Vasopressors will exacerbate the condition. We all know this.... Let's not forget that junior's brittle and the cart goes behind the horse.


Another reason we need this info: Small changes in CO2 will constrict or dilate the pulmonary bed which can rapidly UNbalance circulation. I'm not saying we didn't need to intubate, but ventilation has to be very carefully managed and correlating pCO2 with ETCO2 can be critical for maintaining any systemic perfusion during transport.

Great discussion! Hey, STEMTP.... we want more info, pls!
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#33 STPEMTP

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Posted 09 December 2008 - 08:20 PM

Sorry for the delay folks. Was trying to post reply yesterday, but work decided it wanted to interfere with those plans.....

Ok, here's the actual presentation.

My partner and I had just brought a pt into this ED (I work rural 911, we do some CCT also), when the L&D RN came running into the ED. Upon setting the child down on the ER bed, we offered our help to the ED staff and began assisting.

We quickly identified a probable cardiac defect and preceded with the treatment using low flow O2 due to suspecion of possible ductal dependant lesions. PIV were unsuccessful, and EZ-IO was placed. During the first fluid bolus, O2 was applied to the patient and that was when the kid started turning blue. At this point, we started to consider cyanotic heart defects. The infant seemed to have some difficulty with respirations. Endotracheal intubation was deferred to consult textbook so that we didn't make a bad situation worse. As we were checking the reference books, we found out from the parents that the child had been to well baby check at day 5 and no problems were noted. Pharmacy was contacted to obtain PGE1. Learned it was unavailable. At this time, child's respiratory effort was increasing and decision was made to intubate the child. Child intubated without difficulty. Shortly after tube was placed we noted that the child seemed to be more alert and began to spontaneously move around. sedation was done twice if I recall correctly before the IO decided to it didn't want to be useful anymore. We took another crack at trying to get PIV without any success. 2nd IO placed in other leg. At this time, the child was a shade of purple I never want to see again in a patient who has a pulse. (Flightgypsy, eggplant is a perfect description for the color of the kid. Didn't want to give that to you, would have been a dead give-a-way)

Some of you had asked for labwork, bp's, glucose..... My apoligies. No lab work was performed prior to arrival of transport team (actually, I don't believe that they obtained any labwork either prior to departing for the pediatric hospital). The bp's in all extremities were not done, and I don't recall a bp being taken during my time assisting. Don't know if these would have helped you make the correct call on this child faster than you did. I don't recall a baby xray being taken..... tried to catch up with MD involved to double check, but unsuccessful.

No end tidal CO2 numeric or waveform was obtained due to the equipment available (Zoll M series) did not have neonate adaptor. (Had a partner years back tell me after they tried running adult ETCO2 adaptor on an infant they intubated not obtain any reading and found out that there is a smaller adaptor for children less than 15kg). Only etco2 detector used was the pediatric colormetric device.

Around the time of the intubation, the ER MD asked if we would be able to transport this kid to the pediatric center. I advised I could get a second person to help me to transport this kid, but I was concerned about stability of the patient. (I work medic/emt). The equipment I have is not approved for infant/neonate use (parapac ventilator) and I didn't have an Isolette. Cranking the heat in the back of the units I have can make it very warm, but could I make it warm enough to maintain normal temp in an infant that will probably have minimal coverage with blankets/etc I didn't think I could do that. I declined the transport. I didn't want to wind up in a situation where rushing to get this kid to peds center put us in a very bad situation. If we were to actually do the transport and things took a turn for the worse, the next nearest hospital is 35miles away........ in poor road conditions. That was an adventure that I did not want to enbark on. That was the reason for the question I had in the last post about attempting the transport.

As for the child. Once the transport team arrived, they performed a echo and determined that the kid had hypoplastic left ventricle syndrome, mitral valve atresia (sp?), and right ventricle appeared to be small. They were able to place a umbilical line in the child and transported to the pediatric cardiovascular hospital. As of 48hrs after presention to ED, child was still alive at the pediatric hospital. Since that time, the ED has not been able to obtain any type of followup.
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#34 Flightgypsy

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Posted 10 December 2008 - 07:57 AM

Kudos to you ST. You did a great job staying and helping out the ER staff. I am sure they appreciated the extra help.

With more of the story I agree wholeheartedly that you made the right decision with the equipment, (or lack of) you had available, lack of knowledge and lack of experienced providers to go with you. I would definitely not have used that ventilator either. I am sure that ER Doc wanted him out of there as fast as he could. Just curious to know how long did it take for the team to get to you? I am glad the child was doing ok so far as you heard. He has a long road and multiple operations ahead of him now but at least he has a chance.

Thanks for an interesting discussion.
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#35 STPEMTP

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Posted 10 December 2008 - 04:20 PM

Flightgypsy,

From time of request to time of arrival was approx 90 mins. If we had attempted to transport, I think we might have saved maximum of 20 minutes. More likely less than 10mins.
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#36 fiznat

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Posted 11 December 2008 - 05:22 PM

No end tidal CO2 numeric or waveform was obtained due to the equipment available (Zoll M series) did not have neonate adaptor. (Had a partner years back tell me after they tried running adult ETCO2 adaptor on an infant they intubated not obtain any reading and found out that there is a smaller adaptor for children less than 15kg). Only etco2 detector used was the pediatric colormetric device.


Sorry I know this is kindof a side item but is this true for the LP12 as well? I never thought about it, but I guess it makes sense that a pedi might require a different (smaller) ETCO2 detector for the ETT.
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#37 FlyingScot

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Posted 11 December 2008 - 08:54 PM

Sorry I know this is kindof a side item but is this true for the LP12 as well? I never thought about it, but I guess it makes sense that a pedi might require a different (smaller) ETCO2 detector for the ETT.


Yes it's true for the LP 12. The adult adapter has too much dead space and will give an inaccurate reading. If the baby is small enough it will also drive their CO2 up.
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#38 EDMEDIC

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Posted 14 December 2008 - 07:05 PM

We use LP12's here and we do have neontate EtCo2/ capno detectors, both nasal type and ETT type. They are quite a bit smaller than the intermediate/ adult type. We really don't use the neonates much, so I am not sure how reliable or accurate they truly are..my .02, Brian
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Brian EMT-P/CC
"failing to prepare is preparing to fail"
" you don't know what you don't know"

#39 Jeff73

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Posted 08 February 2009 - 04:03 PM

One option would have been for the referring hospital to have started the PGE1 while awaiting the specialty team. I wondered if this was considered. Four hours is a very long time - spec team doesn't fly?
Another reason we need this info: Small changes in CO2 will constrict or dilate the pulmonary bed which can rapidly UNbalance circulation. I'm not saying we didn't need to intubate, but ventilation has to be very carefully managed and correlating pCO2 with ETCO2 can be critical for maintaining any systemic perfusion during transport.

Great discussion! Hey, STEMTP.... we want more info, pls!

I just want to know how they got a UVC or UAC in a kid that was a week old. Are you sure that is the access they obtained?
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#40 STPEMTP

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Posted 11 February 2009 - 12:01 AM

Jeff73,

I didn't personally witness the umbilical line being placed, but the MD that was the one requesting the transfer is the one who told me that a umbilical line was placed by the neonatal team that arrived.

As for outcome of the child, the last that I had heard was approx 3 weeks after the case was that the child was still alive. I believe the first of the 3 stages of surgery had been completed successfully. I don't know if the child has yet been discharged.
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