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Case #46 My Baby Is Having Trouble Feeding

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#41 JLP


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Posted 14 February 2009 - 11:42 PM

Just an aside, since we were talking about "cyanotic" vs "non-cyanotic" cardiac defects. Not from ped CCT experience, because I don't have any, but from a long time road 911 and six months in a rural clinic in Central America years ago: a neonate who will not feed will dehydrate to the point of shock in a day or so, and simply will not display cyanosis b/c there's no blood reaching the skin to be cyanotic. We have to remeber that the cyanotic/non-cyanotic distinction is reliable only when there is decent volume in the system
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#42 flightnursesarah


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Posted 11 November 2009 - 02:31 AM

I know this is an old case study, but I was just browsing through and found it. I was dispatched to a 4-day-old "sepsis" one day and this is EXACTLY what I found when I got there. Baby was brought in by parents for "trouble feeding" and "sweating." Key things to take from your infant history. Our baby was maybe "eggplant" but I have repeated the story multiple times again as "navy blue." The SIDS babies after they are coded and pronounced dead look more alive than these babies. This baby also presented to the ED with an accu check of 13 and a rectal temperature of 93. Before we arrived, the baby had been given dextrose, fluid boluses, intubated, IV started, NG in place, on an infant warmer. . . . . and this was a VERY rural, literally 1-room (2 beds separated with a curtain) ER. The staff in the ER was the family practice doc that had delivered the baby and the PA that was staffing the ER, along with 2-3 RNs that work the entire hospital when the ER is empty. (As a side note, I am not a NICU RN, I am a transport RN and we take care of all ages, including babies that have been discharged from the hospital. We have a dedicated team for NICU babies--but this baby was "dirty" and had left the hospital). We assessed the baby and called our PICU intensivist for orders. GCS 3, pupils fixed and dilated, no tone, big heart on chest x-ray, hypotensive, bradycardic. We started Prostaglandins and an epi drip, as well as an IO. Our down-time was horrible, almost 2 hours if I recall correctly. (Our pilot actually thought he would time-out, leave us, and send the next shift. Which caused me to work a little faster). As we moved this little precious cargo to our isolette, the baby for the first time opened his eyes. It was a remarkable experience. The prostaglandins actually worked that quickly to open up the PDA. On the 50 minute helo flight back to our hospital, the baby developed more tone and was biting on the tube when we landed. Handing off that baby to the PICU was the biggest relief of my nursing career to date.

This baby ended up being a severe left hypoplast that was actually too sick to have surgery for several weeks. He remained on the Prostaglandin drip until surgery. He developed multiple problems related to the altered perfusion of his GI tract and other body organs, but eventually had open heart surgery. The best part of taking care of this patient was the card I received from the family for Valentine's Day 9 months later. It was a collage of multiple photos of the child in the shape of a heart. Written on the top was the name of my partner, myself, and the pilot, with the words, "Thank you for fixing my broken heart." I have it as a framed keepsake of the worst flight of my life!



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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#43 JPatterson


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Posted 16 November 2009 - 11:13 PM

On a side note, I was wondering how many of you work in similar situation as myself? We deal with the "dirty" babies (no matter how young...hours vs days) and the NICU team does the "clean" babies with us as assistants and the "taxi".
Also, if you do have a similar set-up, do you have access to the NICU for training/skills/exposure or are you limited to the PICU as we are?


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Jeff Patterson NREMT-P