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#53 - Assumptions Do One Thing...


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#1 jjones1418

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Posted 06 June 2010 - 12:55 PM

Same rules as the other cases…
1) You have everything you need on your helicopter. Any drug, procedure, and equipment are available.
2) You have a one hour flight to the other facility.
3) You are a 2 person flight crew.
4) Please provide literature references to your answers if you feel they are needed, and be ready to explain why you choose to do what you do.

Introduction
Its right at shift change, you’ve flown 4 flights in your 24 hour shift, 2 after midnight. You’re tired, ready to go home, and your relief calls and says they’re both running late, stuck behind a major accident in the next city over. You’re toned out for an inter-facility transfer for a pediatric patient that’s AN HOUR AWAY. In flight, you receive the following information…

4 year old male, seizures, being transferred to the large children’s hospital in the metroplex. It’s about an hour flight to the pediatric specialty hospital. No other information is available.

After the long flight, you arrive at the emergency room of a small hospital that doesn’t have much in the way of critical care capabilities. It’s got a doctor, sometimes. You walk in and are met by a distraught nurse, who says it’s a bad case, and she is visibly upset. Parents do not speak English and are standing outside the room. Dad seems despondent and mom is obviously upset.

Nurse says that the patient is a 4 year old male that was brought to the ER by mom and dad, and was found actively seizing in the car. He was given a total of 4mg of Ativan to stop the seizures, and is now resting. She says that the patient was in the ER about 3 days ago with nausea, vomiting, lethargy, and an abnormal amount of incontinence. (Some 4 year olds wet the bed, but this was WAY more than normal from what we gathered. Was also incontinent of bowels) He was discharged home with antibiotics, Zofran ODTs, and diapers.

When you walk in the room, you see a 4 year old male, appears acutely ill. He’s almost unresponsive, but makes an awful-sounding moan and has decorticate posturing with painful stimuli. You have no labs available, as they just started an IV, gave him the Ativan, and called the children’s hospital for a transfer. Then they called you. While moving the patient to change his diaper, they pulled out the only IV they had. You have no access at the moment.

BP – 90/42
P – 146, Sinus Tachycardia
R – 10, erratic and shallow
SpO2 – 95% on NRB
GCS – 6 E1, V2, M3

Physical Exam –
HEENT – Red splotches on eyelids and pupils at a 6 and very sluggish, almost non-reactive. Patient has what appears to be petechial hemorrhages on his face and around the eyes.
Neck – Red marks on neck, looks like a hand print
Chest – Bilateral, equal breath sounds, shallow chest rise, chest stable, no palpable deformities to ribs
Abdomen – Soft, non-distended, no visible trauma
Back – Unremarkable
Extremities – Small scratches on hands, dirty fingernails, otherwise unremarkable
Genitalia – Appears to have a rash, has diaper on which was changed by hospital, diaper is wet
Skin – Small, red ecchymotic areas on face and upper chest

Treatment Prior to Our Arrival –
IV (No longer patent), O2 via NRB, Ativan 4mg total – (2mg on arrival, 2mg about 10 minutes later), Changed Diaper, Called Helicopter. It has been approximately one hour since his last dose of Ativan.
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Jason Jones, EMT-P

#2 Speed

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Posted 11 June 2010 - 06:21 PM

You got any labs? Body temp? What is the nationality of the patient(cultural or religious medical practices)? Skin tenting? Bowel & bladder I&O's?
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Mike Williams CCEMT-P/FP-C

#3 TexRNmedic

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Posted 11 June 2010 - 06:28 PM

The ED can't run a quick CBC, chem, urine tox and/or ABG? I'd love a rectal temp and cBGL too. I can muttle through with basic Spanish. I'm getting a translator or calling a language line for a better history and calling poison control. Nice mix of sympathomimetic and cholinergic sx. The kid is getting a quick wash down decon too. Quick attempt at a PIV. If a no-go then I'll start an IO. 20cc/kg NS IVF bolus. Airway is at risk, breathing looks like it may be inadequate. Atropine (double whammy, dries the kid up and pre-tx for vagal brady) and a little more benzo should be enough to pass a tube. While I'm in the airway, taking a look for signs of Strep (red swollen tonsils/airway plus sx:rash, fever, diarrhea, dehydration). Repeat v/s and waveform ETCO2. Pedi 12 lead ECG. This kid has been loosing fluids and electrolytes for days. I really need to get this kids lytes and start replacing F&E before taking an hour flight.

So any labs?
Temp & cBGL?
Hx?
Onset of sx/illness?
Number of and duration of seizures with a description of what they look like (febrile or other etiology)?
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Wes Seale
Houston , TX

#4 SerendepitySaki

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Posted 11 June 2010 - 07:41 PM

in ADDITION to everything Wes n Mike stated...
  • has there been ANY neuro workup at all?
  • ANY imagery?
  • fundascopic exam?
  • LUNG AND HEART sounds?
  • bust out the iSTAT...get that running when we line him up....
  • urine dipstick as well....
  • WEIGHT? do we have EDR or Broselow?

ASSUMING you've given us all the current labs...and they did NOT do a C&S or start the kid on any abx that actually worked last time, I want MULTIPLE vascular access w/ empiric weight based cef and vanc going in sequentially, vanc slow...[i'd LOVE a freaking gram stain, (and a tap) right about now...which Wes mentioned in passing...]

most likely either tox exposure (nice catch on the decon AND the translator, mi amigo) and/or septicemia with some possible anaphylaxis thrown in.... notice, i am stating empiric coverage...can't hurt, could help.

F&E MOST important, with EPI and other pressors lined up if needed....but i'd get the abx going if i could.... (zebra wise, based on hx, also wondering if the poor little turd has picked up an organophosphate, cholera or something similar) consider working some antihistamines in way down the line....

assuming that that's a Pedie GCS score and that 95% NRB is real, right there w/ Wes, do NOT pass go, do not collect $200....control the seizing, dope em up, put em down, tube em... (i would probably skip the atropine tho... kid's already dry and tachy...can have it ready, but i don't consider atropine a given in pedie RSI...possibly as antidote in this case, tho....)

8. what have we got for an Xport vent?
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#5 SerendepitySaki

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Posted 11 June 2010 - 07:58 PM

would also love most current PLTs and coags on the little dude....hoping the hospital drew a rainbow both admissions?
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#6 TexRNmedic

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Posted 11 June 2010 - 08:31 PM

in ADDITION to everything Wes n Mike stated...

  • has there been ANY neuro workup at all?
  • ANY imagery?
  • fundascopic exam?
  • LUNG AND HEART sounds?
  • bust out the iSTAT...get that running when we line him up....
  • urine dipstick as well....
  • WEIGHT? do we have EDR or Broselow?

ASSUMING you've given us all the current labs...and they did NOT do a C&S or start the kid on any abx that actually worked last time, I want MULTIPLE vascular access w/ empiric weight based cef and vanc going in sequentially, vanc slow...[i'd LOVE a freaking gram stain, (and a tap) right about now...which Wes mentioned in passing...]

most likely either tox exposure (nice catch on the decon AND the translator, mi amigo) and/or septicemia with some possible anaphylaxis thrown in.... notice, i am stating empiric coverage...can't hurt, could help.

F&E MOST important, with EPI and other pressors lined up if needed....but i'd get the abx going if i could.... (zebra wise, based on hx, also wondering if the poor little turd has picked up an organophosphate, cholera or something similar) consider working some antihistamines in way down the line...
assuming that that's a Pedie GCS score and that 95% NRB is real, right there w/ Wes, do NOT pass go, do not collect $200....control the seizing, dope em up, put em down, tube em... (i would probably skip the atropine tho... kid's already dry and tachy...can have it ready, but i don't consider atropine a given in pedie RSI...possibly as antidote in this case, tho....)

8. what have we got for an Xport vent?


Dang S-man. Went right down my diff dx list. Was going to let other play a little first. Toxin vs nasty bug. Either way the kids lytes are in the toilet and he is probably profoundly dehydrated. Low K= floppy kid. This facility sounds like many of the East Texas EDs that are not much more than a tech, RN and mid-level or an on call family practice MD. iSTAT labs and flat plate xray on film is usually all they have. No way this kid has had an LP or CT. Bet they can't pull his records from the last visit either. I'd love blood, CSF and urine C&S /C gram stain, but I think that facility is about an hour away and probably another few hours to cook everything up. Lactate too, but I'll live with the ABG. If I was in a dream world and could get it reasonably quick CBC-diff, CMP, INR/PTT, lactate, UA /c osmo, ABG and CXR. Thinking realisticly with the CBC, chem, tox and ABG. Love, love, love the empiric broad spectrum abx coverage. Presuming a few things, but I'd pull a D5NS-20meq KCL from the EDs stock for the kiddo. Not a big routine atropine pusher for ETI, but this kid has all of cholinergic SLUDGE. I want to dry up his little oropharnyx and would be nice to see if it reverses any of the SLUDGE. Not sure what this kid got into. Anybody else in the household /c anything close to similar sx? Malnurished or developmentally delayed? I'd be half tempted to wear at least a surgical mask during transport. Cipro doesn't tx every meningitis causing pathogen. ;) Broslow- I'd go ahead and start working on drug calcs (pressors, sedation etc) for this kid. I tend to write on the stretcher sheet, so its all right there by the pt's head when I need it.
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Wes Seale
Houston , TX

#7 JLP

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Posted 11 June 2010 - 08:54 PM

Same rules as the other cases…
1) You have everything you need on your helicopter. Any drug, procedure, and equipment are available.
2) You have a one hour flight to the other facility.
3) You are a 2 person flight crew.
4) Please provide literature references to your answers if you feel they are needed, and be ready to explain why you choose to do what you do.

Introduction
Its right at shift change, you’ve flown 4 flights in your 24 hour shift, 2 after midnight. You’re tired, ready to go home, and your relief calls and says they’re both running late, stuck behind a major accident in the next city over. You’re toned out for an inter-facility transfer for a pediatric patient that’s AN HOUR AWAY. In flight, you receive the following information…

4 year old male, seizures, being transferred to the large children’s hospital in the metroplex. It’s about an hour flight to the pediatric specialty hospital. No other information is available.

After the long flight, you arrive at the emergency room of a small hospital that doesn’t have much in the way of critical care capabilities. It’s got a doctor, sometimes. You walk in and are met by a distraught nurse, who says it’s a bad case, and she is visibly upset. Parents do not speak English and are standing outside the room. Dad seems despondent and mom is obviously upset.

Nurse says that the patient is a 4 year old male that was brought to the ER by mom and dad, and was found actively seizing in the car. He was given a total of 4mg of Ativan to stop the seizures, and is now resting. She says that the patient was in the ER about 3 days ago with nausea, vomiting, lethargy, and an abnormal amount of incontinence. (Some 4 year olds wet the bed, but this was WAY more than normal from what we gathered. Was also incontinent of bowels) He was discharged home with antibiotics, Zofran ODTs, and diapers.

When you walk in the room, you see a 4 year old male, appears acutely ill. He’s almost unresponsive, but makes an awful-sounding moan and has decorticate posturing with painful stimuli. You have no labs available, as they just started an IV, gave him the Ativan, and called the children’s hospital for a transfer. Then they called you. While moving the patient to change his diaper, they pulled out the only IV they had. You have no access at the moment.

BP – 90/42
P – 146, Sinus Tachycardia
R – 10, erratic and shallow
SpO2 – 95% on NRB
GCS – 6 E1, V2, M3

Physical Exam –
HEENT – Red splotches on eyelids and pupils at a 6 and very sluggish, almost non-reactive. Patient has what appears to be petechial hemorrhages on his face and around the eyes.
Neck – Red marks on neck, looks like a hand print
Chest – Bilateral, equal breath sounds, shallow chest rise, chest stable, no palpable deformities to ribs
Abdomen – Soft, non-distended, no visible trauma
Back – Unremarkable
Extremities – Small scratches on hands, dirty fingernails, otherwise unremarkable
Genitalia – Appears to have a rash, has diaper on which was changed by hospital, diaper is wet
Skin – Small, red ecchymotic areas on face and upper chest

Treatment Prior to Our Arrival –
IV (No longer patent), O2 via NRB, Ativan 4mg total – (2mg on arrival, 2mg about 10 minutes later), Changed Diaper, Called Helicopter. It has been approximately one hour since his last dose of Ativan.


OK - assist ventilations with BVM; Get IV right now if a big site is easily available, but I'm likely going to slam in an IO now and get an IV after I've got a bolus in, kid needs fluid ASAP as he is clearly maintaining perfusion with tachycardia. Start with 20ml/kg, repeat if lungs stay clear and no further neuro deterioration. Keep 1g/kg mannitol handy in case focal changes occur or neuro goes further south with the bolus.

Check blood glucose at bedside; DKA is a possibility with the lethargy, N & V, and profuse urination, albeit the rest of the picture is less likely to fit.

Look for old injuries; the petechial hemorrhages and marks on neck make abuse and brain injury a possibility. Get someone to interview parents separately.

Have someone who speaks their language get a better history, use Language Line if necessary; I want to know if they live on a farm or near one, has there been chemical spraying, is anyone else sick. Find out where they get their water (well, cistern, natural source, municipal) - looking for nitrite contamination from fertilizer or GI infection source.

if GCS does not increase after bolus, repeat if lungs are clear, if BP still not coming up, start a pressor. Dopamine 5mcg/kg/min is a good start with kids, get an epi infusion prepped as well if needed. If HR comes down but GCS is still crap, load up with more benzos (AFTER bolus) and intubate. Vent with normal parameters initially pending ABG's. Do we have an iSTAT?

Do up a Dilantin 20mg/kg bag in case seizure returns, but don't run yet.

Start ceftriaxone on suspicion of meningococcal infection, we can always d/c later. Draw samples for culture and for CBC/electrolytes/coags. Doxicycline or tetracycline are also a thought - sounds a lot like Rocky Mountain Spotted Fever (where is this?)

Foley cath, I want a clear picture of ins-and-outs. That kind of urine output suggests DI, maybe a brain injury or encephalitis. check diaper for appearance & smell (dilute vs concentrated, odour suggesting urosepsis, "tea" colour like rhabdo, unusual colour or smell).
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#8 SerendepitySaki

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Posted 11 June 2010 - 09:44 PM

yeah guys, we're like the Bobbsey triplets....B) aside from minor variations, we seem to be singing the same song in three part harmony.....
@ Wes: right there with you man... definitely contact precautions... just in case... and mentioned atropine for symptoms at least 2x... (organophoshate? antidote?)
@Wes and JLP: that's why i asked for a urine dipstick.... not stocked often enough prehospital, but even the most shit hole facility should have em...can wring enough piss out of the diaper to get specific grav, protien, leukocyte esterase, sugar, nitrites, etc... can get a LOT of diff dx bang for buck....
@JLP: mannitol - nice touch.
decon, contact precautions, increased 360 via translator ...c'mon Jase is it Spanish?....Wes and I can knock a LOT of hx out if it is.....airway, multiple access w/ F&E, iSTAT, and empiric coverage if Jason'll let us play....
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#9 TexRNmedic

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Posted 11 June 2010 - 10:17 PM

yeah guys, we're like the Bobbsey triplets....B) aside from minor variations, we seem to be singing the same song in three part harmony.....
@ Wes: right there with you man... definitely contact precautions... just in case... and mentioned atropine for symptoms at least 2x... (organophoshate? antidote?)
@Wes and JLP: that's why i asked for a urine dipstick.... not stocked often enough prehospital, but even the most shit hole facility should have em...can wring enough piss out of the diaper to get specific grav, protien, leukocyte esterase, sugar, nitrites, etc... can get a LOT of diff dx bang for buck....
@JLP: mannitol - nice touch.
decon, contact precautions, increased 360 via translator ...c'mon Jase is it Spanish?....Wes and I can knock a LOT of hx out if it is.....airway, multiple access w/ F&E, iSTAT, and empiric coverage if Jason'll let us play....


Now worries Sean. Just wanted to make sure you understood my rationale.

Teach me something here guys. Isn't manitol going to cause further interstitial and intravascular volume depletion (osmotic effect and then the kid just pees it out)? Would you just fix that with IVF replacement and pressors? The manitol is for cerebral edema and to improve our CPP right? I've seen it given for TBI, just not an infectious process. Who knows- he may be crumping with a slow bleed. Boy that would be a mess, cerebral HTN and dehydrated like a mutha.

Definitely agree with an olfactory assessment. Nasty urine, C-diff, another GI bug, ketones, toxins-almond, garlic, chemical order breath.

Seizures- hyponatremia?
Floppy hypoventilating kid-K or mag?

Jason any more neuro exam details (he responds to pain-what about Kernig's/Brudzinski, what does his retina look like?)

Ready for more details. Respondes a las preguntas por favor!
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Wes Seale
Houston , TX

#10 jjones1418

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Posted 11 June 2010 - 11:01 PM

Update soon! At the hospital with the wife, kid, and new baby.

He's finally here!

Trystan Keith Jones
9 lbs, 5 oz.
20" long

For those saying,"OMG 9 lbs?!?!," C-section...
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Jason Jones, EMT-P

#11 SerendepitySaki

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Posted 11 June 2010 - 11:03 PM

that's a TEXAS baby for ya! if he's a true texan, he'll probably lose a pound when you circumcise him! CONGRATS CONGRATS CONGRATS!!!!!!!!!!!!!
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#12 JLP

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Posted 11 June 2010 - 11:04 PM

Now worries Sean. Just wanted to make sure you understood my rationale.

Teach me something here guys. Isn't manitol going to cause further interstitial and intravascular volume depletion (osmotic effect and then the kid just pees it out)? Would you just fix that with IVF replacement and pressors? The manitol is for cerebral edema and to improve our CPP right? I've seen it given for TBI, just not an infectious process. Who knows- he may be crumping with a slow bleed. Boy that would be a mess, cerebral HTN and dehydrated like a mutha.

Definitely agree with an olfactory assessment. Nasty urine, C-diff, another GI bug, ketones, toxins-almond, garlic, chemical order breath.

Seizures- hyponatremia?
Floppy hypoventilating kid-K or mag?

Jason any more neuro exam details (he responds to pain-what about Kernig's/Brudzinski, what does his retina look like?)

Ready for more details. Respondes a las preguntas por favor!


you are dead on about the mannitol, it is only going to make dehydration worse. the only reason I would use it would be if the boluses caused evidence of catastrophic cerebral edema, say in a long-duration DKA patient where cerebral osmolality was reeeealllllly high and the brain just sucked in any water going into the blood, or if the underlying event was cerebral edema that worsened with boluses. Not very likely, but I've heard of it - dehydrated ill kid gets boluses, one pupil goes huge and LOA goes in the crapper. Boy would that suck, DI due to high ICP and we diurese him? The devil and the deep blue sea, there. Hyponatremia is a good thought, would fit with fluid loss and free water replacement, would explain seizures and neuro def's.
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#13 SerendepitySaki

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Posted 11 June 2010 - 11:12 PM

gonna let you two gentlemen handle any late breaking developments.....just an hour working upper back, then another hour grilling assorted meats, listening to Mofro and chilling with my man Samuel Adams, now off for a concert with my little redheaded valkyrie.... got Mofro tix for July....new album release in August... farmer's market tomorrow and planetarium on sunday.....*sigh* i just doesn't get much better.... oh wait! it does... spending the rest of the weekend wrapping up another case study and some hemonc/tox stuff i was working on....life's too sweet.... CONGRATS AGAIN JASON!
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#14 TexRNmedic

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Posted 11 June 2010 - 11:26 PM

[quote]Update soon! At the hospital with the wife, kid, and new baby.

He's finally here!

Trystan Keith Jones
9 lbs, 5 oz.
20" long

For those saying,"OMG 9 lbs?!?!," C-section... [/quote]

Congrats man. That's great. I have another Texan on the way in about 6 weeks.

[quote name='JLP' date='11 June 2010 - 06:04 PM' timestamp='1276297454' post='22814']
you are dead on about the mannitol, it is only going to make dehydration worse. the only reason I would use it would be if the boluses caused evidence of catastrophic cerebral edema, say in a long-duration DKA patient where cerebral osmolality was reeeealllllly high and the brain just sucked in any water going into the blood, or if the underlying event was cerebral edema that worsened with boluses. Not very likely, but I've heard of it - dehydrated ill kid gets boluses, one pupil goes huge and LOA goes in the crapper. Boy would that suck, DI due to high ICP and we diurese him? The devil and the deep blue sea, there. Hyponatremia is a good thought, would fit with fluid loss and free water replacement, would explain seizures and neuro def's.
[/quote]

Ah...My ESP doesn't always work right and I wasn't sure if I was on the same page. Yeah, I'm sticking with dehydration and lytes as my pressing issue until I have more info. Fits with the presentation and critical illness. Could just be a poorly managed gastroenteritis gone way to far. Me thinks Jason will be busy with his little man for a day or two. Will have to wait and see.

[quote]gonna let you two gentlemen handle any late breaking developments.....just an hour working upper back, then another hour grilling assorted meats, listening to Mofro and chilling with my man Samuel Adams, now off for a concert with my little redheaded valkyrie.... got Mofro tix for July....new album release in August... farmer's market tomorrow and planetarium on sunday.....*sigh* i just doesn't get much better.... oh wait! it does... spending the rest of the weekend wrapping up another case study and some hemonc/tox stuff i was working on....life's too sweet.... CONGRATS AGAIN JASON![/quote]

About to fire up the grill myself Sean. If I ever get you out here to Texas I need get a Shiner in your hands. Similar to SA but TEXAN by way of Bavaria. Makes all the difference. Enjoy Mofro dude. Doubt they will head this far west anytime soon.
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Wes Seale
Houston , TX

#15 TexRNmedic

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Posted 11 June 2010 - 11:45 PM

Not a super pedi guru or anything, so I'll leave it up to those that are, but if the guy is pooping out volume faster than I can put it in, I'd be looking for Octreotide prior to lift off. I want to keep the fluids and lytes where they need to be. An hour is a long time to have a kid pooping all over the back of the aircraft (in a confined space at that), not to mention the decon. I can hear it now -out of service for decon. Blood or chemical? No sir, $#!t.
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Wes Seale
Houston , TX

#16 onearmwonder

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Posted 12 June 2010 - 12:28 AM

Why do we think this kid is having SLUDGE effects other than N/V/D? He actually seems to be having anti-muscarinic effects with tachycardia, miadrisis(sp?), and hot. Is the family into some holistic approach to what's causing his real issues with the seizures, rashes, altered LOC, and N/V/D? Scapalomine etc... for txs? Correct me if I am wrong...

Matt

Not a super pedi guru or anything, so I'll leave it up to those that are, but if the guy is pooping out volume faster than I can put it in, I'd be looking for Octreotide prior to lift off. I want to keep the fluids and lytes where they need to be. An hour is a long time to have a kid pooping all over the back of the aircraft (in a confined space at that), not to mention the decon. I can hear it now -out of service for decon. Blood or chemical? No sir, $#!t.


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#17 TexRNmedic

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Posted 12 June 2010 - 01:39 AM

Why do we think this kid is having SLUDGE effects other than N/V/D? He actually seems to be having anti-muscarinic effects with tachycardia, miadrisis(sp?), and hot. Is the family into some holistic approach to what's causing his real issues with the seizures, rashes, altered LOC, and N/V/D? Scapalomine etc... for txs? Correct me if I am wrong...

Matt


Great diff dx Matt.

To quote myself:

Nice mix of sympathomimetic and cholinergic sx....Atropine (double whammy, dries the kid up and pre-tx for vagal brady) and a little more benzo should be enough to pass a tube. While I'm in the airway, taking a look for signs of Strep (red swollen tonsils/airway plus sx:rash, fever, diarrhea, dehydration). Repeat v/s and waveform ETCO2. Pedi 12 lead ECG. This kid has been loosing fluids and electrolytes for days. I really need to get this kids lytes and start replacing F&E before taking an hour flight.


For those that don't already know SLUDGE
Salivation
Lacrimation
Urination
Defecation
Gastrointestinal Upset
Emesis

Which he has just about all of (cholinergic). However he also has tachycardia and mydriasis. Both sides of the equation, but the balance is currently tipping more toward cholinergic stimulation. Cholinergic tox is much more common than anticholinergic tox. Organophosphates, a funky mushroom, who knows? We've yet to hear if the skin is dry and hot or what the temp is. Anti-muscarinic meds wouldn't cause tachycardia by themselves. Anticholinergics are like taking the brake off. Something has to be pushing on the gas pedal too- catecholamine response to sepsis, hypoxemia or dehydration maybe. If he had been taking scopalamine he would probably present with dry mucous membranes, dialated pupils and probably urinary retention (retention not happening here). Just working out loud through the differential diagnoses while waiting for more information. The mydriasis may be reflecting a neuro issue and impact upon CNIII (hyponatremia induced cerebral edema). The petechiae may be from a strep or other infection, coagulapathy or maybe just because the kid has been heaving his guts up for several days.

The bigger threat right now is the seizures/ams, impending respiratory failure, dehydration and probable electrolyte dyscrasia.

:D
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Wes Seale
Houston , TX

#18 DartmouthDave

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Posted 12 June 2010 - 02:43 AM

Hello,

Well, peds isn't my strongest point. So, here goes....

I am leaning towards an infectious process because the patient has had a 3-4 day history of worsening symptoms as opposed to a toxidrome. Once we get an update with a temperature and appearance of the patient's skin.



"Neck – Red marks on neck, looks like a hand print" <--------< I am quite perplexed with this.

"Extremities – Small scratches on hands, dirty fingernails, otherwise unremarkable" <--------< Cat scratches? Toxoplamsosis??

Toxoplamsosis can cause seizures, rash, bloody eyes and of course alerted LOC and sepsis.

Still, a hard call with what we have. Supportive treatment for now. Flluids, abx, tube, benzos and a loading dose of Dilantin.

Cheers
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#19 jjones1418

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Posted 12 June 2010 - 02:48 AM

Just a few things we're going to clarify before I toss out the next update. Everyone's doing well here at the hospital. I'm on the laptop, but I don't really have an hour or so to go through all of the posts. Supposed to go home tomorrow, so we'll see.

1) Where do we stand on the airway management issue? What drugs do we want to use?

2) Anything in his physical exam that is jumping out at you? Dave, what are you thinking?

3) He's hispanic, no strange religious practices.
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Jason Jones, EMT-P

#20 jjones1418

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Posted 12 June 2010 - 03:01 AM

JLP, you also hit on the physical exam. What makes you think abuse / brain injury?
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Jason Jones, EMT-P