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#53 - Assumptions Do One Thing...


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#41 BrianACNP

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Posted 13 June 2010 - 01:40 AM

not going there tiger... even though my background IS research molecular biology, with an emphasis on immunology.... suffice to say i don't agree with Brian 110% and would love to see specific definitive references.....i agree with MOST of Brian's points right down the line, (especially the PRIMARY reason for giving steroids in sepsis and that dex is NOT the agent of choice) others, not so much.... no time to look it up myself AND we're coming at it from slightly different angles to begin with....

my ENTIRE point was that empiric dex probably would not hurt anything, but that it was not high upon the "to-do" list....
poor Dave muddled things by first lumping CNS and Sepsis together, then separating them....we've sidebarred this more than long enough...my apologies to Jason and CONGRATS again on the beautiful boy!


Hey...I didn't start this part of the thread....Just responding for those reading these posts...I'm just clarifying statements that were made related to steriods in sepsis for suppression of inflammation.

There is no doubt that steriods can provide anti-inflammatory effects in certain disease processes...for example, Asthma and COPD. Regarding sepsis, the literature is quite evident that steriod use is indicated for replacement in the suspected or proven adrenally insufficient patient, which is primarily indicated setting of septic shock/refractory hypotension....it's the only indication in the setting of sepsis. With the overwhelming SIRS response, there is no way anyone will suppress the inflammatory response with steriods unless a big enugh dose is given that will unfortunately suppress the immune system and potentially kill the patient. This was recognized long before I was born. I've personally never read any literature that supports administration of corticosteriods for its anti-inflammatory effects in the setting of sepsis...and it's not routine clinical practice....at least where my NP experience is in both NC (CLT and Greenville) and Philadelphia at PENN.

Tex...you're right.....APC is the primary drug used for its anti-inflammatory effects as well as its other effects on coagulation, etc...Again, not a standard drug to give for all septic patients...very specific criteria for its use (ie: 2 or more organ system failures, APACHE score > 25, etc). But I've seen dramatic clinical improvement with its use.

Brian
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#42 DartmouthDave

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Posted 13 June 2010 - 05:19 AM

Hello,

Sorry. When I wrote CNS-Sepsis I meant an infection of the CNS. Meningitis, toxo, et al.....

In these cases from what I have seen and read Dexamethsone can help. How this works was present by BrainACNP.

Looking back at my post I can see how things got muddled somewhat between the adrenal suppression and sepsis management (Hydrocotisone ect...) and preventing long term CNS dysfunction (Dexamethsone).

Still, all in all, a good discussion thus far.

Waiting for an update.


Cheers
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#43 SerendepitySaki

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Posted 13 June 2010 - 05:36 AM

Dave, actually, it works via an ENTIRELY different mechanism than what brianACNP described as efficacious in SIRS (vs meningitis).... something to think about tho....file under a-ha! NOW we're getting somewhere..... why might it work effectively one way in meningitis and yet, that mechanism is arguably not clinically significant in SIRS?

again, this is not the place to continue that conversation...feel free to PM me (or brianACNP) or to start a new thread.

Hello,

Sorry. When I wrote CNS-Sepsis I meant an infection of the CNS. Meningitis, toxo, et al.....

In these cases from what I have seen and read Dexamethsone can help. How this works was present by BrainACNP.

Looking back at my post I can see how things got muddled somewhat between the adrenal suppression and sepsis management (Hydrocotisone ect...) and preventing long term CNS dysfunction (Dexamethsone).

Still, all in all, a good discussion thus far.

Waiting for an update.


Cheers


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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#44 SerendepitySaki

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Posted 13 June 2010 - 05:44 AM

here's a nice pediatric sepsis reference from 2009:

http://emedicine.med...72559-treatment

This kid may not even be septic. Just part of the the work-up, diff dx and early EBM, goal directed therapy. This article is good backpocket info.
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#45 jjones1418

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Posted 13 June 2010 - 06:12 AM

So now you decide to intubate your kid. You give the appropriate drugs, and he’s intubated with a cuffed ETT without difficulty. You’re able to quickly establish a 2nd PIV, and you’re maintaining an appropriate EtCO2 with BVM ventilations at the moment. You’ve got whatever sedative you want to give him, so you sedate him after the intubation.


His Vitals Are:

BP – 98/60
P – 146
R – 16 via BVM
SpO2 – 99%
EtCO2 – 34 mmHg
GCS – 3 (Sedated and Intubated)


While you’re getting him secured to your sled/flat/stretcher or whatever you have, you are met by a pissed off police officer who demands that you wait while he takes pictures of the “injuries.” He’s got another police officer friend arresting the father. He says that child abuse is NOT tolerated in his town. The nurse is agreeing with the police officer, and says, “That’s what I thought when they brought him in!”

What now?
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Jason Jones, EMT-P

#46 SerendepitySaki

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Posted 13 June 2010 - 06:19 AM

bwahahhahahha........ not going there.... i derailed the thread for an entire page the last time i opened MY mouth....B) kid keeping you up or are you at work? all the best, either way.....thanks again for a great case, especially with all you've got going on.....
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#47 jjones1418

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Posted 13 June 2010 - 06:28 AM

Ah hell, forgot this.

Oh, and that iStat finally warmed up and actually have an arterial sample from JUST prior to intubation.

Na – 135
K – 2.9
iCa – 1.08
Glu – 110

Hgb – 13.1
Hct – 34.3

pH – 7.22
pCO2 – 44
pO2 – 124
HCO3 – 16
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Jason Jones, EMT-P

#48 jjones1418

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Posted 13 June 2010 - 06:31 AM

And the kid has me up. I'm at the hospital still. Bilirubin was high, so he's sun-bathing for another day.
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Jason Jones, EMT-P

#49 SerendepitySaki

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Posted 13 June 2010 - 06:34 AM

best of luck man....will keep you and trystan and the missus in my thoughts.....
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#50 jjones1418

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Posted 13 June 2010 - 06:37 AM

Thanks!
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Jason Jones, EMT-P

#51 redlingc

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Posted 13 June 2010 - 07:46 AM

OK, so now that Johnny Law is on the scene... I would advise him that the kid does not have the time to sit around for a photo shoot at the moment and he can walk and take pics as we are loading him if he wants or that he is more than welcome to meet up at the recieving facility, but before pissing him off I would ask what kind of info he has about the abuse.

As far as my pt management at this point, I would keep him sedated versed/fentanyl combo and give him another bolus of 20 ml/kg. The kiddo is pretty hypokalemic so he needs some K to hopefully prevent any arrythmias on the way. None of the flight programs around me have K so hopefully they can just pull it out of the ER meds and not have to wait for them to have someone mix it up and go find it and get that started before we totally bug out, might even help Johnny out. That's about the extent of what I can figure out at the moment... Let's load him up and get on the way.
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#52 BrianACNP

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Posted 13 June 2010 - 09:58 AM

Dave, actually, it works via an ENTIRELY different mechanism than what brianACNP described as efficacious in SIRS (vs meningitis).... something to think about tho....file under a-ha! NOW we're getting somewhere..... why might it work effectively one way in meningitis and yet, that mechanism is arguably not clinically significant in SIRS?

again, this is not the place to continue that conversation...feel free to PM me (or brianACNP) or to start a new thread.


Again, just clarifying what was stated referencing SIRS/Sepsis and use of corticosteriods for those reading these posts....no indication from my standpoint for PM or new thread.

Brian
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#53 buffettrn

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Posted 13 June 2010 - 12:55 PM

I am thinking that the neck and hands is looking like abuse. The pettichial (sic) hemmorages strangulation. Hypoxia could lead us to the cerebral edema causing our decreased LOC and dilated pupils. I think that despite the dehydration mannital may still be a good idea to reduce my assumed cerebral edema. You can reduce the edema but continue to give fluids to maintain fluid balance. The mannital will reduce the intracellular fluid more than the intravascular and will temporarily increase your intavascualar volume. Secure the airway. Secure several lines. Consider a dilantin load for the seizure and I would look at cerebral cooling until we can get to a real medical facility. Antibiotics are a good idea but would culture blood and urine first. Just love scene calls with walls.
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#54 TexRNmedic

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Posted 13 June 2010 - 10:00 PM

Ah hell, forgot this.

Oh, and that iStat finally warmed up and actually have an arterial sample from JUST prior to intubation.

Na – 135
K – 2.9
iCa – 1.08
Glu – 110

Hgb – 13.1
Hct – 34.3

pH – 7.22
pCO2 – 44
pO2 – 124
HCO3 – 16



Our acidosis looks more metabolic in origin. Lytes are waaaaay better than expected. I had a young lady (5 year old) with a 1.2K the other day and she looked way better than this kid. Makes me think something is going on besides a head injury. I'll take the popo's business card and will have the LEOs on the other get ahold of him for photos. I'm sure they will have plenty of experience documenting suspected abuse. Secure tubes and lines, grab a couple 10 meq KCl bags and get on the way. Doesn't look like we have much more we can fix on the ground. In case I missed it, any allergies (El chico tiene alergias)?
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Wes Seale
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#55 jjones1418

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Posted 13 June 2010 - 10:51 PM

Our acidosis looks more metabolic in origin. Doesn't look like we have much more we can fix on the ground.


This is the point I was trying to make, along with the whole "assumption" thing. Sometimes you DON'T get the info you want, need, or must have. Sometimes you fly into these hospitals and it's like running a scene flight with a BLS ambulance crew. They don't have much done, but they damn sure do everything they can. Sometimes recognizing that the patient is NOT having his or her needs met at the current location is the best assessment the practitioner can do. (No offense, just saying that all hospitals aren't as capable as Parkland or John Peter Smith)

The point is to do what you can with the limited info, secure the ABCs, and beat feet to the specialty hospital.


Now, the real story about this patient.

All of the information I gave you was what we had. The only "lab" we had was an ABG that was something close to what I gave you. We didn't have the whole iStat cartridge. The lytes were a bad attempt at coming up with some "borderline" labs that I was told the patient had at the receiving hospital. We flipped him and checked him really quick and saw red marks on his back as well. We secured his C-spine then put the patient down with Lidocaine, Atropine, Fentanyl, and Etomidate & intubated him easily. The patient's copious secretions were suctioned. He also had some white-tinged dried saliva on his mouth. We had the police officer snap pictures quickly and were out the door. It looked like an abuse case to us as well. In flight, he was sedated with one dose of versed and didn't require any other sedation for the remainder of the flight. His vitals were unchanged for the most part, except that he didn't have a respiratory effort at all on arrival at the receiving facility.

He died 8 hours after admission at the tertiary care facility.

We heard from the facility that the mother arrived and said that the marks on his neck were from her holding him to try and stop him from seizing. She said that him hitting the posts on his bed from seizing so hard was what alerted her to his seizure, hence the red marks on his back. She said that she didn't know what happened to him. This flight was done in early May, when everyone was just starting to go outside and play more. The little scratches on his hands turned out to be some type of bite mark. He was diagnosed, post-mortem of course, with rabies.

We assumed from the get go that the patient had been abused, and to say that it didn't affect me is a lie. I don't think my care would have changed, but I can guarantee I would have been more compassionate to the family about their sick child. The impending birth of a child of my own this past week made me think about this case, so I wanted to share it. Hope everyone learned something, because I learned SO much from this. You have to assess the patient, take the WHOLE picture into consideration. One red mark, one hand print, one assumption can throw off your treatment!
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Jason Jones, EMT-P

#56 SerendepitySaki

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Posted 13 June 2010 - 11:08 PM

thanks again for a great case, Jason, especially with all you have going on.... hope trystan's bili is doing better!

This is the point I was trying to make, along with the whole "assumption" thing. Sometimes you DON'T get the info you want, need, or must have. Sometimes you fly into these hospitals and it's like running a scene flight with a BLS ambulance crew. They don't have much done, but they damn sure do everything they can. Sometimes recognizing that the patient is NOT having his or her needs met at the current location is the best assessment the practitioner can do. (No offense, just saying that all hospitals aren't as capable as Parkland or John Peter Smith)

The point is to do what you can with the limited info, secure the ABCs, and beat feet to the specialty hospital.


Now, the real story about this patient.

All of the information I gave you was what we had. The only "lab" we had was an ABG that was something close to what I gave you. We didn't have the whole iStat cartridge. The lytes were a bad attempt at coming up with some "borderline" labs that I was told the patient had at the receiving hospital. We flipped him and checked him really quick and saw red marks on his back as well. We secured his C-spine then put the patient down with Lidocaine, Atropine, Fentanyl, and Etomidate & intubated him easily. The patient's copious secretions were suctioned. He also had some white-tinged dried saliva on his mouth. We had the police officer snap pictures quickly and were out the door. It looked like an abuse case to us as well. In flight, he was sedated with one dose of versed and didn't require any other sedation for the remainder of the flight. His vitals were unchanged for the most part, except that he didn't have a respiratory effort at all on arrival at the receiving facility.

He died 8 hours after admission at the tertiary care facility.

We heard from the facility that the mother arrived and said that the marks on his neck were from her holding him to try and stop him from seizing. She said that him hitting the posts on his bed from seizing so hard was what alerted her to his seizure, hence the red marks on his back. She said that she didn't know what happened to him. This flight was done in early May, when everyone was just starting to go outside and play more. The little scratches on his hands turned out to be some type of bite mark. He was diagnosed, post-mortem of course, with rabies.

We assumed from the get go that the patient had been abused, and to say that it didn't affect me is a lie. I don't think my care would have changed, but I can guarantee I would have been more compassionate to the family about their sick child. The impending birth of a child of my own this past week made me think about this case, so I wanted to share it. Hope everyone learned something, because I learned SO much from this. You have to assess the patient, take the WHOLE picture into consideration. One red mark, one hand print, one assumption can throw off your treatment!


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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#57 SerendepitySaki

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Posted 13 June 2010 - 11:10 PM

FYI: FWIW... would be more than delighted to "cook up" labs and physical exam for anyone with a story tell, but that might be holding back because they feel they are lacking details, or don't have the time to put into it....PLEASE do NOT hesitate to contact me me off-line....let's keep these case studies rolling people... you've all got a LOT to share and we've ALL got a lot to learn.....
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#58 jjones1418

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Posted 13 June 2010 - 11:16 PM

We're home today. Doing phototherapy at home. Have a re-draw on labs tomorrow. We'll see. He's not looking like a banana anymore.
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Jason Jones, EMT-P

#59 SerendepitySaki

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Posted 13 June 2010 - 11:44 PM

glad to hear it man.... glad to hear it!
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LET THE WILD RUMPUS BEGIN !!!!!!
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#60 DartmouthDave

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Posted 14 June 2010 - 12:42 AM

Hello,

Thank you for an excellent case study. A nice way to learn new stuff.

Rabies. Interesting. I am going to have to look it up. I am not too ashamed to say that I don't know anything about it. I was thinking along the lines of T.O.R.C.H as a casue.

Once again...thank you

Cheers
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