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#56 Carpe Diem!


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#21 SerendepitySaki

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Posted 20 June 2012 - 05:12 PM

so, not to waste anyone's excellent differentials and txs, but i intended this as a classic hyponatremia, secondary to inappropriate dilution of ready to feed formula...

sue, stemtp, onearm, wes, brian.... GREAT stuff.....thanks for playing! .... humbled and honored by your contributions....

TAKE HOMES:

UNRELATED: please don't lose track of the iStat pearls i posted

RELATED:

periorbital edema is often found in hypervolemic hyponatremia in neonates...

i originally wrote it a while back for a neonatal forum to emphasize holistic managment, pyschosocial barriers to care and potential discharge issues.... hence, the non-english speaking FIRST-time mother with limited support network....

i ALSO wrote it to emphasize a low volume/high technical skill set.... to get people to dive into the books and their own organizational policies and procedures.... (now, if i could just get EVERYone to do the same with presumptive hypomagnesemia!)

EXCELLENT point by Wes w/ regards to ongoing nutritional needs... (IV dextrose)....(also need to think about heat loss...those two always biggees w/ neonatal CCT)

as Brian clearly and concisely mentioned (before i could post the reference link i was holding in reserve to make JUST those points)

1. we don't necessarily care about differential dx,

2. correction of acute hyponatremia occurs in stages, dictated by patient presentation...

3. Central Pontine Myelinolysis (CPM) is a very real and lasting SEVERE neurologically devastating consequence of inappropriately rapid Na+ replacement... this is a low volume/high technical skill that you only get one chance to get it right... know before you go and approach with due caution...

mildly fragged, so might be overlooking something, but i think that's everything i wanted to bring out... anyone else?





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

#22 onearmwonder

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Posted 21 June 2012 - 01:59 AM

Thanks Sean... Nice refresher...

Matt
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#23 bushmed

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Posted 25 October 2012 - 03:05 PM

I like Sue's tx so far.

To recap plus my $0.02

O2 by infant BVM. Broslow tape out.
Keep the kiddo euthermic.
Monitor- ECG, SPO2, NIBP, ETCO2
Vascular access. PIV if quick. I prefer an Illinois bone needle IO for kiddo this size and age. BGL and iSTAT CG8 (this is what I would usually have immediately available). VBG and lactate if available at the sending facility quickly.
Accurate patient weight and since it is probably available, patient's discharge weight.
Benzos- ativan 0.1mg/kg first dose, 0.05mg/kg additional doses- caution if benzyl alcohol but we are about to intubate.
Atropine and fentanyl. ETT per Broslow.
Based on presentation (color, mottling, vital signs) consider IVF bolus.
Reassess interventions to this point.
H&P- Fontanels, description of seizure activity, head to toe exam looking for infected scalp monitor site, umbilicus, rash, or trauma. Abdomen assessment, especially liver palpation.
PO intake history, diaper count and stool consistency.
MOM'S GBS STATUS AND ANY TREATMENT?!!!!!!
If I am really feeling frisky- pre and post ductal SPO2. May play with the Sonosite in a bit if something raises my CV suspicion.
Phone call to the attending back home regarding anticonvulsants and abx tx.
Another reassessment to this point, vital signs and start packing for the road.
DDX- Meningitis/sepsis with GBS high on the list. Atypical cardiac presentation. Some sort of congenital neurological disorder/ malformation or metabolic disorder. Trauma. Toxic exposure.

Transfer modality and travel time to tertiary care? That should get a pretty good start at stabilizing.



How would you differentiate between a TET and VSD with pulmonary hypertension using the sonosite?
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#24 SerendepitySaki

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Posted 25 October 2012 - 04:34 PM

i'll see if i can find some echoes, etc... and show you... in the mean time, what are YOUR thoughts?
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup

#25 MSDeltaFlt

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Posted 25 November 2012 - 02:21 AM

I like Sue's tx so far.

To recap plus my $0.02

O2 by infant BVM. Broslow tape out.
Keep the kiddo euthermic.
Monitor- ECG, SPO2, NIBP, ETCO2
Vascular access. PIV if quick. I prefer an Illinois bone needle IO for kiddo this size and age. BGL and iSTAT CG8 (this is what I would usually have immediately available). VBG and lactate if available at the sending facility quickly.
Accurate patient weight and since it is probably available, patient's discharge weight.
Benzos- ativan 0.1mg/kg first dose, 0.05mg/kg additional doses- caution if benzyl alcohol but we are about to intubate.
Atropine and fentanyl. ETT per Broslow.
Based on presentation (color, mottling, vital signs) consider IVF bolus.
Reassess interventions to this point.
H&P- Fontanels, description of seizure activity, head to toe exam looking for infected scalp monitor site, umbilicus, rash, or trauma. Abdomen assessment, especially liver palpation.
PO intake history, diaper count and stool consistency.
MOM'S GBS STATUS AND ANY TREATMENT?!!!!!!
If I am really feeling frisky- pre and post ductal SPO2. May play with the Sonosite in a bit if something raises my CV suspicion.
Phone call to the attending back home regarding anticonvulsants and abx tx.
Another reassessment to this point, vital signs and start packing for the road.
DDX- Meningitis/sepsis with GBS high on the list. Atypical cardiac presentation. Some sort of congenital neurological disorder/ malformation or metabolic disorder. Trauma. Toxic exposure.

Transfer modality and travel time to tertiary care? That should get a pretty good start at stabilizing.


I also like this. One thing I would add here is another option on benzo admin route if IV/IO access is proving difficult while seizing, and that is IN benzos. Vascular access is a hell of a lot easier when yohr pt isn't trying to bounce off the bed.
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#26 SerendepitySaki

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Posted 26 November 2012 - 02:21 PM

absolutely! if available, great alternative... in terms of teaching a man to fish... here's a link for y'all... have provided before, but things get lost in the sands of time... good reminder.... thanks mike!

http://intranasal.net/SeizureRx/
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LET THE WILD RUMPUS BEGIN !!!!!!
Sean G. Smith, RN-Alphabet Soup