The other night while on ALS rotations I came across the following patient.

Dispatch info: Elderly Male AMS. Diabetic history.

On arrival find an 84 year old male sitting at table in no apparent distress. Wife states that he been sleeping a lot and just woke up after a 20 hour sleep. Patient is AxOx3 denies any pain or distress and states that his wife was nervous because he wasn’t answering properly. Glucose stick reads 119. Hx of HTN, NIDDM and Asthma.

Airway is patent, breathing is eupneic and color and temp are normal. Lungs reveal an end expiratory wheeze in upper left lobe and nearly absent lung sounds in all other fields. SpO2 is 79% on room air. EKG is NSR as is 12 lead. No edema noted.

Turns out patient is taking a strong narcotic based cough medicine for a persistent productive cough x 4 days, possibly the cause of his lethargy (the narcs that is).

My treatment plan was hi-con O2 and transport. (15 lpm had brought his sat up to 98%). My preceptor wanted to treat the wheeze with albuterol and ipratropium which I thought was unnecessary. She got her way and a treatment did nothing for his slight wheeze and sat was already at 98%.

A while later when I returned to the ER I confirmed that his CXR showed a bilateral pneumonia just as I had suspected.

Question; do we really need to treat every wheeze? If o2 corrected the saturation problem do we need to throw a drug in too?

You may have seen this already…funny but sadly all too true (sorry about the language)

Great page here

Our remake of an old mnemonic (Not performed in this order)

MOIST N DAMP

Morphine
Oxygen
Intubation
Sit-up
Twelve lead
Nitrates
Dangle legs
Ativan (lorazepam)
Monitor Q 3-5
Pulmonary Congestion (CPAP)

Your comments are welcome!

Updated in this post – See here http://www.rhmedicclass.com/index.php/12-lead-ekg-in-acs/

(From Tim Phalen’s lecture)

• LVH – Primary cause is HTN
  • increased QRS amplitude – variety of formulas exist – read the interpretation – machine does the math. (Or – look at v1 – from baseline to most negative deflection – count mm – then look at v5 and v6 and count the tallest. add depth of v1 to highest of v5 or v6 – if over 35 you have LVH (if under age 35 use 53mm)
• BBB – Primary cause is aging process
  • Widens the QRS complex – QRS Dur. >0.12 sec (120ms)
• Ventricular Rhythms including paced
  • Widens the QRS complex – QRS Dur. >0.12 sec (120ms)
• Benign Early Repolarization (BER)
  • ST elevations often in lateral leads and lead II
  • Tall peaked T waves – and tall QRS
  • Fishhook ST segment
  • Young healthy male (20-40 years, +African Americans)
  • does not typically produce reciprocal changes
• Pericarditis (epicardium may be inflamed too)
  • May be in all leads
  • May be in leads not grouped anatomically
  • sharp pain
  • localize with a finger
  • positional – prefer leaning forward
  • radiates to base of neck or shoulder blade
  • might hear friction rub on auscultation
  • does not typically produce reciprocal changes

March 29, 2009, Dr Cooper

Pediatric Circulatory Emergencies

PAT

Is he in shock? Volume or Cardiogenic, assess vitals, mentation, etc, (BP last indicator)

Peds, who present with dysrhythmias, present like they are in shock. They won’t tell you that they have palpitations, etc, do not presume that if a child is in shock you always give fluid…must rule out cardiogenic causes.

Shock- failure of circulation to meet the metabolic demands of the tissues (energy)

• Hypoperfusion – inability of circulation to deliver blood to tissues, results in hypoxia
• Hypotension – not enough pressure to deliver blood to core organs
• Compensated shock – inability to meet needs of peripheral tissues
• Decompensated shock – inability to meet metabolic demands of core organs
• Cardiopulmonary failure – moribund state resulting in from total respiratory and/or circulatory collapse

Preload – tension in ventricle wall at end diastole – corresponds with RAP/LAP (potential amount of force that can be generated by the ventricle based upon the amount of stretching by the muscle fibers – determined by end diastolic volume

Afterload- tension in ventricular wall at end systole (covaries with PVR peripheral vascular resistance) (pressure head against which the heart has to squeeze)

Contractility – force developed by the ventricular wall during systole

Pediatric Hemodynamic changes

• Blood Loss Heart rate immediately increases and only drops at around 45% loss
• BP maintains until about 30% loss and then drops severely (soft arteries can constrict much better than adults)
• CO starts dropping immediately and also drops severely of at 30% loss

Shock – A Hydraulic Solution

Pump Failure (cardiogenic)

• Electrical dysrhythmias (defib cardiovert)
• Mechanical – cardiomyopathy (inotrope, vasopressor)

Pipe Failure

• Distributive –(anaphylaxis, neurogenic – decreased vascular tone) (volume resuscitation MAST, Epi, contain the spread)
• Obstructive (Pneumothorax, Tamponade) (decompress tension pneumo)

Prime Failure

• Hypovolmic dehydration, hemorrhage, GI
• Dissociative –CO poisoning (o2 specific antidote)

Kids have proportionally larger blood volume but absolute volume is smaller

Softer more compliant vessels – capable of intense vasoconstriction

Smaller heart ventricles less compliant – less stretch per Starling’s Law – cannot really increase contractility – more dependent on rate to increase CO

Pulse higher than 150 – (5x age in years) is tachycardia, BP <70 +2 x age is lowest BP

Hypovolemic shock most common is peds, then septic, then cardiogenic

Hypovolemic – mostly dehydration, then hemorrhagic, GI

Septic –more common endotoxin vs extotoxin – (results in inability for cells to extract o2)

Cardiogenic – usually electrical (SVT VFIB)

Kids don’t usually get clammy unless cardiogenic, mottled in Hypovolemic

Simultaneous palpation of proximal and distal pulses (eg. femoral vs Pedal) big diff indicates compensated shock

Fluid Doses 20ml/kg of NS or LR – does it help? See study…Bottom line – maybe not be effective in short transport times. Focus on maintaining airway.

2 attempts or 90 sec, AC or saphenous at ankle. Then try IO. IO must be injected under pressure, gravity drip will not work

Pediatric Trauma

• Immature anatomy
• Different mechanisms
• Long term sequela
• Age specific equipment

• Larger heads, softer skulls – will fall head first, will decompensate quickly due to head trauma, soft tissue obstruction due to decrease tone leading to hypoxemia, ICP, cerebral edema,
• Proportionally smaller torso yet larger organs
• Impact – smaller total body mass
• More often hit by cars than unrestrained passengers (abdomen and L spine from improper seat belt position)
  • Waddell’s Triad
  • 1. Femur fracture
    2. Intra-abdominal or intrathoracic injury
    3. Head injury
• Falls from height
• Fall from bike – head – unhelmeted bike riders 2^nd leading cause of head injury death in US kids (#1 MVA)

Normoventilate(30) for resp failure, decomp shock, traumatic coma

Hyperventilate (35)– single dilated pupil, fixed dilated, apneic spells

SCIWORA Syndrome: (Spinal Cord Injury w/o Radiologic Abnormality)

Head Trauma – ….

Neck Trauma ……

Chest Trauma – soft bone structure –

Abdominal Trauma – upper organs are lower, lower organs are higher (liver not well protected), thinner walled, abdominal viscera less protected

MSK Trauma, lose less blood, growth plate involvement, incomplete fractures, vascular injury common

ABCDEF – Airway Breathing Circulation Disability (pupils and GCS), E exposure, (but keep warm) F (focused physical on stable patient)

El Physiocontrol Lifepak 12, así como muchos otros tipos de equipos médicos usados se pueden comprar en línea por mucho más barato que comprar nuevos.

3/25/09 Dr Cooper

Pediatric Airway Management

Bag and drag, get control of lungs and heart will follow – get control of airway and move

Start with PAT – Appearance – example, seesaw respirations – upper airway obstruction. Snoring; soft tissue, gurgling; secretions, stridor; croup FBAO, epiglottis. Hoarseness; laryngeal trauma

• Mandibular block, needs to be moved forward– use OPA or Jaw thrust
• Larynx, higher and more forward in the throat, airway is funnel shaped, particulate matter can get wedged below cords but above cricoid ring.
• Size of Infant airway= drinking straw. Adult=Garden hose

Management

• Non- rebreather
  Pulse Oximeter of 90-95%, GCS 14, AVPU of V , compensated shcok – SBP 70-90 + 2x age
• BVM, Spo2 <90%, SBP <70 + 2x age (decompensated shock), Traumatic Coma, AVPU P or U, GCS 8 or less – disable pop-off valve, watch the chest just rise,
  • Size the mask, completely cover nose and mouth, face mask cannot press against eye, causes profound vagal response in baby
  • EC Clamp
• OPA – teeth to angle of mandible
• NPA – nares to tip of earlobe
• Positioning
  • Medical – Sniffing plus
  • Trauma – Neutral airway position
  • Squeeze – relax, 20 times per minute
  • Do not hyperextend neck in either case
  • Infant – pad entire body (or use a backboard with a hole for head). Head is too high and padding aligns plane of face to be parallel with stretcher. Disproportion ends around 8 years of age. Older child may need a shoulder roll.
  • Steeles rule of three, spinal cord is only one third of spinal canal. Hard to add further injury as long as you keep some degree of caution, a little movement won’t injure,
  • May have to remove C collar in order to intubate

Technique for high pressure ventilation- Sniff plus, jaw thrust up into mask, two thumbs on side of mask

ETT – respiratory failure decompensated shock, traumatic coma

• Miller Blade to lift floppy epiglottis (less than 8 years)
• Uncuffed tube – allows for larger diameter tube, and cuff pressure may cause pressure on tracheal mucosa
• Pass tube just below where black mark disappears
• 4 Ps
  • Prepare – suction o2 scope and tube
  • Position patent and operator – eye level of airway –
  • Preoxygenate
  • Perform intubation _ don’t persist longer than you can hold your own breath
    • Smaller mouth, developing dentition, etc avoid levering, suction avoid prying
  • RSI where used – GCS 5-9
  • Confirm placement primarily and secondary (wave form capnography)
• Neonatal Intubation – very delicate maneuver
• DOPE for common ETT problems
  
  • Displacement – re-auscultate
    
  • Obstruction – suction
    
  • Pneumothorax – absent sounds on one side
  • Equipment failure –
  • Don’t screw around, bad tube – remove
• Nasogastric Intubation
  • Straight back into nares will follow curve of throat, measure from nares, around ears down to xyphoid process

ETT vs BVM – No significant mortality differences, true for medical and trauma patients.

BVM the single most important skill to master

(TUBE TOOLS – CD Rom)

The Physiocontrol Lifepak 12 as well as many other types of used medical equipment can be purchased online for much cheaper than buying new.

___________________

Respiratory Problems

• Respiratory distress – increased effort but enough to compensate for tissue hypoxia – due to mild hypoxemia (days)
• Respiratory failure increased or decreased effort not enough to compensate for tissue hypoxia – due to sever hypoxemia (hours)
• Respiratory arrest – if uncorrected leads to cardiopulmonary arrest (2 minutes)

• Upper airway obstruction – extrathoracic
• Lower airway disease – intrathoracic

Grunting = PEEPing

Peripheral mottling – circulatory problem; central mottling- respiratory problem

Sniffing and tripod – severe distress, head bobbing or grunting – respiratory failure

Oxyhemoglobin dissociation curve – kid won’t turn blue until o2 is dangerously low

Pediatric Respiratory volumes -Kids have smaller oxygen cushion than adults, will deteriorate more quickly. Higher o2 requiements

Upper Airway Obstructions

• Croup
• FBAO
• Bacterial Tracheitis
• Least common.epiglottitis rare due to vaccine

Lower Airway

• Asthma –reactive airway disease
• Bronchiolitis – caused by RSV
• Pneumonia – lung tissue disease
• FB – small FB lodged in lower airway – generally caused resorbtion atelectasis

Pediatric Airway Assessment – determine degree of problem – altered mental status very worrying sign, indicates respiratory failure – BVM – if the baby accepts the mask he needs the mask.

Treatment – o2 always primary – everything else is adjunct

Pediatric Assessment, Dr Cooper

3/23/09

See www.cpem.org

• Planning: Triage & transport – Needs vs. resources – enroute, review and plan
• Arrival: General Impression: Pediatric Assessment Triangle (PAT) – Hands off assessment – ABC Appearance, Work of Breathing, Circulation to skin
• Initial Assessment: Rapid cardiopulmonary assessment – Hands on
• Focused History: pertinent negatives, relevant findings

Pediatric Assessment Triangle

1. Appearance
   

• Alertness
• Distractibility
• Consolibility
• Eye contact
• Quality of cry
• Spontaneous movement
• (All critical to whether brain is perfused properly)

   

1. Work of Breathing
   

• Chest rise
• Rocking motions
• Retractions
• Nasal flailing
• Head bobbing
• Grunting
• Snoring
• Stridor

(C)Circulation

• Pallor
• Mottled
• Blue
• Grey

Initial Assessment: Rapid cardiopulmonary assessment – Hands on

• Airway –clear? Maintainable?, stable?
• Breathing – ventilation, oxygenating, stable? In peds rates and effort are not necessarily related like adults, effort much more important!
• Circulation: Shock? Cardiogenic?, stable? Shock: inability of blood to meet metabolic needs of the tissues- Mental status, pulse rate and character; distal vs. proximal, skin color, BP. Cardiogenic shock: Dysrhythmias, other , compensated, decompensated, cardiopulmonary failure (cardiogenic shock not initially treated with fluid)

Focused History: pertinent negatives, relevant findings

Why peds don’t have heart attacks: no CAD, atherosclerosis, etc –congenital heart diseases are rare. Adults drop dead, kids droop dead (secondary to respiratory arrest, etc)

Anatomic & Physiologic differences

Child airway – funnel shaped, narrowest part is at crichoid ring- adult s cylinder, narrowest at glottis

• Small jaw, large tongue, prone t soft tissue obstruction – reposition
• Immature immune system. lack of specific antibodies, protective mucus layer
• Infants are nasal breathers, keep clear
• Floppy omega shaped epiglottis
• Narrow subglottic area

Remember if suspected C spine injury, stabilize c spine before/while maintaining airway

Breathing anatomy

• Adult – diagonal ribs, stiff cartilage, stronger muscles
• Ped – horizontal ribs, soft cartilage, weaker muscles – diaphragmatic breathers, much less alveoli – faster o2 depletion. Susceptible to barotraumas, high risk of Pneumothorax, bag until chest rise, no more. (head bobbing grunting – near end resp failure)young tissue – high elastin content– shift mediastinum -easily

Breathing assessment requires an open Airway! – ASSESS A, THEN FIX A! THEN GO ON TO B!

• Is ventilation adequate – inspect chest rise – capability    
• Auscultation – air entry
• (Missed slide)

Always consider hypoxia first as cause for AMS

• Auscultate in armpits, small chest, sounds travel
• ETT only of BVM ineffective
• Consider NG/OG if abdominal distention

Circulation

• Adults, big hearts large chambers and thin walls, Starlings Law (like a spring, recoil helps CO)
• peds – small chambers thick walls – can’t vary CO well with heart walls, CO depends only on HR
• Adults – stiff vessels – vigorous response to hypovolemia and hypothermia
• Peds – soft vessels – more compliant vessels
• Smaller blood volume, lose lager percentage compared to adult
• Smaller fat mass – larger relative blood volume

Bleeding control – direct pressure – retain systemic o2

Shock assessment – cause assessment – cardiogenic etc – Simultaneous palpation of central and peripheral pulses – strong central weak peripheral – compensated – everything weak; decompensated shock

• Tachycardia = 150 – 5x age in year
• Kids get mottled – not clammy
• Cap refill – use warm extremities
• Minimum systolic BP: 80 + 2x age

Adrenaline makes you stupid – use a Broselow Tape

Random topics of interest, not in lectures yet

1/11/09

• ACE inhibitor (ACEI) blocks conversion of angiotensin I to angiotensin 2 – results in lowering of BP, used to treat HTN & CHF.
  (Mechanism of Action: inhibits angiotensin converting enzyme, interfering w/ conversion of angiotensin I to angiotensin II) RAAS
• Vasopressin
• Calcium Channel Blocker (CCB) Most calcium channel blockers decrease the force of contraction of the myocardium (muscle of the heart). This is known as the negative inotropic effect of calcium channel blockers.
• Pituitary
• Krebs cycle
• Diuretic
• Fremitus
• Uremia
  is a term used to loosely describe the illness accompanying kidney failure (also called renal failure), in particular the nitrogenous waste products associated with the failure of this organ.

  In kidney failure, urea and other waste products, which are normally excreted into the urine, are retained in the blood. Early symptoms include anorexia and lethargy, and late symptoms can include decreased mental acuity and coma. It is usually diagnosed in kidney dialysis patients when the glomerular filtration rate, a measure of kidney function, is below 50% of normal.^[2]

• Tetany – is a medical sign, the involuntary contraction of muscles, caused by diseases and other conditions that increase the action potential frequency. The muscle cramps caused by the disease tetanus are not classified as tetany; rather, they are due to a blocking of the inhibition to the neurons that supply muscles.
• Motor_end_plate
• Cushing’s Triad
• Pnuemonia
• Pulmonary embolism (PE)