with Maybelle Kou, Inova Fairfax, on the Hot Seat
The Case
PMH: RAD as above
IMM: UTD
NKDA
VS: T 37.3 HR 154 RR 62 Sat 98% ORA
Gen: awake, alert, but fussy
Skin: No rash
HEENT: EOMI, PERRL, bilateral upper eyelids mildly swollen, conjunctivae clear
Resp: tachypneic, with belly breathing, suprasternal and subcostal retractions, diminished at bilateral bases without crackles, +very mild intermittent scattered expiratory wheezes
CV: tachycardic, regular rhythm, no murmur, femoral pulses present x 2
Abdomen: soft, non-tender, non-distended, with no organomegaly
GU: Normal female anatomy
MSK: moves all extremities, no edema
Neuro: Grossly normal for age
You prepare to give a respiratory treatment.
Questions for you:
The patient received albuterol 2.5 mg nebulization treatment and did not improve. On re-evaluation, she appears tired, pale, and less interactive. You note that she is very tachypneic with unchanged respiratory distress. Extremities are cool. You order an EKG, x-ray, and place a call to cardiology. Cardiology is stuck in the CICU planning to place a different patient on ECMO and will evaluate your patient as soon as possible. The x-ray is shown below.
Her new vital signs are: RR 70 | HR 175 | BP 72/40 | 94% on room air.
You are planning to arrange ICU admission and establish IV access.
How would you approach this case? Please share your opinions by clicking on "comments" below. It is easiest if you're also logged into your gmail account but you can do it without as well. Just select "Name/URL" from the drop down menu, write your name, and click submit. You can also post anonymously although this seems less fun. To read posted comments, click on "comments" below and scroll up.
Come back later for the denouement of this case
About the Hot Seat. Hot Seat cases are written by PEM fellows at Children's National, Inova Fairfax, and Johns Hopkins. The Hot Seat Attending is a selected faculty member who comments on the case without knowing the outcome. Emily Willner is the faculty mentor for the series.
I like to have a "now" solution and a "next steps" solution. Always good to plan for progression of events. I would assume this kid is going to crump in the next 15 minutes and need to be crashed on ECMO so best to plan accordingly for both phases.
ReplyDeletefor NOW decision...........I want to know if the patient is hypotensive and tachycardic because of restricted cardiac output (pericardial effusion) or diminished cardiac function (myocarditis/cardiomyopathy). A bedside ultrasound is very helpful here. in the meantime, NRB O2 and good access is a must. Re-evaluating perfusion is a must for deciding inotropes....need a better sense of central vs. peripheral perfusion. And a little fluid (5-10ml/kg) is important to fill the tank.
If this is all pericarditis, then you can try to decrease afterload while preparing the child for a pericardial tap/drain. Intubating these kids is bad news because you'll drop the preload amidst tamponade physiology. So i'd have dopamine and a big needle on hand while waiting for a CICU bed/eval.
If this is function (myocarditis/cardiomyopathy), then there are fewer life-saving interventions we have as ED docs before the kid crashes. These are the PEM-docs worst nightmares. Inotropic combos like epinephrine/milrinone or epi/dopa are good.....so is good ol' dobutamine. But these are all arrhythmogenic and risky. I would alert the CICU attending that this child is a potential ECMO candidate and the child needs to get out of your ED in case ECMO is a potential next step. All teams should be ready if the child fails initial attempts at inotropes to improve function/perfusion/BP. If intubation is attempted, i'd have all hands on deck assuming the child will bottom-out and crash. And I wouldn't attempt intubation unless I had central access either with a femoral line or IO.
So I guess that means:
put in code room, O2, IO/CVL, get backboard, pull inotropes, have airway equipment and pericardial needle ready, bedside US, and get the patient to a definitive place where ECMO is a possibility if your inotropes (+/- pericardiocentesis) fail.
and then get a chloraprep and erase the words "I'm not sick from his forehead"
Agree with Dave (does he carry a hotseat-bat-phone on him at all times?).
ReplyDeleteBig red flag on wheezer that this isn't asthma is puffiness/edema. But given the damage is done with the albuterol, what next? (Ant-albuterol?. Flumalbuteril? Both not in the Pyxis) Definitely call cardiology back and have them get a bed ready for this kid. In the meantime, since this kid is actually at UMC and it's snow-mageddon:
In crisis room: Put O2 NRB mask on, defib pads on, sit child up in bed if tolerating, and re-vitalize - get line and labs/gas (incl BNP), if hypotensive, do mini (5-10 ml/kg) bolus while thinking:
Figure out quickly if this kid is warm or cold, wet or dry.
Exam didn't tell us about warmth/perfusion/cap-refill initially, but second exam said he's "cold" (other cold signs in general are AMS, narrow pulse pressure, thready pulses). Next, is he wet? - yes (wet signs in general are: edema, crackles, wheezing, cxr pulm edema seen in him I believe with vessel fullness beyond the 2/3 mark laterally, elevated JVP, HSM).
Cold (poor perfusion) and wet (increased filling pressures) - which to fix first or fix them both simultaneously? The expression I was taught was "warm them up (improve cardiac output with milrinone as an inotrope/vasodilator) then dry them out (with lasix)." But this kid is circling the drain, will certainly die if you do nothing, and if you haven't heard from cardiology, it's time to get aggressive so you'll probably do both at once.
Then here is where an external brain (table/guideline/dosing-chart) is worth a thousand words - we had an awesome acute heart failure guideline at Texas Children's and I'm going to try to attach but might need Sonny's help....
Hot seat attending:
ReplyDeletePART one (as evidently I have too much to say).
Wow, Paul and David, you guys are always here first: you must spend all day on the computer.
Since the audience has probably read their responses already let me add a few more things to think about.
Can you imagine a novice level history being given to you here?
My recent enlightenment exercise is to encourage all medical trainees to paint a descriptive picture of the patient; not just a succinct history that includes pertinent positives and negative ROS, but also to communicate a good visual. All folks in an ED should know from the doorway if the child is sick or not sick. Give your trainee this expectation and hopefully it will pay forward and get you into the patient’s room before they crash. Documentation also should contain pertinent negatives. AND DO NOT COMMIT THE ED SIN OF PREMATURE CLOSURE.
Luckily we have direct bedding otherwise I would be concerned that in the middle of cough and cold season, this little one would sit out front for a bit, especially if the child were still bundled up in multiple layers of clothes. As I try to remind trainees as they go into the umpteenth patient with a cough: don’t miss myocarditis in a sea of bronchiolitis. But I can also extrapolate (having trained in general emergency medicine) as to my suspicions of this not being primarily a respiratory illness: decreased urine output, respiratory distress in the setting of swollen eyes could also point to a cardiac or renal process.
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ReplyDeleteHot seat attending part 2:
ReplyDeleteMissing details from THE CASE:
1. Blood pressure. I know. It is not a favourite vital sign to obtain. Most screaming children will have one, but for the puffy, fussy toddler with a dry diaper...I want it and I want it now.
2. Skin: Turgor/Cap refill? Can assess in seconds, easy test to do. TOUCH the patient. Are they cool and clammy? Children need to be undressed.
3. Cardiac exam: FEEL for thrills or heaving. Listen for gallops or rubs (not mentioned here but in the spirit of what seems to be a sick kid with resp distress….)
3. Neuro: “grossly normal for age”. Sounds like an EMR clickbox. Again, I encourage learners to describe the passive neuro exam. If the child is sitting limply in mom’s lap breathing at 62 (vs fighting every device known to man while sucking voraciously on a pacifier,) there is a problem.
Initial assessment: Respiratory distress with VS concerning me for imminent respiratory failure BUT WITHOUT A BLOOD PRESSURE I CAN’T SAY DEFINITIVELY THEY ARE IN SHOCK.
DDX: Bronchiolitis, pneumonia, cardiac: myocarditis with or without effusion, unknown CHD, renal disease, sepsis, hypothyroidism.
Management: Move ASAP to a resuscitation room, just in case.
A: Consider hi-flow nasal cannula to titrate for sats above 95%. Consider Bi-Pap if you have it.
B: One can attempt a breathing treatment here (as is done with many adults with “cardiogenic” asthma) but one needs to be wary of the sympathomimetic effects that can occur. More strain, less gain. (While we’re in the RAD territory, in a child with steroid dependent asthma, one could argue that the reason to give a steroid here is more for stress dosing although I am sure this might be controversial).
C: Establish IV access: i-stat lytes (glucose and potassium), as well as VBG. IO if you can’t get venous. TSH and free T4 as well as cardiac panel including troponin.
Fluids: controversial if you suspect congestive heart failure but if the patient is in shock, treat with a 5-10 cc/kg bolus.
Bedside ultrasound to assess size, ventricular function and rule out effusion and tamponade. EKG to rule out ischemic changes.
When the XR comes back (if you are not blessed with an ultrasound) with a heart the size of a football, confirming your suspicion of cardiogenic shock, I hope you have already called your PICU team/prepared transport.
Pressor considerations:
Depends on what you have at your place. If you are in a community ED and need to transfer, remember dobutamine is not a bad choice and readily available unless pt is crashing and you need EPI. Don’t be afraid to IO but do use local anesthetic if possible. As Paul and David mentioned, this is the sort of patient to optimize cardiac output BEFORE attempting intubation, and you also need to be careful about meds. Adjunct airway and difficult airway algorithms apply. Non-invasive positive pressure ventilation would be really great here as long as the patient is not too far gone.
I'm not sure that BNP would be helpful in this situation.
ReplyDeleteNot sure it is acutely, not much literature from PEM sources, tho I recall a few critical care articles on BNP from probably a decade ago.
DeleteBTW - love Paul's warm/cold and wet/dry differentiation. totally agree here! this is a great approach to acute cardiac failure.
ReplyDeleteGreat responses, thank you!
ReplyDelete