Ped EM M&M - Dr. Pinzon

Asthma Exacerbation
9yo male with numerous hospitalizations but no Iintubations. Was fine yesterday... now is not... is hypoxic and diaphoretic.


Avoiding Intubation

• Noninvasive positive pressure ventilation

1. CPAP / BIPAP 
2. Indications for NIPPV

            -- Hypoxemic despite high flow O2
            -- Temporizing measure
            -- While awaiting maximal therapeutic effects of drugs

http://pedemmorsels.com/delayed-sequence-intubation/

    -- Limitations - requires patient cooperation, not definitive airway.
    -- Intubate when the above doesn't work - but increased morbidity and mortality with intubation

1. Over 1/2 complications occur immediately after intubation
2. Ketamine - improves airway compliance and reduces bronchospasm  
3. PRVC and SIMV/VC preferred
4. Initial vent settings
   

       - Low tidal volume
       - Respiratory rate
       - Short inspiratory time
       - I:E ratio 1:3 to 1:5

Delayed sequence intubation 

• Think of it as procedural sedation when the procedure is preoxygenation.
  

1. Ketamine
2. Preoxygenate with BiPAP
   
3. Administration of a paralytic agent 
4. Don't forget to adjust the vent (before High-5's).
   

---

10 day old with vomiting

  - Hx of "GERD" since day of life 4; Mom GBS + but treated and baby full term without complications; +constipation
  - Green emesis day of presentation - looks great at bedside

  - Neonate with Bilious Emesis - KEEP IT SIMPLE... Neonate with Bilious Emesis = Badness until proven otherwise.
        -- Surgical vs non surgical - Surgical includes duodenal atresia, malrotation with volvulus, NEC. Also consider Sepsis.

Malrotation
    - arrest of normal rotation of embryonic gut > usually presents in infancy
        -- >50% of kids will present before one month of age
        -- >90% have vomiting - it won't always be bilious
        -- > Urgent surgical consultation if kid looks bad

    - Imaging
        -- Plain films - not sensitive or sepcific
                - May see double bubble sign
        -- Upper GI = study of choice