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Ped EM M&M - Dr. Pinzon

9/26/2013

0 Comments

 
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
Picture
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
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  • RESIDENCY
    • About CMC
    • Curriculum
    • Benefits
    • Explore Charlotte
    • Official Site
  • FELLOWSHIP
    • EMS
    • Global EM
    • Pediatric EM
    • Toxicology >
      • Tox Faculty
      • Tox Application
    • (All Others)
  • PEOPLE
    • Program Leadership
    • PGY-3
    • PGY-2
    • PGY-1
    • Alumni
  • STUDENTS/APPLICANTS
    • Medical Students at CMC
    • EM Acting Internship
    • Healthcare Disparities Externship
    • Resident Mentorship
  • #FOAMed
    • EM GuideWire
    • CMC Imaging Mastery
    • Pediatric EM Morsels
    • Blogs, etc. >
      • CMC ECG Masters
      • Core Concepts
      • Cardiology Blog
      • Dr. Patel's Coding Blog
      • Global Health Blog
      • Ortho Blog
      • Pediatric Emergency Medicine
      • Tox Blog
  • Chiefs Corner
    • Top 20
    • Current Chiefs
    • Schedules >
      • Conference/Flashpoint
      • Block Schedule
      • ED Shift Schedule
      • AEC Moonlighting
      • Journal Club/OBP/Audits Schedule
      • Simulation
    • Resources >
      • Fox Reference Library
      • FlashPoint
      • Airway Lecture
      • Student Resources
      • PGY - 1
      • PGY - 2
      • PGY - 3
      • Simulation Reading
      • Resident Wellness
      • Resident Research
      • Resume Builder
    • Individualized Interactive Instruction