This is an offshoot of another thread that strayed far off its path.
I will be posting questions that spring from situations I see on my quaternary level PICU to test your knowledge of critical care topics that apply to children. As we know, children are not small adults and the reasons they are admitted to ICU are very different from those of adults. For example, PICUs see virtually NO life-style related comorbidities such as COPD from a 2 pack-per-day cigarette habit, cardiovascular disease from a 10 Big-Mac-per-week habit or end-stage cirrhosis from a 6-drink-per-day habit. Congenital anomalies, trauma (accidental and non-accidental), metabolic disorders, ingestions and respiratory infections are our biggest offenders.
Question #1:
Name the 4 main treatments for JET (junctional ectopic tachycardia).
Infant with bilateral pulmonary vein stenosis and chronic lung disease/pulmonary hypertension. Vented on pressure control. S/p GI virus. Pt was about to get a bath but stooled in tub so moved to the bed for a sponge bath. Pt began hiccoughing persistently. Suctioned with no effect. Ng tube removed without relief. Began nasal flaring and retracting with stridor. Desat to 50s, not resolved with ambu/suction. Easy to hand ventilate. Trach changed, no effect. Nebs stacked x 3, no effect. Trach changed from pedi to neo for concern of internal granuloma then suctioned for small amount of frank blood. Respiratory distress worsening, satting in the 70s on 50% fio2. Ativan 1mg given with minimal effect. Tachycardic to 200. Rate increased to 20 on the vent and peep increased to 8 with min effect. When pt settles and is in sync with vent sat improve to as high as 90, but rarely able to settle and constant coughing, persistent nasal flaring and retracting. Fio2 increased to 70% for sats between 60s/70s. Large projectile emesis at this time. Pt positioned on side with small improvement. Saline neb and 2 more xopenex given, aggressive chest pt and suction. Transport team called, sats 92% on 70%. Weaned to 60% after falling asleep and maintaining but severe resp distress persists. Given 25mcg fentanyl x 4, line established. Temp at this time 104. PR tylenol given. IV decadron administered. Further decompensation requiring paralytic. Dual empirical abx coverage, saline bolus. 8 hours later paralytic lifted, afebrile, sats mid 90s and able to be weaned down to 40% but still requiring slightly increased vent support. Happy, playful. What happened to this pt?
Specializes in NICU, PICU, PCVICU and peds oncology.
This appears to have been a pulmonary hypertensive crisis that began with a viral illness. When he was moved from the tub to the bed, there was a vagal incident that caused the hiccoughing, which then led to bronchospasm. (In a child I knew well, I might almost call it a snit.) Trach simulates vagus nerve -> hiccoughs -> bronchospasm -> increased WOB/desat -> pyrexia/tachycardia/ongoing desat -> increased pulmonary vascular resistance -> further desat/tachypnea/WOB -> increased vent settings and hand-ventilation -> gastric distension -> vomiting -> paralysis -> recovery. It's more likely that the event caused the fever and not the viral illness. What solved the problem was deepsedation and paralysis that allowed for more effective ventilation and pulmonary vasodilation. In the long term this child should probably be on sildenafil to improve pulmonary circulation in addition to his bronchodilators and steroids.
Specializes in NICU, PICU, PCVICU and peds oncology.
Well, the respiratory distress could be secondary to mucus plugging secondary to dehydration secondary to the GI virus and diuretics. Although the "easy to hand-ventilate" sort of argues against it.
Something acute caused the hypertensive crisis. We thought for sure it was a plug because his symptoms were initially so tracheal. We were really surprised to not find a plug when we changed the trach!
Labs essentially at baseline for pt x for mildly elevated WBCs and creeping BUN, which was first treated with a pedialyte bolus PNG and then normal saline once a line was established.
Isitpossible, LPN, LVN
593 Posts
okay Jan,patiently waiting!! (happy holidays)!