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).
What about a coarctation? I feel like with TGA with VSD, we'd be more likely to see increased vascularity on the chest x-ray due to increased pulmonary blood flow, which the poster didn't mention. But maybe we should be seeing that with the coarct too. And the poster didn't mention any cardiomegaly, which might be present with both. Had the baby been having wet diapers that day? Do we have four point BPs and pre- and post-ductal saturations? I think we would draw cultures and start antibiotics just to cover for the possibility of sepsis. I'd want to get this baby intubated. And what Jan said, echo, prostaglandins, fluid, bicarb, cardiology consult.
Specializes in NICU, PICU, PCVICU and peds oncology.
Let's hope the sepsis workup was done in the ED!! Or at least started. Coarct is a possibility given the pulse discrepancy between upper and lower extremities... but I think that post was edited while I was composing my reply.
Specializes in ER, NICU, PICU, Critical Care Transport.
Great Job working through this. This one has fooled me before in the middle of the night. The next time it didn't. Working, once again in the middle of the night, with a second year resident we admitted the patient. Checked 4 extremity b/p's and there was a huge difference between the upper and lower extremities. Pt was intubated, given some bicarb and placed on a PGE4 gtt while waiting on cards to ECHO. For the newer nurses reading this: The PDA doesn't always close right after birth and can take up to 4 weeks. Coarctation isn't a "true" ductal dependent heart defect, but when the duct does start to close it can pull on the aorta and close off an already narrow coart increasing the work load on the heart and dropping cardiac output. The decrease in bicarb on the ABG is because of anaerobic metabolism and lactic acid production.
Sorry for the glitches with the post. LittleneoRN you're up. Good job.
Oh my! I consider myself a newbie and a guest on this forum, so I don't know what to ask! Sorry to you true PICU folk, but I don't think I can stray things back toward the peds world. :) I'll have to stick with one more neonatal question since that's what I know. A practical tidbit of sorts. Maybe you see lots of umbilical lines in your PICU, but I know our PICU nurses see them infrequently and aren't super comfortable with them.
A two day old presents to the ER with significant jaundice and meets criteria for a double volume exchange transfusion. The neonatal nurse practitioner is able to place both a umbilical arterial catheter and double lumen umbilical venous catheter, which will be quite handy for the exchange. The baby is transferred to the PICU because it is RSV season and the NICU is trying to avoid taking admissions from home. A chest and abdomen film is taken to confirm line placement.
How do you tell the difference between a UAC and UVC on x-ray?
How do you know if the UVC is properly placed?
How do you know if the UAC is properly placed per x-ray? What is the rule of thumb for approximate depth of insertion? (Not that it's your job to place, but it's nice to know if the depth makes sense.)
Specializes in NICU, PICU, PCVICU and peds oncology.
I'm going to go out on a limb here and predict that there won't be any PICU nurses who will take that one on! On my unit we see UVCs and UACs in our neos who've had cardiac surgery but we really don't have any in-depth knowledge of the ins-and-outs (tongue firmly in cheek). But let's see what comes up.
Ok, I wasn't sure if they were more common in other PICUs than ours. I think when our heart kids go down for their repairs, they get new lines and the umbilical ones come out. We can see what happens or move on. Everything I could think of was too simple or firmly neonatal. :)
Specializes in NICU, PICU, PCVICU and peds oncology.
Yeah, for us it depends on what else the anaesthetist can find for access. If it's not great then they leave the umbilical lines for us to use. If you like we can open the floor to another poster who might wish to get their licks in, or I can come up with another scenario... I've got 15 years to draw from. But why don't we wait until tomorrow and see if there is anyone who wants to give it a shot?
PS... I see you've found the thread I conned Steve into starting! Think I'll wander over and poke my nose in.
I think I'll still hang around here a bit too as I like learning some new things. I'm not very good on the spot, but a great question or scenario for this might just pop into my head someday. Feel free to throw up another question whenever you think. :)
I'm a newbie at this but I'll give it a shot...my terminology may not be correct though...however I can look at an xray and figure out whether placement is correct, or if the UVC is in the liver at least!
Is it cheating if I'm a nicu nurse...
UVC - enters through the umbilical vein, on xray it will initially appear to swoop downwards and then loop back up, it courses to the left (on xray, right on the pt) through the portal vein and ends in the right atrium
UAC - Enters through the umbilical artery and takes a direct course upwards towards the heart and ends in the aorta
I'm not entirely sure of the correct depths, I can almost always tell if its not deep enough or too deep unless its a very slight difference
littleneoRN
459 Posts
What about a coarctation? I feel like with TGA with VSD, we'd be more likely to see increased vascularity on the chest x-ray due to increased pulmonary blood flow, which the poster didn't mention. But maybe we should be seeing that with the coarct too. And the poster didn't mention any cardiomegaly, which might be present with both. Had the baby been having wet diapers that day? Do we have four point BPs and pre- and post-ductal saturations? I think we would draw cultures and start antibiotics just to cover for the possibility of sepsis. I'd want to get this baby intubated. And what Jan said, echo, prostaglandins, fluid, bicarb, cardiology consult.