I need to establish if the standard of care for the following case was
met --- I feel that it was met, and how!! (Since the final outcome was
poor there is some jousting going on by the PICU).
10 y/o ex-preemie, known severe Asthmatic, (hx of BPD), had a trach
closure 14 days prior to ED arrival. Seen by the PMDx2 over that period
for recurrent respiratory distress. Sent home, "he is getting used to the
Arrives in the PED in extremis, (Neb at home, neb en route), Neb
started in the ED,Solumedrol given, and ABG done < 5 mins after arrival
on a non-rebreather mask ( replaced by BVM immediately).
1st ABG -- pCo2 = 193, pO2 = 83, pH = 6.89, BE = -3 , and 87% Sat.
To summarize :- he could not be intubated by the ED doc, or the
Anesthesiologist, but ENT was in house-- and a trach was done within 25
mins after arrival !
He subsequently blew bilat pneumothoraces, and had
witnessed PEA, that was corrected. Bilat chest tubes were placed,
pharmacologic resusc. worked, and the patient stabilized. The 3rd gas was
Q. My theory is that one could initially oxygenate but not ventilate the
patient secondary to a possible Ball valve effect from the trach closure
granulation tissue. Thus the high pCo2 and almost good O2 after 100% O2 ??
AND the Pneumos could be the result of the same...AND I feel that in this
case the use of a percutaneous needle cric would not be feasible S/P the
tracheostomy (and would have added to the pCo2).
Q. Was the initial management appropriate?--- pt was unknown to us.
Any feedback will be greatly appreciated!!!!
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