Tough to say what is going on without a bit of context….
This is a 7 week old infant. No real background history of note other than a 2 day story of a diarrheal illness in the context of a community rotavirus epidemic.
Presented to a remote community nursing clinic with diarrhoea , poor oral intake and tachypnoea. The wonderful RAN recognised this as a sick kid and arranged urgent transfer. However – this is northern Australia and that means 6 hours in transit. Out little one continues to loose watery stool and has had a few vomits en route
By the time the child arrived in ED at 6 PM the VBG looked like this:
On exam – there was marked tachypnoea, rapid and shallow with a rate of 80, SpO2 = 98% RA
The pulse rate is 200, sluggish capillary refill with cool hands and feet.
Looks tired, lethargic, not really responding much to the pain of IV access attempts.
After a few IV fails we move to a tibial IO line (see the JAMIT video here). In the meantime we get an art line up (US guided?)
No fever, no obvious chest infection – a CXR is clear. ENT exam is NAD, no murmurs or skin lesions / rash.
So – in summary – this is one sick chick. Profound metabolic acidosis, not perfusing the brain, skin and probably kidneys…. an IDC is placed and about 3 ml of dark urine dribbles out.
So here we are. Lets talk logistics. This little one needs to go to a PICU, the closest one is about 1000 miles away by plane. there is no way that any flight team will take her without a definitive airway – the risk of mid-flight crash is just too high. IN fact as you are contemplating your next move she has a brief apnoea…. action stations.
Here are my questions for you.
Q1: What can we do to optimise the picture prior to embarking on intubation?
Q2: What drugs would you use to facilitate the ETT placement?
Q3: How are you going to set up your ventilator / circuit as part of your pre-tube set up?
Q4: Just to be controversial…. do you run in any bicarb?
OK, its a tricky case. Let me know how you would go about the planning and execution of this intubation
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact