Clinical Case 094: Little one in big trouble

Todays case is a Paediatric peril.

Just for fun I thought I might run this case backwards.  Start with where we end up and how we got there.  You can tell me how you would have done the middle bit.

Not the prettiest set of numbers!


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:

pH = 6.91  pCO2 = 20   HCO3- = 7   lactate = 7.8   Na+ = 168  K+ = 5.5   Cl- = 120  Hb = 190  glucose = 4.5 (81 in the USA)

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



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