COLLABORATIVE CARE. Collaboration. Mission/Purpose. Mission/Purpose

Transcription

1 COLLABORATIVE CARE Collaboration Pediatric Critical Care Patients St. Charles, Bend Oregon Grand Rounds September 6th, 2013 Mission/Purpose Mine Pediatric critical care starts with the first evaluation Pediatric Critical Care has no start or end Mission/Purpose Yours, St. Charles Providers, Sept

2 Collaboration Our Goals Airlink/KIDS team Pictures of ED/PICU Grassroots approach outgoing, dedicated, just plain nice CASE Initial Evaluation 2

3 Initial Evaluation Transport Evaluation 18 months, 12kg Found at bottom of irrigation pond, unresponsive EMS arrived - crying ED- Grunting, intubated Transport Evaluation InPatient Evaluation Labs- Lactic acid 8.3, 7.29/37/18-9 IVF D5NS, 40 Sedation- Fentanyl/Versed Vent- rate- 25, peep5, TV-70, ETCO2 37 Time hours 3

4 InPatient Evaluation InPatient Evaluation Arrive as Trauma Patient No other injuries Assessment- Aspiration Event Plan- recheck/follow/extubate with weaning ventilator Followup Evaluation Extubated day after Home at 2 days No neuro deficits Assessment Evaluation Aspiration events Rapid progression ECMO possibility Outcomes Hard to predict See Video 4

5 Case 2 Initial Evaluation Initial Evaluation Initial Evaluation 2 year old, Day 1, March 2013 Rhinorhea, congestion tx from Pioneer History of asthma exacerbations Suspected Asthma Exacerbation Solumedrol, Albuterol, Mag, Azithro 5

6 Initial Evaluation Day 2-3 RR High Flow to 7 Arterial PaO2 of 46 Continuous nebs/solumedrol Other Ideas for Treatment Asthma Audience Input Collaboration, Dr. H further mag doses increase albuterol to 20 start terbutaline start bipap continued poor aeration Transport Evaluation Crackles/Wheezes/Decreased Aeration Albuterol 20/hr When to intubate???? 6

7 Review Articles NEW Ventilation from our very own Dr. Quint VDR replaces ECMO InPatient Evaluation 84 hr intubated 5 day PICU stay 7

8 InPatient Evaluation Followup Evaluation RSV positive by PCR Rhinovirus positive by PCR Weaned drugs in PICU/Transferred Discharged after 6 days Receives Influenza shot Pediatric Pulmonary consultation Assessment Evaluation Treatment of Asthma-- Quick review to see what has changed 8

9 CASE 3 Initial Evaluation 9

10 Initial Evaluation 10month, Feb 2013 Fevers, cough, bronchiolitis RSV Infection/Croup Worsened on Day 2 Xray with increasing consolidation Intubation/Fluids Transport Evaluation Via Airlink Ionotropes, ventilation InPatient Evaluation InPatient Evaluation Fulminant Shock Dopamine/Epi/Norepi/Calcium/Steroids ph 7.05/57/43/15-15 ECMO TEAM 10

11 InPatient Evaluation InPatient Evaluation RSV and MSSA Pneumonia Severe Shock As sick as you can get with compressions ECMO put in ECMO pictures here 6 of us, Neonatal and Pediatric ECMO InPatient Evaluation InPatient Xrays ECMO- 18 days CVVHD- Hemodialysis HEME- Plasmapharesis/IVIG Other- Trach/g tube/broviac/bronchs QuickTime and a H.264 decompressor are needed to see this picture. 11

12 InPatient CT- ECMO #17 Followup Evaluation QuickTime and a decompressor are needed to see this picture. Pulmonary- acting well Assessment Evaluation CASE 4 12

13 Initial Evaluation Initial Evaluation 3 year old, History of intubation, HFOV at age 1 Viral symptoms, Albuterol q2, 81% RA ED, increased RR/HR Diagnosis of Asthma/Respiratory Failure Transported Via AirLink 15 mg/hr InPatient Evaluation Arrival to PICU diffuse rhonchi, retractions, appeared better, per dad PICU course 20 mg/hr, mask cpap, IV steroids?high flow?bipap 3 days PICU, total 11 days in hospital RSV (+) Prednisone, Flovent, Albuterol 13

14 CASE 5 Initial Evaluation 3 month old with decreased feeding and listless 911 called CT head- neg, Xray abd- mass, USdilated InPatient Evaluation US- large multiloculated mass c/w lymphangioma 14

15 Abdominal MRI Followup Evaluation QuickTime and a decompressor are needed to see this picture. d/c with PICC with IV abx (febrile) readmit on 7/24-7/30 resection of mass and bowel CASE 6 Recent Broadcast QuickTime and a H.264 decompressor are needed to see this picture. 15

16 Recent Broadcast Don t lose the white coats QuickTime and a H.264 decompressor are needed to see this picture. QuickTime and a H.264 decompressor are needed to see this picture. Initial Evaluation Transport Evaluation 5 month, old previous healthy, presented to ED, insert video of moms description here, get off aperature Airlink Unremarkable transport 16

17 InPatient Evaluation Followup Evaluation Well appearing child on Ventilator, see xray Input list of weakness in 5 month old here Assessment Evaluation Botulism Sent, + for Type A Received botulism immunoglobulin On ventilator for 25 days, then bipap Discharged in good condition Other Topics Here are the recent RSV articles >2012 My summary 1) Hypertonic saline recommended for mild/moderately sick kids 2) High flow works 3) ECMo is needed and should be offered up to 14 days 4) CXR is actually helpful for looking at risk for intubation, 17

18 END thanks, St. Charles team RCH team Transport Teams 18