C3 Project: Pediatric Respiratory Emergencies

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Scott p -

Thanks for a great update!
Can I just ask abit more about the recommendation to use ketamine in the acute asthmatic. I have only used this drug in asthmatics when there is a need for intubation (only adults, having never had to intubate a child with asthma).
I would feel somewhat uncomfortable to use ketamine in an acutely wheezing child, presumably at least moderately unwell who hasn't settled with MDI or nebs. Can you comment further on this please

Mel H. -

From Ilene,

Thanks for the question. You're not alone- on the rare occasion when I've tried it, most people have been a bit surprised. i think it probably stems from people giving it as an intubation med and noticing the child got enough better to make intubation possibly not necessary. There have been a number of case reports and a 10 patient pediatric series with good outcomes and min side effects at high doses (1mg/jg bolus --> 0.75 mg/kg/hr drip). The largest study that I know of was in Annals in 2005 and that showed no efficacy but no significant adverse events, though the dose was notably lower (0.2--> 0.5). There have been a few case reports in adults as well showing promise and minimal side effects (JEM 2011), but I'd probably save it for the young adults with good hearts! -Ilene

Jon C, MD -

One simple question. During the lecture Dr Claudius mentioned several times of deferring an intubation to the anestheologist. Was this the standard practice at her facility or part of educating those taking an ABEM test? The community hospital I have work at since completing residency, anestheologist manage the OR patients. The EM docs perform the ED intubations and are called to the ICU for intubation if the respiratory tech is unable to tube the patient.
What's up with calling the anestheologist ?

Mel H. -

FROM Ilene:
I think there are certain situation in pediatric airway when the intubation or management of anestesia can be a time bomb and getting the whole crew in is helpful. Kids with congenital malformations that involve micrgnathia and a large tongue (esp if the syndrome is Down's which also requires intubation in c-spine precautions) are anticipated difficult intubations, esp in infants. Unless the reader has access to and is comfortable with pediatric fiberoptic intubation devices, I'd advise having someone who is available at bedside. Could he or she get out of the situation transiently if they paralyze and can't intubate by doing a needle cric- sure. But I think recognizing a potentially difficult airway and sparing the kid that is part of good practice in a semi-emergent setting. Similarly, in the case of a symptomatic, but partially obstructive foriegn body, I think that tube is better left to the OR. In this case, anesthesia is not the key, but the fact that ENT is ready to rigid bronch the kid and get the FB out if they obstruct with paralysis which they likely will. For me, those are the 2 big situations where I think we can get ourselves and our patients into big trouble by not asking for back-up. Please let me know if I mentioned this in regards to another situation as well, and accept my apologies in advance for the omission.
In regards to CHLA and USC, the fact of the matter is that I don't know if I ever saw an anesthesiologist in my 11 years there. I think I might have bumped into 1 in the cafeteria once. The few times I had patients in the above categories, either ENT took quickly unintubated to the OR in the latter case, and in the former case, I intubated because anesthesia didn't respond to pages. But I will tell you that they were all difficult, and in 1 case I was not involved in, several fellows and pediatric ED attendings attempted before a successful intubation and things could have gone really bad had it not been a time when multiple physicians were not readily available. I agree that most peds intubations are easy, but also feel like recognizing the ones that are not is important.

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