-=> Andrew Burke was saying.....
 AB> I am a part-time EMT with 5 years experience. Today my partner, and I
 AB> responded to a Child S.O.B. call. Upon arrival at scene we found a 10
 AB> month female being cared for by the rural fire dept. first responders.
 AB> O/E child was lethargic and drowsy, pupils sluggish, resps 'gurgling',
 AB> and decreased air entry to bases. Child had apparantly no history to
 AB> speak of other than a bout of diarrhea about a week ago, which was
 AB> treated with pedialyte, I assume for dehydration. No other meds or
 AB> allergies. Deciding baby was unstable, we initiated rapid transport to
 AB> local hosp (20 mins away). En route child became increasingly dyspniac,
From the description you give here, sounds like the child was in
DESPERATE need of oxygen. What was the child's effort? Were there
significant abdominal retractions or was the child so weak that her
respiratory effort was almost non-existent? Was her skin cool, clammy &
pale? Was the skin temp of the extremities cooler than her trunk? Almost
sounds to me that this child would have benefited by O2 with BVM.
Children respond much more negatively to hypoxia than adults, and as a
result need much more aggressive ventilation. What was the child's pulse?
Appropriate rates for this age should have been around 100-160. If she
was less than 100, a real good indication that she was hypoxic.
 AB> eventually going into respiratory arrest shortly after arrival at
 AB> emerg.  Endotracheal intubation was initiated and pediatricians, RT's,
 AB> X-Ray, 12-lead, and lab was called....
The scenario you paint still makes me believe that the child was
extremely hypoxic, and went into respiratory arrest.
 AB> and D50 was started.  White count was 32, however temp was normal.
 AB> Baby continued to deteriorate, eventually showing arrythmias which
 AB> continued on to pulseless V-Tach.  Full pediatric ACLS was performed,
 AB> with no treatment proving helpful, and baby was pronounced some time
 AB> later, after every effort had been made. Upon questioning one
 AB> of the ERP's post-arrest, no explanation was given to me regarding
 AB> possible causes of the arrest.  It has been my experience with other
 AB> follow-up questions that information is hard to come by.
 AB> My question is what would/could cause such an arrest?
 Like I've already stated, it sounds to me the child went into
 respiratory arrest because of severe hypoxia. Why the child became
 dyspneic in the first place, it is difficult to say. With a white count
 of 32 (was that 32,000? Normal is 5,000-10,000) there might be some
 type of blood abnormality or infection (depending on if this was 32K or
 not.) Another question that could have been asked to determine if the
 child was still dehydrated was if she had been using more or less
 diapers than normal. If she had been using less, it is probable that
 the child was dehydrated and that she just wasn't producing much urine
 because the body needed as much fluid as possible. Was the child
 constipated after the diarrhea? Sometimes people use "home remedies" for
 diarrhea that constipate, which if severe enough, can cause metabolic
 imbalances also. It is possible that the child's previous medical
 history of diarrhea could have contributed. Was the treatment given at
 that time Dr. prescribed or a home remedy? If the child was treated by
 a rememdy "just because the parents felt it was the right thing to
 do...," this may have been insufficient and caused an electrolyte
 imbalance that the child was unable to compensate. There are a host of
 explanations that could have produced the respiratory distress, without
 definitive testing and examination, anyone would be just guessing.
 AB> ...although we were within protocol in our pre-hospital care, is there
 AB> possibly any other treatment that might have had a beneficial effect
 AB> with our patient? We are equiped with the Spacelabs 610 A.E.D, although
 AB> protocol restricts use to 12 years/100 pounds.
Maintain an open airway and use 100% oxygen by BVM would be my first
thought. AED use ... remember, according to current AHA ACLS guidelines,
AED's are to be used on pulseless, breathless patients. If the child had
respiratory effort with a pulse prior to arrival at the E.R., you would
not have used this. As a thought, don't look to use the "spectacular"
without first trying the "basic" methods. If you are a BLS squad, treat
the patient appropriately; use the methods and equipment appropriate and
acceptable for your patient. I have seen squads attach monitors to
patients, attach pulse oximeters and have absolutely no idea what the
tracing or results mean OR what to do after they get these results.
Don't do a non-BLS or ALS skill without first making sure all BLS skills
and treatments have been initiated. As I look back in your post, you
make no mention of skin color, temperature or appearance, nor do you
mention vital signs like pulse, B/P and respirations. These are just as
important information to have as the past medical history. It is hard,
especially with a pediatric patient, but we must try to maintain our
composure and not get "tunnel-vision" and treat the obvious and ignore
the important!
 AB> defibrillation was performed 5 times, ranging from 50 to 200 joules.  I
 AB> am interested in hearing from anyone with experience in this area as to
 AB> opinions on this call, other people's experiences, etc.  Any
 AB> information would be greatly appreciated.
According to ACLS and PALS, the acceptable pediatric setting for a
defibrillator are 2-4 joules per Kg. A 10 month old would have weighed
between 7.5 and 10 kg. This would mean that the initial joule setting
would have been 15-20, and subsequent shocks would have been between
30-40. Your description of "...defibrillation was performed 5 times,
ranging from 50 to 200 joules ...," to me appears excessive and
inappropriate. This possibly could have damaged the myocardium, but not
being there and knowing all the particulars, I can only comment on what
the established protocols and accepted practices are currently. I hope
I've answered some of your questions, or at least eased your mind some,
or at the very least, maybe said something you can use in the future.
Any other questions I'd be happy to help out if I can.
Bob Morgan, EMT-P
doodaman@fast.net
... Confuse people:  start making sense.  
--- -=[RA 2.02/pro]=-
---------------