Case study: "pediatric" RSI

[Underwhelmed]

Greetings from asscrackistan.

Here are some tidbits from a LN mascal that I think would prove interesting for the M.D's, PA's, and Deltas here.

Five dudes deciding to ride on a tractor at the same time have a roll-over. Two have what appear to be depressed skull fractures, one being more severe than the other, on the basis that one is walking around, and the other is seizing on the table with his jaw clenched. He was about 5'7, 70-80 kilos max. Priorities of work here are obvious: ABC's, then supportive care for [closed?] head injury. Here is a rundown of the timeline:

Primary survey: Awake, but not oriented, combative, anxious, screaming "it hurts" in pashtu. Bleeding would over right temple, unable to determine depth. Good evidence of med-severe TBI. Ketamine was administered IM for concious sedation, as well as cardiostable analgesia, being that the MOI would also suggest occult bleeding elsewhere.

Ketamine for closed head injury has lost some of its demonization due to studies suggesting it does not increase ICP significantly. No concerns there. Seizure-like activity begins shortly after this, so the treatment plan changes to protecting ICP spikes, as well as C-spine integrity.

100mg of cardiac lidocaine, 1mg atropine, 2 mg vecuronium is drawn up and administered while preoxygenation is initiated. Etomidate 30mg, succynlcholine 100mg are then administered, intubating conditions are acheived predictably.

Vocal cords are obstructed by secretions. Damn. Suction for 30 seconds, bag again for 1 min, try again. First doc tries, with a mac 3 and 7.5 ETT, ends up in the gut. [Ortho surgeon, cut him some slack].

Second attempt shows swollen vocal cords, presumably from the intubating trauma. Miller 3 and 7.0 are attempted, no dice. 1 min of bagging again, then straight to surgicial cricothyrodotomy. Size 4 tracheostomy tube is introduced, and does not fit. We had to scale down to a 5.0 uncuffed ETT, tape the hell out of it, and turn the PEEP on the vent up to preposterous levels to maintain desirable etco2. Sats are doing good, and sedation/NMB was maintained with serial doses of vecuronium and midazolam pending medevac. Pupils improved, and vitals calmed down. No sign of impending herniation, and seizures were obviously averted with paralysis.

Lessons learned for myself and my collegues:
1. Broselow tape isn't 100% guaranteed. This 5'7 80kg casualty was between 10-12 years old [found this out after the fact from the family arriving], which accounted for the small airway. Afghans are extremely hard to estimate age-wise. Make every effort to have a waide range of airway equipment handy.

2. Ketamine is a great drug, albeit a source of heated debate for RSI. I've taken fire on this forum before for talking about it; however I would like to reiterate that premedicating with atropine should take priority when at all possible, to avoid the secretion problems we ran into. By the time we gave it, we were already racing against the clock, and losing our pulmonary toilet fast.

3. The AAR called into question the use of the depolarizer for paralysis, but please note that vec was used incramentally as a defasiculator. Etomidate, and sux have served me well for seven years, but vec is GREAT when it's available.

Please pitch in so that I may benefit from the collective experience here, if you have anything that stands out that you would like to add.

[Priest]

70-80kg, doesnt sound like any 10-12 year old afghan kid I've ever seen

[Doczilla]

Sounds like a shit sandwich, but I can't see it going another way. Bad stuff just happens sometimes. I might have gone for a gum elastic bougie after seeing the swollen cords. I don't see a problem with the ketamine, since it will provide some analgesia as well as settle the kid down. I don't have bad feelings either about a depolarizing paralytic in a head injury. I think the greater risk of a spike in the ICP comes from rooting around in the airway of a patient who is inadequately relaxed. My feeling with the sux is to go with a nice big dose early. I don't give defaciculating doses of nondepolarizing paralytics anymore. If you're that worried about it, you can use rocuronium (if you've got it) instead of the sux, which will have a similar time to onset of action. I agree with Priest about the size of the kid. Average size for that age will be about 35-40kg, with some great variation due to timing of the adolescent growth spurt. Still, that's a big kid. I wouldn't think to pull out the broselow tape on a kid that's 5'7", no matter what the family said about how old he is.

'zilla