Hot Seat #72: transport for lung whiteout
Posted on: March 28, 2016, by : Lenore Jarvis MD MEd
Lenore Jarvis MD, Children’s National Health System
With Pavan Zaveri MD, Children’s National Health System
The Case
3 yo M h/o asthma presenting as a bounceback to an OSH for cough and fever x 5 days. You are taking the ED Transport calls. The OSH is calling you for transport to your facility.
You are told the child has been sick with a cough and fever x 5 days that has progressively worsened. He is now SOB with retractions. Per report, he was “fine” until the past week.
PMHX: asthma, immunizations UTD (unsure about flu)
PE: 39.2C, HR 166, no bp, RR 30s-40s, 88% on RA initially. Sating 100% on NRB.
Gen: appears in distress; patient sitting up, but can tolerate lying flat
CV: tachycardic, “normal” pulses and cap refill
Resp: decr BS on left, normal BS on right; retracting
Abd: soft, NTND
OSH Labs/Imaging:
WBC 18.5, Hct 24, plt 338, 85 seg, 8 lymphs; ESR 134, CRP 28
CMP: normal except for gluc 166, alb 1.7
lactate 2
Flu/RSV/strep negative
BCx x 2 pending
waiting on urine
CXR (AP only) – complete whiteout left lung with mild midline shift away from whiteout (rightward)
CTX/vanc and NS bolus given
The OSH cannot send the patient one-way, and they are asking you to arrange transport. The OSH is 35 min away by ambulance. Flying is an option.
Question for you:
How would you approach this case? Please share your opinions by clicking on “What do you think?” below.
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I think spring break left a void here or maybe it was that it’s more of a transport question. I wonder what triggered Lenore to make this a hot seat case.
The differential is broad from space-occupying lesion/tumor to complicated pneumonia to unusual lung infection (fungal/TB) to cardiac cause….More on that when he arrives….
For the transport questions, I’m not sure how the fellows responded, but to keep in mind, 100% NRB is not able to be admitted to the floor, except in the case of a pneumothorax, for which it is treatment, so not knowing the child’s oxygen need, the floor wouldn’t take it directly so I wouldn’t even call them. Though bad numbers and CXR “read”, that doesn’t automatically buy the PICU, so bring them to the ED (like most moderate respiratory kids) so we can sort it out and get them where they need to be, look at the CXR, get further imaging depending on our friendly radiologist’s advice and review of that film and ensure “safe” for the floor.
If the child is doing “ok” on a non-rebreather, likely he needs some level of support less than that, and our nurse and medics can manage that, so no RT needed in my read of the case.
Now, for a bit of a discussion on differential….
– pneumonia – possible, fits the time course with worsening sxs and progression of illness
– space-occupying lesion – maybe, to me, this is where the time course can defy understanding, but gets complicated when the outside ED doc (and/or the parents) tries to fit the story into a neat package and some of the history is altered in translation….Imperative to start from scratch – that’s where the resident comes in who doesn’t take all the existing pieces to cut corners but gets all the info on their own (usually)
– cardiac – put an US probe and let’s see….
Alright, my overnight shift just ended, signout is over…I’m signing off from this as well 🙂
Agree with Pavan on several transfer acceptance issues. Assumptions will get you into trouble This does not sound like the sort of kid to send directly upstairs.
A ground transport of 35 minutes for a non-intubated child with resp issues is ok with me vs helicopter. I’m ok with accepting most transfers with respiratory issues. At OSH you don’t have the luxury of knowing the transport personnel experience or capabilities. You also have to rely on an accurate report without being swayed if there is premature closure on the part of the transferring doc.
In short: Make sure the story makes sense or go back and run through the details again.
I’m interested in ruling out a post-obstructive pneumonic/atelectatic process vs empyema vs mass vs FB vs vascular ring vs cardiac(less likely) +/- all sorts of infectious etiologies. US or CT would be helpful, with PICU admission at the least. Continue 100%NRB, consider HFNC. Give antipyresis and address SIRS. Looking forward to the denouement.