CASE 32
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Incident
An 11-year-old boy has been camping with his parents and now presents to a small nurse-led rural clinic with a history of 6 hours of increasing respiratory distress, fever, vomiting and wheezing. He has a past history of severe asthma including four episodes requiring ventilation in the last 8 years.
Clinical information:
• Alert, anxious, speaking words only.
• P 145.
• RR 34.
• SaO2 91% on high-flow oxygen (via nebuliser mask).
• Widespread expiratory wheeze.
• Temperature 38°C (100.4°F).
Management:
• Continuous nebulised salbutamol.
The above image is visible to you via a telemedicine video link-up between the clinic and the PHR service base.
Relevant information
Questions
32.1 What pre-retrieval advice would be appropriate?
Unfortunately, the patient has deteriorated while the team was en route. Clinical assessment on arrival:
• Moribund.
• P 159.
• RR 22.
• BP 89/65 mmHg.
• SaO2 88% on high-flow mask oxygen.
An intravenous cannula has been placed and a 500 mL crystalloid fluid bolus given.
32.2 Outline your initial and ongoing management.
Following the establishment of invasive ventilation, the patient has improved clinically. A moderate amount of tenacious sputum is suctioned from the tracheal tube. During final preparations prior to departure, the transport ventilator alarms repetitively due to high peak airway pressures and the SaO2 trace becomes unrecordable.
32.3 Outline your management.
The child’s mother is understandably distressed and asks for your permission to accompany her son in the aircraft on the return journey.
32.4 How will you respond?
Discussion
32.1 Clinical assessment is difficult by telephone. If available as in this scenario, telemedicine consultation may be helpful, particularly to aid clinical assessment of the pattern and work of breathing (note the significant supraclavicular soft tissue recession and so called ‘tripod’ posturing in the above image). Peak expiratory flow rate and a portable chest X-ray should be performed, if available.
If the clinical assessment confirms asthma of moderate to life-threatening severity, escalation of current therapy is required.
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