Pediatric Resp Emergencies

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Pediatric Resp Emergencies

  1. 1. Pediatrics Respiratory Emergencies
  2. 2. Respiratory Emergencies <ul><li>#1 cause of </li></ul><ul><ul><li>Pediatric hospital admissions </li></ul></ul><ul><ul><li>Death during first year of life except for congenital abnormalities </li></ul></ul>
  3. 3. Respiratory Emergencies Most pediatric cardiac arrest begins as respiratory failure or respiratory arrest
  4. 4. Pediatric Respiratory System <ul><li>Large head, small mandible, small neck </li></ul><ul><li>Large, posteriorly-placed tongue </li></ul><ul><li>High glottic opening </li></ul><ul><li>Small airways </li></ul><ul><li>Presence of tonsils, adenoids </li></ul>
  5. 5. Pediatric Respiratory System <ul><li>Poor accessory muscle development </li></ul><ul><li>Less rigid thoracic cage </li></ul><ul><li>Horizontal ribs, primarily diaphragm breathers </li></ul><ul><li>Increased metabolic rate, increased O 2 consumption </li></ul>
  6. 6. Pediatric Respiratory System Decrease respiratory reserve + Increased O 2 demand = Increased respiratory failure risk
  7. 7. Respiratory Distress
  8. 8. Respiratory Distress <ul><li>Tachycardia (May be bradycardia in neonate) </li></ul><ul><li>Head bobbing, stridor, prolonged expiration </li></ul><ul><li>Abdominal breathing </li></ul><ul><li>Grunting--creates CPAP </li></ul>
  9. 9. Respiratory Emergencies <ul><li>Croup </li></ul><ul><li>Epiglottitis </li></ul><ul><li>Asthma </li></ul><ul><li>Bronchiolitis </li></ul><ul><li>Foreign body aspiration </li></ul>
  10. 10. Laryngotracheobronchitis Croup
  11. 11. Croup: Pathophysiology <ul><li>Viral infection (parainfluenza) </li></ul><ul><li>Affects larynx, trachea </li></ul><ul><li>Subglottic edema; Air flow obstruction </li></ul>
  12. 12. Croup: Incidence <ul><li>6 months to 4 years </li></ul><ul><li>Males > Females </li></ul><ul><li>Fall, early winter </li></ul>
  13. 13. Croup: Signs/Symptoms <ul><li>“Cold” progressing to hoarseness, cough </li></ul><ul><li>Low grade fever </li></ul><ul><li>Night-time increase in edema with: </li></ul><ul><ul><li>Stridor </li></ul></ul><ul><ul><li>“Seal bark” cough </li></ul></ul><ul><ul><li>Respiratory distress </li></ul></ul><ul><ul><li>Cyanosis </li></ul></ul><ul><li>Recurs on several nights </li></ul>
  14. 14. Croup: Management <ul><li>Mild Croup </li></ul><ul><ul><li>Reassurance </li></ul></ul><ul><ul><li>Moist, cool air </li></ul></ul>
  15. 15. Croup: Management <ul><li>Severe Croup </li></ul><ul><ul><li>Humidified high concentration oxygen </li></ul></ul><ul><ul><li>Monitor EKG </li></ul></ul><ul><ul><li>IV tko if tolerated </li></ul></ul><ul><ul><li>Nebulized racemic epinephrine </li></ul></ul><ul><ul><li>Anticipate need to intubate, assist ventilations </li></ul></ul>
  16. 16. Epiglottitis
  17. 17. Epiglottitis: Pathophysiology <ul><li>Bacterial infection (Hemophilus influenza) </li></ul><ul><li>Affects epiglottis, adjacent pharyngeal tissue </li></ul><ul><li>Supraglottic edema </li></ul>Complete Airway Obstruction
  18. 18. Epiglottitis: Incidence <ul><li>Children > 4 years old </li></ul><ul><li>Common in ages 4 - 7 </li></ul><ul><li>Pedi incidence falling due to HiB vaccination </li></ul><ul><li>Can occur in adults, particularly elderly </li></ul><ul><li>Incidence in adults is increasing </li></ul>
  19. 19. Epiglottitis: Signs/Symptoms <ul><li>Rapid onset, severe distress in hours </li></ul><ul><li>High fever </li></ul><ul><li>Intense sore throat, difficulty swallowing </li></ul><ul><li>Drooling </li></ul><ul><li>Stridor </li></ul><ul><li>Sits up, leans forward, extends neck slightly </li></ul><ul><li>One-third present unconscious, in shock </li></ul>
  20. 20. Epiglottitis Respiratory distress+ Sore throat+Drooling = Epiglottitis
  21. 21. Epiglottitis: Management <ul><li>High concentration oxygen </li></ul><ul><li>IV tko, if possible </li></ul><ul><li>Rapid transport </li></ul><ul><li>Do not attempt to visualize airway </li></ul>
  22. 22. Epiglottitis Immediate Life Threat Possible Complete Airway Obstruction
  23. 23. Asthma
  24. 24. Asthma: Pathophysiology <ul><li>Lower airway hypersensitivity to: </li></ul><ul><ul><li>Allergies </li></ul></ul><ul><ul><li>Infection </li></ul></ul><ul><ul><li>Irritants </li></ul></ul><ul><ul><li>Emotional stress </li></ul></ul><ul><ul><li>Cold </li></ul></ul><ul><ul><li>Exercise </li></ul></ul>
  25. 25. Asthma: Pathophysiology Bronchospasm Bronchial Edema Increased Mucus Production
  26. 26. Asthma: Pathophysiology
  27. 27. Asthma: Pathophysiology Cast of airway produced by asthmatic mucus plugs
  28. 28. Asthma: Signs/Symptoms <ul><li>Dyspnea </li></ul><ul><li>Signs of respiratory distress </li></ul><ul><ul><li>Nasal flaring </li></ul></ul><ul><ul><li>Tracheal tugging </li></ul></ul><ul><ul><li>Accessory muscle use </li></ul></ul><ul><ul><li>Suprasternal, intercostal, epigastric retractions </li></ul></ul>
  29. 29. Asthma: Signs/Symptoms <ul><li>Coughing </li></ul><ul><li>Expiratory wheezing </li></ul><ul><li>Tachypnea </li></ul><ul><li>Cyanosis </li></ul>
  30. 30. Asthma: Prolonged Attacks <ul><li>Increase in respiratory water loss </li></ul><ul><li>Decreased fluid intake </li></ul><ul><li>Dehydration </li></ul>
  31. 31. Asthma: History <ul><li>How long has patient been wheezing? </li></ul><ul><li>How much fluid has patient had? </li></ul><ul><li>Recent respiratory tract infection? </li></ul><ul><li>Medications? When? How much? </li></ul><ul><li>Allergies? </li></ul><ul><li>Previous hospitalizations? </li></ul>
  32. 32. Asthma: Physical Exam <ul><li>Patient position? </li></ul><ul><li>Drowsy or stuporous? </li></ul><ul><li>Signs/symptoms of dehydration? </li></ul><ul><li>Chest movement? </li></ul><ul><li>Quality of breath sounds? </li></ul>
  33. 33. Asthma: Risk Assessment <ul><li>Prior ICU admissions </li></ul><ul><li>Prior intubation </li></ul><ul><li>>3 emergency department visits in past year </li></ul><ul><li>>2 hospital admissions in past year </li></ul><ul><li>>1 bronchodilator canister used in past month </li></ul><ul><li>Use of bronchodilators > every 4 hours </li></ul><ul><li>Chronic use of steroids </li></ul><ul><li>Progressive symptoms in spite of aggressive Rx </li></ul>
  34. 34. Asthma <ul><li>SILENT CHEST= DANGER OF RESPIRATORY FAILURE </li></ul>
  35. 35. Golden Rule <ul><li>Pulmonary edema </li></ul><ul><li>Allergic reactions </li></ul><ul><li>Pneumonia </li></ul><ul><li>Foreign body aspiration </li></ul>ALL THAT WHEEZES IS NOT ASTHMA
  36. 36. Asthma: Management <ul><li>Airway </li></ul><ul><li>Breathing </li></ul><ul><ul><li>Sitting position </li></ul></ul><ul><ul><li>Humidified O2 by NRB mask </li></ul></ul><ul><ul><ul><li>Dry O2 dries mucus, worsens plugs </li></ul></ul></ul><ul><ul><li>Encourage coughing </li></ul></ul><ul><ul><li>Consider intubation, assisted ventilation </li></ul></ul>
  37. 37. Asthma: Management <ul><li>Circulation </li></ul><ul><ul><li>IV TKO </li></ul></ul><ul><ul><li>Assess for dehydration </li></ul></ul><ul><ul><li>Titrate fluid administration to severity of dehydration </li></ul></ul><ul><ul><li>Monitor ECG </li></ul></ul>
  38. 38. Asthma: Management <ul><li>Obtain medication history </li></ul><ul><ul><li>Overdose </li></ul></ul><ul><ul><li>Arrhythmias </li></ul></ul>
  39. 39. Asthma: Management <ul><li>Nebulized Beta-2 agents </li></ul><ul><ul><li>Albuterol </li></ul></ul>
  40. 40. Asthma: Management <ul><li>Subcutaneous beta agents </li></ul><ul><ul><li>Epinephrine 1:1000--0.1 to 0.3 mg SQ </li></ul></ul>POSSIBLE BENEFIT IN PATIENTS WITH VENTILATORY FAILURE
  41. 41. Asthma: Management <ul><li>Use EXTREME caution in giving two sympathomimetics to same patient </li></ul><ul><li>Monitor ECG </li></ul>
  42. 42. Asthma: Management <ul><li>Avoid </li></ul><ul><ul><li>Sedatives </li></ul></ul><ul><ul><ul><li>Depress respiratory drive </li></ul></ul></ul><ul><ul><li>Antihistamines </li></ul></ul><ul><ul><ul><li>Decrease LOC, dry secretions </li></ul></ul></ul><ul><ul><li>Aspirin </li></ul></ul><ul><ul><ul><li>High incidence of allergy </li></ul></ul></ul>
  43. 43. Status Asthmaticus Asthma attack unresponsive to  -2 adrenergic agents
  44. 44. Status Asthmaticus <ul><li>Humidified oxygen </li></ul><ul><li>Rehydration </li></ul><ul><li>Continuous nebulized beta-2 agents </li></ul><ul><li>Atrovent </li></ul><ul><li>Corticosteroids </li></ul><ul><li>Aminophylline (controversial) </li></ul><ul><li>Magnesium sulfate (controversial) </li></ul>
  45. 45. Status Asthmaticus <ul><li>Intubation </li></ul><ul><li>Mechanical ventilation </li></ul><ul><ul><li>Large tidal volumes (18-24 ml/kg) </li></ul></ul><ul><ul><li>Long expiratory times </li></ul></ul><ul><li>Intravenous Terbutaline </li></ul><ul><ul><li>Continuous infusion </li></ul></ul><ul><ul><li>3 to 6 mcg/kg/min </li></ul></ul>
  46. 46. Bronchiolitis
  47. 47. Bronchiolitis: Pathophysiology <ul><li>Viral infection (RSV) </li></ul><ul><li>Inflammatory bronchiolar edema </li></ul><ul><li>Air trapping </li></ul>
  48. 48. Bronchiolitis: Incidence <ul><li>Children < 2 years old </li></ul><ul><li>80% of patients < 1 year old </li></ul><ul><li>Epidemics January through May </li></ul>
  49. 49. Bronchiolitis: Signs/Symptoms <ul><li>Infant < 1 year old </li></ul><ul><li>Recent upper respiratory infection exposure </li></ul><ul><li>Gradual onset of respiratory distress </li></ul><ul><li>Expiratory wheezing </li></ul><ul><li>Extreme tachypnea (60 - 100+/min) </li></ul><ul><li>Cyanosis </li></ul>
  50. 50. Asthma vs Bronchiolitis <ul><li>Asthma </li></ul><ul><ul><li>Age - > 2 years </li></ul></ul><ul><ul><li>Fever - usually normal </li></ul></ul><ul><ul><li>Family Hx - positive </li></ul></ul><ul><ul><li>Hx of allergies - positive </li></ul></ul><ul><ul><li>Response to Epi - positive </li></ul></ul><ul><li>Bronchiolitis </li></ul><ul><ul><li>Age - < 2 years </li></ul></ul><ul><ul><li>Fever - positive </li></ul></ul><ul><ul><li>Family Hx - negative </li></ul></ul><ul><ul><li>Hx of allergies - negative </li></ul></ul><ul><ul><li>Response to Epi - negative </li></ul></ul>
  51. 51. Bronchiolitis: Management <ul><li>Humidified oxygen by NRB mask </li></ul><ul><li>Monitor EKG </li></ul><ul><li>IV tko </li></ul><ul><li>Anticipate order for bronchodilators </li></ul><ul><li>Anticipate need to intubate, assist ventilations </li></ul>
  52. 52. Foreign Body Airway Obstruction FBAO
  53. 53. FBAO: High Risk Groups <ul><li>> 90% of deaths: children < 5 years old </li></ul><ul><li>65% of deaths: infants </li></ul>
  54. 54. FBAO: Signs/Symptoms <ul><li>Suspect in any previously well, afebrile child with sudden onset of: </li></ul><ul><ul><li>Respiratory distress </li></ul></ul><ul><ul><li>Choking </li></ul></ul><ul><ul><li>Coughing </li></ul></ul><ul><ul><li>Stridor </li></ul></ul><ul><ul><li>Wheezing </li></ul></ul>
  55. 55. FBAO: Management <ul><li>Minimize intervention if child conscious, maintaining own airway </li></ul><ul><li>100% oxygen as tolerated </li></ul><ul><li>No blind sweeps of oral cavity </li></ul><ul><li>Wheezing </li></ul><ul><ul><li>Object in small airway </li></ul></ul><ul><ul><li>Avoid trying to dislodge in field </li></ul></ul>
  56. 56. FBAO: Management <ul><li>Inadequate ventilation </li></ul><ul><ul><li>Infant: 5 back blows/5 chest thrusts </li></ul></ul><ul><ul><li>Child: Abdominal thrusts </li></ul></ul>

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