Pediatric Resp Emergencies

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