pediatric emergency

1. Pediatric
Respiratory
Emergencies
Dr. Deba john
“Respiratory emergencies are 1 of the most common reasons parents
seek evaluation for their children in the Emergency department”

2. Respiratory Disorders
Respiratory Disorders are the 2nd leading cause of
ER visits in children (#1 is Injury and poisoning)

3. • Discuss the differences between pediatric and adult anatomy
& physiology
•How to properly assess a pediatric patient with respiratory
distress and discuss emergency room presentation of common
pediatric respiratory diseases
• ABCDE tool for Assessment
•Discuss Most Common Pediatric Respiratory Emergencies
Objectives

4. Kids are
not little
Adults

5. NOSE: Generally smaller, increased resistance,
Smaller septum & nasal bridge is flat and flexible . . .
Obligatory nose breathers
VOCAL CORDS: located at C3-4 versus C5-6 in
adults . . . Larynx is more anterior
Contributes to aspiration if neck is hyperextended
CRICOID RING Is the narrowest part of the airway
instead of vocal cords
AIRWAY DIAMETER is 4 mm vs.. 20 mm in adult
TRACHEAL RINGS more elastic & cartilaginous,
can easily crimp off trachea
More SMOOTH MUSCLE, makes airway more
reactive or sensitive to foreign substances
Airway: Child vs Adult

6. Body Surface Area
Children do not have a
larger body surface area
than adults. They have a
larger PERCENTAGE of
surface area for their
weight than adults do.
This is because children
do not have highly
developed muscle.
Most of their mass is fat
and water which weighs
less. Bones are also less
dense at a younger age.

7. • Head to Body ratio and
relative size and location of
anatomic features make
children more susceptible to
head and abdominal injury
• Underdeveloped anatomy
leads to chest pliability and
less protection of thoracic
cage and less effective use
of accessory muscles
• Arrest – Cardiac arrest
typically results from
untreated respiratory arrest
Child vs Adult

8. Thorax - Child vs Adult
• Horizontal ribs – more diaphragmatic
breathing
• Flatter Diaphragm
• Ribs & Sternum is cartilage - less
stability of chest wall, requires more
use of diaphragm
• Less pulmonary reserve
• Heart takes up more thoracic space
• Poor accessory muscle development
• Larger abdominal organs - pushes up
diaphragm

9. Airway
Urgencies
can quickly
progress to
airway
Emergencies

10. ABCDE
Assessment Tool
Underlying Principle - -
•Use a systematic approach
•Complete initial exam and re-assess regularly
•Assess the effects of treatment/interventions
•Correct life-threatening abnormalities before
moving on to the next part of assessment

11. Look for signs of airway obstruction
• Paradoxical chest and abdominal
movements (See-Saw)
• Accessory Muscle Use
• Central cyanosis
• Absent to no Breath sounds
• Depressed consciousness
Treat airway obstruction as a medical emergency
• In the majority of cases, simple methods of airway
management are all that is necessary - - Positioning,
Chin Lift, Suctioning, Oral/Nasal Airway - - Tracheal
Intubation may be required where simple measures fail
Give Oxygen
• Keep SpO2 > 90% - - Diminish risk of hypoxic damage

12. Look for general signs of respiratory
distress, sweating, cyanosis,
accessory muscle use – It is vital to
diagnose and treat immediately life
threatening conditions (Severe
Asthma, Tension Pneumothorax,
Foreign Body)
•Respiratory Rate & rhythm
•Equal chest expansion
•Breath sounds
• Stridor, Rales, Rhonchi, Wheezing
•Air Exchange
•Chest deformity
•Abdominal distension

13. Respiratory pathology that may compromise circulatory state - - -
tension pneumothorax
•Look for signs of poor cardiac output
• Peripheral and central pulses
• Blood Pressure
• Reduced level of consciousness
• Low urine output (less wet diapers)
• Reduced PO intake
• Look for signs of bleeding
•IV Fluids for patients that present with tachycardia and/or poor
capillary refill
In almost all medical/surgical
emergencies, consider hypovolemia
to be the primary cause of shock
unless proven otherwise.

14. Signs of Disability - - coma/convulsion - -
Common causes of unconsciousness
include profound hypoxia, hypercapnea,
cerebral hypoperfusion or recent
sedative/analgesic drug ingestion
•Review ABC’s – exclude hypoxia and hypotension
• Assess tone, Pupil size
• R/O Accidental Ingestion – give appropriate
antagonist where available
• Monitor LOC
• Blood Glucose Level
D can also stand for signs of dehydration
• Signs of shock have already been looked for
while assessing circulation but specific
examination for skin turger, sunken eyes, dry
mucus membranes

15. Check Temperature - - Kids will
become hyper/hypo thermic faster
than an adult
Look all over the body - - - back, groin
Assess in well lit area

16. Other than Trauma - - -
5 Most Common Respiratory
Emergencies
• Asthma
• Croup
• Bronchiolitis
• Epiglotitis
• Foreign bodies

17. Upper
Airway
Disease
Croup
Foreign Body
Epiglottitis
Bacterial Tracheitis
Asthma
Bronchiolitis
Pneumonia
Foreign Body
Lower
Airway
Disease
Noise during Inspiration
Proximal to Thoracic Inlet
Nose – Pharynx – Larynx
• Awake/Crying
• It child Improves
• Nose/Pharynx
• If child Deteriorates
• Larynx
Noise during Exhalation
Distal to Thoracic Inlet
Trachea, Bronchi,
Peripheral Airways

18. Upper
Airway
Disease

19. Basics
Upper respiratory viral
infection
Occurs mostly among
ages 6 months to 3 years
More prevalent in fall and
spring
Edema develops,
narrowing the airway
lumen (Steeple Sign)
Severe cases may result
in complete obstruction
Croup

20. Croup
• Physical exam/Assessment
• Tachycardia, tachypnea
• Skin color - pale, cyanotic,
mottled
• Decrease in activity or
LOC
• Fever
• Breath sounds - wheezing,
diminished breath sounds
• Stridor, barking cough,
hoarse cry or voice
• Any difficulty swallowing?
• Drooling present

21. Management
Assess & monitor ABC’s
High flow humidified O2; blow
by if child won’t tolerate mask
Limit exam/handling to avoid
agitation
Be prepared for respiratory
arrest, assist ventilations and
perform CPR as needed
Do not place instruments in
mouth or throat
Rapid transport
Croup

22. Basics
Bacterial infection and
inflammation of the
epiglottis
Usually occurs in children 3-
6 years of age
Can occur in infants, older
children, & adults
Swelling may cause
complete airway obstruction
Thumb sign
True medical emergency
Epiglotitis

23. Assessment/History
When did child
become ill?
Has it suddenly
worsened after a
couple of days or hours?
Sore throat?
Will child swallow
liquids or saliva?
Is drooling present?
High fever (102-103
degrees F)
Onset is usually
sudden
Epiglotitis
Signs & Symptoms
May be sitting in Tripod
position
May be holding mouth
open, with tongue
protruding
Muffled or hoarse cry
Inspiratory Stridor
Tachycardia/tachypnea
Pale, mottled, cyanotic
skin
Anxious, focused on
breathing lethargic
Very sore throat
Nasal Flaring
Look very sick with high
fever

24. Management
Assess & monitor ABC’s
Do not make child lie down
Do not manipulate airway
High flow humidified O2; blow
by if child won’t tolerate mask
Limit exam/handling to avoid
agitation
Be prepared for respiratory
arrest, assist ventilations and
perform CPR as needed
Transfer of Children’s Hospital
Epiglotitis

25. Aspirated Foreign Body
• Basics
• Common among the 1-3
age group who like to put
everything in their mouths
• Running or falling with
objects in mouth
• Inadequate chewing
capabilities
• Common items - gum, hot
dogs, grapes and peanuts

26. Assessment
Complete obstruction will
present as apnea
Partial obstruction may present
as labored breathing,
retractions, and cyanosis
Objects can lodge in the lower
or upper airways depending on
size
Object may act as one-way
valve allowing air in, but not
out
Aspirated Foreign Body

27. Aspirated Foreign Body
Complete Obstruction
Attempt to clear using BLS
techniques
Attempt removal with direct
laryngoscopy and Magill forceps
Cricothyrotomy may be indicated
Partial obstruction
Make child comfortable
Administer humidified oxygen
Encourage child to cough
Have intubation equipment
available
Transport to hospital for removal
with bronchoscope

28. Supraglottic Area (Insp. Stridor)
• Anaphylaxis
• Epiglottitis
• Retropharyngeal/Peritonsillar
Absess
• Laryngomalacia
• Congenital Malformation
• Tumor of oral cavity or pharynx
Glottic & Subglottic Area (Insp. Stridor)
•Laryngotracheitis (croup)
•Tracheomalacia
•Anaphylaxis
•Foreign Body in Airway
• Subglottic Stenosis
• Bacterial tracheitis
• Vocal Cord Paralysis
Intrathoracic Area (Exp Stridor and/or Wheezing)
•Infection (bacterial tracheitis, bronchitis)
•Foreign Body in Airway or Esophagus)
•Anaphylaxis
•Congenital Malformation
•Tumor
https://www.uptodate.com/contents/assessment-of-stridor-in-
children?source=search_result&search=stridor&selectedTitle=1
~150
Stridor

29. Lower
Airway
Disease
• Narrower trachea and bronchi
• Poiseulle’s Law - Edema
If radius is halved,
resistance increases
16x

30. Discussed this morning my Dr. Rotta
Asthma

31. Basics
Respiratory infection of the
bronchioles
Occurs in early childhood
(younger than 1 yr)
Caused by viral infection
Assessment/History
Length of illness or fever
Has infant been seen by a doctor
Taking any medications
Any previous asthma attacks or
other allergy problems
How much fluid has the child been
drinking
Bronchiolitis

32. Signs & symptoms
Acute respiratory
distress
Tachypnea
May have intercostal
and suprasternal
retractions
Cyanosis
Fever & dry cough
May have wheezes -
inspiratory & expiratory
Confused & anxious
mental status
Possible dehydration
Bronchiolitis
Management
Assess & maintain
airway
When appropriate let
child pick POC
Clear nasal passages
if necessary
Prepare to assist with
ventilations
IV LR or NS TKO rate
Intubate if airway
management
becomes difficult or
fails

33. Other than the 5 Most Common
Respiratory Emergencies
• Dehydration/
Shock
• Ingestions
• Anaphylaxis
• Seizures

34. Dehydration
Mild, Moderate & Severe
• Physical
Assessment/ Vital
signs
• Capillary refill
• Skin color
• Alertness, activity
level

35. Mild dehydration
Infants lose up to 5% of their body weight
Child lose up to 3-4% of their body weight
Physical signs of dehydration are barely visible
Dehydration
Mild, Moderate & Severe
Moderate Dehydration
Infants lose up to 10% of their body weight
Children lose up to 6-8% of their body weight
Poor skin color & turgor, dry mucous membranes,
decreased urine output & increased thirst, no tears
Severe Dehydration
Infants lose up to 15% of their body weight
Children lose up to 10-13% of their body weight
Danger of life-threatening hypovolemic shock

36. Management
If mild or moderate
Give fluids orally if there is no
abdominal pain, vomiting or
diarrhea and is alert
Severe
High flow O2
IV/IO with NS or LR
Fluid bolus of 20 ml/kg IV/IO
push
Repeat fluid bolus if no
improvement
Dehydration
Mild, Moderate & Severe

37. •Ingestion of a potentially
toxic substance, drug,
household or industrial
chemical, plant or waste
products
Ingestions/Poisonings
History
Home environment
Medications in home
Where are chemicals stored?
Hobby-related exposures
Physical clues (open bottles,
plants with missing leaves, etc)

38. Physical exam
• Vital signs
• Excitation or
•Depression
• Pupils
• Mental Status
• Skin
• Management
• ABC’s
• Decontamination
Unknown Ingestions
Laboratory workup.
Every child should
have…
Acetaminophen level
Salicylate level
Ethanol level
Chemistry panel
including LFT’s
Calculate anion gap
Urinalysis
Consider urine toxicology
screen, ABG, urine,
pregnancy, imaging (CXR or
KUB), Osmolality

39. Ingestion Management
Management:
• Stabilize and ABC’s as needed
• Oxygen as needed
• IV with Normal Saline (keep Hydrated)
• NG if unconscious or will not drink
• If opiate poisoning
• Narcan
• If acetaminophen poisoning
• N-acetylcysteine

40. • Causes
• Vaccines
• Drugs
• Insect bites
• Food
• Latex
• Venoms
Anaphylaxis
Usually begins within a few minutes after
exposure evident within 15”
Symptoms – Sneezing, Coughing, Itching, Flushing
of skin, Facial edema
Anxiety, Palpitations, Nausea, Vomitting, Respiratory
Distress, Hypotesnion

41. •Recumbent Position
• Elevate Feet
• Establish and maintain
airway
• Oxygen
• Start IV – Normal Saline
• Epinephrine per
protocol
Anaphylaxis Management

42. Seizures
Common Age Range - 6 mos - 6 yrs
The CNS of children is more
immature, making children
more likely to seize
•1% of all patients in ED are
Pediatric seizure patients
• Occurs in 2-5% of pediatric
patients
• 80% are febrile
• Other causes
• Infection
• CNS
• Immunizations
General considerations
• Stabilize and ABC’s as
needed
• Oxygen as needed
• Watch for aspiration
• Watch glucose
• Treat fever
Febrile seizures that
continue for more than
five minutes should be
treated.

43. Pediatric Trauma

44. Pediatric Trauma
• Trauma is leading cause of
death in children Most
common mechanisms
• MVA 43%
• Burns 15%
• Drowning 15%
• Firearms 3%
• Falls 2%
• Most commonly injured body
areas-head, trunk, extremities
Head 48%
Abdomen 11%
Chest 9%
Extremities 32%

45. Anatomic Characteristics of the Pediatric
Patient and Significance to Trauma Care
Large Volume of Blood in Head
Cerebral edema develops rapidly
Poor Muscular support in neck
Flexion/extension injuries occur
Decreased Alveolar surface area
Injury leads to rapid compromise
Increased Metabolic rate
Higher oxygen demand
Decreased airway caliber
Increased airway resistance

46. Anatomic Characteristics of the Pediatric
Patient and Significance to Trauma Care
Heart higher in chest & Small pericardial sac
Prone to injury and cardiac tamponade
Thin walled, small abdomen
Organs not well protected
Bones soft and pliable
Fractures less common
Renal function not well developed
Prone to develop acute renal failure
Large % body surface area
Prone to hypothermia

47. Multi-System Injuries
• Multi-system injury is the rule rather than the exception
• Because of the smaller body mass, energy from linear forces (e.g. fenders,
bumpers, falls) results in greater force applied per unit body area
• Children have less fat, less elastic connective tissue and close proximity of
organs, which leads to more multi-system organ injuries
• The skeleton is incompletely calcified and
more pliable
• If the bones are broken, assume that a
massive amount of energy was applied
• Internal organs may be damaged without
evidence of overlying bone fractures

48. Children prone to head
injuries
Be alert for signs of
child abuse
Facial injuries common
secondary to falls
Always assume a spinal
injury with head injury
Head, Face, and Neck Injuries
Children are susceptible to the secondary effects of brain injury
produced by hypoxia, hypotension, seizures and hyperthermia
Open fontanels and mobile cranial suture lines are more tolerant of
expansion of intracranial mass lesions, decompensations may not
occur until the mass lesion has become large

49. Burns
Second leading cause of pediatric deaths
Scald burns are most common
Rule of nine is different for children
Each leg worth 13.5%
Head worth 18%
Thermal Injuries & Burns
Risk Factors
Excessive sun exposure
Hot water heaters set too high
Exposure to chemicals or electricity
Thin skin
Carelessness with burning cigarettes
Faulty electrical wiring

50. Thermal Injuries
Management of Burns
• Stabilize ABC’s
•Primary Survey
•Establish Airway and Assist
Ventilation if needed
•Keep saturations 97%
•Fluid Resuscitation

51. Thermal Injuries
Transfer to Burn Center
• Second-degree burn over
10% BSA or any third degree
burn
• Electrical or lightening burns
• Inhalation injury
• Chemical Burn
•Circumferential burn

52. • Leading cause of accidental
death in children under 5 yrs
• Highest incidence in Males & African-
Americans
• Inadequately supervised in swimming
pools, bathtubs or around other liquid-
filled containers
• Children under the age of 1 year most
often drown in toilets, bathtubs and
buckets
• 7% appear related to child abuse or
neglect
• Children that drown in pools were out
of sight for less than 5” and were in
the care of one or both parents at the
time
• Second peak is seen in males 15-25 yrs
• Tend to occur at rivers, lakes and
beaches
Near Drowning

53. Drowning
Management of Near Drowning
• Stabilize ABC’s
• Primary Survey
• Establish Airway and Assist Ventilation if needed
• NG Tube (usually have swallowed lots of water)
• Watch for hypothermia
• R/O Head Injury, Seizure
• Watch for ARDS
• Pulmonary Hypertension
• Stabilize Electrolytes

54. Pediatric Airway

55. Airway Size & Placement
OET Size = Age + 16 / 4
(Size or nare, Diameter of Pinky, Broselow Tape)
Tape at 3 x size of tube
Eg: 4 year old: 16+4 / 4 = 5.0, tape 3 x 5 = 15 cm
Airway sizes may vary unpredictably among pediatric patients of
same age and weight. Have more equipment available: at least 3
different sized endotracheal tubes.
The appropriate ETT size may be determined by the following
formula
(age in years):

56. Broselow Tape

57. Rapid Sequence
Simultaneous administration of neuromuscular
blockade agent and sedative
Recommended by the Emergency College of Medicine
committee of the American College of Emergency
Physicians for every emergency child intubation with
intact upper airway reflexes
Paralytics Succinylcholine,
Vecuronium, Pancuronium,
Rocuronium
Sedative Versed, Ketamine,
Pentothal, Etomidate
Analgesics Morphine, Fentanyle,
Katamine

58. Pediatric Intubation
• Proper Positioning
• Larger head that flexes forward
• Straight Blade for kids < 4yrs
• Larger Epiglottis/Floppy
• Cuffless OET < 8 yers unless
using microcuff OET
• Different angles
• Larynx is more anterior
• Use cricoid pressure with
caution

59. Don’t bury the tube!!!
Tape at 3 x OET Size

60. Common problems
• Bronchiolitis
• Foreign Body
• SIDS
• Vomiting and
diarrhea/dehydration
• Meningitis
• Child abuse
• Household accidents
Children 1-5 months

61. Common problems
• Febrile seizures
• Vomiting and
diarrhea/dehydration
• Bronchiolitis or croup
• Car accidents and falls
• Child abuse
• Ingestions and foreign
body obstructions
• Meningitis
Children 6-12 months

62. Common problems
• Auto accidents
• Vomiting and diarrhea
• Febrile seizures
• Croup, meningitis
• Foreign body
obstruction
Children 1-3 years

63. Common Problems
• Croup, asthma,
epiglottitis
• Ingestions, foreign
bodies
• Auto accidents,
burns
• Child abuse
• Drowning
• Meningitis, febrile
seizures
Children 3-5 years

64. Common Problems
• Drowning
• MVA's
• Bike vs Motor
Vehicle
• Fracture
• Sports Injuries
• Abuse
• Burns
Children 6-12 years

65. Common Problems
• Asthma
• Auto accidents, sports
injuries
• Drug and alcohol abuse
• Sexual abuse,
pregnancy
• Suicide gestures
Children 12-15 year

66. Take-a-ways
• Kids can deteriorate quickly –
you constantly have to be on
your toes!
• Anatomy and Physiology is
different than adults - - Be
aware of the differences and
the impact disease can make
• Use the ABCDE Assessment
tool
• Do a thorough systematic
approach and reassess often

67. Take home note:
Remember that an adequate airway
and oxygen-rich approach may be the
difference between life and death
Sick pediatric patients can be terrifying,
but they usually only have one thing
wrong.
Support their airway,
breathing and
cardiovascular status and
their amazing bodies will
usually take care of the
rest