Download Pediatric Respiratory Emergencies

Pediatric Respiratory
Emergencies
Amy Gutman MD
[email protected]
www.PreparedRescuer.com
Overview
• Review critical aspects of emergency care
of pediatric respiratory emergencies
– Epidemiology
– Anatomy
– Specific disease processes
• Key concept: children have unique
pathophysiology & respond differently to
respiratory illnesses than adults
• Importantly:
– How to recognize “sick”
– Management strategies for respiratory
distress
– Timely recognition of respiratory distress &
appropriate intervention key to preventing
progression to cardiac arrest
Sick or Not Sick?
Epidemiology
• 26% US population, 10% EMS calls
– Rate of ED visits in poorest communities
86% higher than rate in wealthiest
communities (414 visits: 1,000 children
vs 222:1,000
• Respiratory distress #1 cause of admissions
& death during 1st year except for congenital abnormalities
• Most pediatric cardiac arrests begin as respiratory failure
• Minimal training, few ill pediatric patients makes it difficult to obtain &
maintain skills
• Multiple sized patients, equipment sizes & drug dosages confusing in
stressful situations
Top 10 MCC
for Pediatric
Visits in 23 Study
States,
2010
AHRQAHRQ
Statistical
Brief
#52.ED
Healthcare
Cost
and
# ED visits
treat & # ED visits resulting
Utilization Project (HCUP); May
2010
# ED visits (% all
pediatric ED visits)
release (% all
pediatric ED visits)
in admission (% all
pediatric ED visits)
225,100 / 2%
177,000 / 79%
48,100 / 21%
328,100 / 3%
288,500 / 88%
• Asthma
Majority of ED visits “treat-and-release”
39,600 / 12%
Rank
1
2
3
Primary diagnosis
Pneumonia
Acute Bronchitis
227,100 / 2%
195,000 / 86%
32,100 / 14%
9,600
/ 76.6%
• Appendicitis
However, 500,000 pediatric41,000
ED/ 0.3%
visits result
in/ 23.4%
admission,31,400
with
the most common cause being
respiratory
5
Fluid & electrolyte disorders
91,800 / 0.7%
61,500 / 67.0%
30,300 / 33.0%
4
6
disorders
58,000 / 0.5%
38,700 / 66.7%
• Mood
Four
of the ten most common
admitted conditions:
19,400 / 33.3%
8
125,800 / 1.0% & URI 109,000 / 87.3%
16,800 / 12.7%
– Pneumonia, asthma, acute bronchitis,
–andInsubcutaneous
0-4 yrs,tissue
respiratory
conditions
1/3 ED visits
resulting
in admission
Skin
infections
192,300 /=1.6%
176,300
/ 92.4%
16,000 / 12.7%
9
Urinary tract infections
7
10
Epilepsy, Seizures
Other URI (nose, throat, trachea)
164,900 / 1.3%
150,300 / 91.4%
14,600 / 7.6%
1,428,700 / 12%
1,414,600 / 89%
14,100 / 12%
“External” Airway Anatomy
• Large head, large tongue, small mandible
• Narrowest at subglottic / cricoid area
• Relatively straight cervical spine
• Less rigid thoracic cage with poor
accessory muscle development
• Horizontal ribs, diaphragm breathers
• Increased metabolic rate, increased O2
consumption, limited O2 reserves
Smaller “Internal” Airway
• Epiglottis floppy, U shaped & anterior
• Larynx anterior
• Short floppy trachea
• Small soft airways in obligate nasal
breathers
– Nose = 50% airway resistance
– Large tonsils, adenoids rapidly swell
Laminar Flow: Laminar flow directly related to
pressure
difference
between two ends of a
•the
Pliable
/ floppy trachea
collapses easily
(Poiseuille’s Law)
vessel
inversely
to the resistance of
– Adult:&
1 mm
edema = 81%related
size
– Pedi: 1 mm edema
size
flow= 44%
through
the vessel
Patient Needs
• Fear of separation, being hurt &
the unknown
• Allow family to be with patient as
long as it does not distract you
• Never lie!
• Always explain your plan to child
• Position at eye level, remain calm,
speak slowly
Assessment
• Pre-arrival preparation & scene size-up
Work of Breathing
• General assessment (Pediatric Assessment Triangle)
– “Sick” vs “Not Sick” vs “Could Rapidly Become Sick”
– Clinical indicators reflect CV, respiratory & neurological status
• ABCDE & transport decision
• Ongoing assessment including more thorough history & exam
CUPS: Critical, Unstable, Potentially Unstable, Stable
HPI & Exam
•
HPI
–
–
–
–
•
How fast deteriorating?
Fever?
Noisy breathing?
What has been done so far?
PMH
– Prematurity, hospitalizations, Illnesses, intubations, immunizations?
– Allergies?
– Medications?
•
Exam
–
–
–
–
–
–
Sick or Not Sick?
Rate?
Noisy?
Position?
Color?
Symmetric?
“Normal” Vitals
AGE
AGE
HR
HR
0-3 mo
140
60-90
20-60
3 mo–2 yrs
140
90–105
55-65
2 yrs–5 yrs
90
95–105
55-65
6yrs–10 yrs
80
100–115
60-72
>10 yrs
75
115–125
65-85
SBP
SB
DBP
Appearance
• Alertness
• Distractibility
• Consolability
• Eye contact
• Speech/cry
• Spontaneous motor
activity
• Color
Abnormal Breathing Sounds
• Stridor
– High pitched sound heard on inspiration
– Indicates upper airway obstruction
• Grunting
– Short, low pitched sound heard in expiration
– Auto-PEEP to keep small airways open as progresses towards respiratory failure
• Wheezing
– High-pitched whistling sound heard expiration > inspiration
– Indicates lower airway obstruction
• Crackles
– Crackling sounds heard on inspiration
– Associated with cardio-vascular disease, lung disease, infection
Respiratory Distress vs Failure
• Distress
– Maintain oxygenation only by increasing work of breathing
• Failure
– Cannot compensate for inadequate oxygenation despite extra respiratory
effort & rate
– Circulatory & respiratory system collapse
Distress
Tachypnea
Nasal Flaring / Pursed Lips
Stridor / Wheezing
AMS / Agitation
Agitation
Tachycardia
Delayed Capillary Refill
Pale
Failure
RR > 60
Retractions
Grunting
Mottling
Head Bobbing
Severe Air Hunger
Bradycardia
Hypotension
Arrest
Bradypnea
Inefficient
respirations
Cyanosis / Grey
No air movement
Management Strategies
• Treat symptoms, not the disease
• Kids in respiratory distress needs oxygenation
as uncorrected respiratory distress
deteriorates to bradycardia & cardiac arrest
• Priority is to support breathing effort
– Remember the basics!
• If pulse remains low or breathing inadequate,
re-evaluate airway, ventilations, O2 & tubing
Airway Management
•
Use PAT to determine oxygenation status &
delivery device
•
Neutral “sniffing” head position
– Towel under shoulders; do not flex head
which collapses trachea
– Head-tilt chin lift or jaw-thrust
•
<5 seconds to look, listen & feel
•
Suction airway
•
Appropriate ventilation volume & rate
– 4-6 mg/kg
– Maintain optimal CO, venous return, cerebral
blood flow & coronary perfusion
– Limits regurgitation & aspiration
7 Ps…Not Just For RSI
1. Preparation
2. Pre-oxygenation
3. Premedication
4. Paralyze
5. Pass tube
6. Placement proof
7. Post-intubation care
Endotracheal Intubation
Sanders Jr RC, Ron M. Walls RM, et al. Level of Trainee & Tracheal
Intubation Outcomes. NEAR for Children Investigators. Pediatrics.
131:3, March 2013
• 2005 AHA:
• METHODS:
– Cuffed ETT effective & safe for all ages
15 PICU Prospective
multicenter
observational cohort (7/2010 – 12/11)
–• Un-cuffed
ETT recommended
in neonates
• Outcome measures: FPS, overall success, & adverse associated events
•• RESULTS:
Rapidly deoxygenate &
• 1265 primary ETI encounters by pediatric providers
decompensate
1st & overall
attempt
success Residents (37%, 51%)
–• Prepare
to start
compressions
• 1st & overall attempt success Fellows (70%, 89%)
– “Hail
Mary” plan
• 1st & overall attempt success Attendings (72%, 94%)
• OR 4.29; 95% CI (3.24–5.68)
• Overall
ETI FPS
rate 68%
• Attending
vs Fellow
vs Resident assoc with fewer adverse events (OR
0.42;
95% CI, 0.31–0.57)
– EM
physicians
FPS rate 74%*
– EMS overall success rate: 50%–80%
• CONCLUSIONS:
• Resident tracheal intubation success low with high adverse events
• Necessary intensive resident procedural training before “live” ETIs
*Resuscitation. 2012 Nov;83(11):1363-8.
ETT & Resuscitation
• Smartphone apps:
– RapiTube, Difficult Airway, PediStat , PediSafe
• Traditional Calculations:
– Un-cuffed = (Age / 4) + 4
– Cuffed = (Age / 4) + 3
– General = Age + 16/4
• [6yo + 16]/4 = 22; 22/4 = 5.5 ETT
• Ready ETT 0.5 mm smaller & larger
• Use blade you like:
– In very young Miller directly lifts floppy epiglottis
– In older children Macintosh slides into vallecula & indirectly lifts epiglottis
Alternative Airways
• Supraglottic, LMA, videoscope
• Supraglottics & LMAs placed blindly
with insertion times approximately 5
secs even during compressions
• Confirm BL lung sounds, ETCO2, tube
fog, rising O2 sat & HR
Secure The Tube!
Secure The Baby!
Upper vs Lower Airway Diseases
• Upper Airway
–
–
–
–
–
Foreign Body Obstruction
Retropharyngeal Abscess
Bacterial Tracheitis
Epiglottitis
Croup
• Lower Airway
– RSV / Bronchiolitis
– Asthma
– Bronchitis / Pneumonia
Apparent Life Threatening Events (ALTE)
• Lifeless, pulseless or unresponsive
infant recovering spontaneously &
“looks normal”
– 1-2% infants
– Most common at 2-3 mo, uncommon
>2 yrs
• All require transport & admission
• DDX:
–
–
–
–
–
Arrythmias
Congenital heart disease
Abuse / Trauma
GERD
Infectious / Metabolic / Neurological
Respiratory compromise
– Munchausen’s
Foreign Body Aspiration /
Obstruction (FBAO)
• >90% respiratory deaths in <5 yo; 65% infant
deaths from respiratory causes
• Suspect in sudden respiratory distress, choking /
coughing, stridor or wheezing
• DDX: seizure, syncope, arrhythmia or overdose
• Large objects lodge in upper airway & trachea
– 20% FBAO
– Acute dyspnea, drooling, stridor & cyanosis
• Small objects lodge in bronchus / terminal airway
Choking / FBAO
•
Able to talk / minimal distress, rapid transport in position
of comfort
•
Responsive but significant distress:
– Child: abdominal thrusts or Heimlich
– Infant: chest thrusts, back blows
•
Unresponsive, open airway & only remove object if visible / accessible
– Begin CPR with airway check
– Look for FB prior to starting each ventilation; if visible attempt removal with Magill’s
– Airway management via PPV or advanced airway attempt
•
Rapid transport & notify receiving hospital
•
Medical Control for needle cricothyroidotomy if unable to clear obstruction, unable to
intubate or ventilate
Even If obstruction clears prior to your arrival, still transport
Retropharyngeal Abscess
• URI complication
• Lymph nodes between posterior
pharynx & pre-vertebral fascia
– Soft palate bulging obstructs nose
– Posterior pharynx bulging obstructs
trachea
• Abrupt fever, severe distress, painful
swallowing
• Head hyperextension
• Noisy respirations, drooling
Epiglottitis (H. Influenza)
• 4-6 yo most common
• 10 X decrease since H. flu vaccinations
– 10% vaccinated, but exposed to virulent strain
• High fever, sore throat, stridor, drooling, tripoding &
severe respiratory distress
• Supraglottic edema completely obstructs airway
– DO NOT attempt to visualize (“Sniff Test”)
• Manage according to severity, but rapidly transport
in upright position with humidified O2
Respiratory Distress + Sore Throat + Drooling
Croup (Viral Parainfluenza)
• Nightly recurring fever, hoarseness,
“barking seal” cough from laryngeal &
tracheal edema
• 6 mo to 4 yr
– Males > Females
– Fall, early winter
• Management:
–
–
–
–
–
Reassurance
Humidified, cool air
Steroids
Racemic epinephrine
Rare advanced airway management;
consider alternative diagnoses
Bacterial Tracheitis
• Post URI
• Purulent sputum, high fever,
pseudomembrane
• Toxic appearance + stridor
• Croup-like symptoms responding
poorly to croup management
Bronchiolitis (RSV)
• Viral bronchiolar edema from air
trapping
• >80% < 1 yo
• Epidemics January - May
• Recent URI with gradual onset of SOB
• Expiratory wheezing, tachypnea,
cyanosis
• Management
– Humidified oxygen
– Bronchodilators
– Advanced airway as needed
Asthma
• Lower airway hypersensitivity causing bronchospasm,
edema & mucus production
– Varying degrees of respiratory distress
– All that wheezes is not asthma
– Non-wheezers often in severe respiratory distress
• Important History
–
–
–
–
Prior ICU admission / intubations
>3 ED visits or >2 admissions in past yr
>1 MDI used in past mo or every 4 hrs
Symptom progression despite aggressive treatment
• Management is aggressive airway, pharmacology & fluid resuscitation
–
–
–
–
Position of comfort, humidified O2
Beta-2 agents (Albuterol)
Anticholinergics (Atropine, Ipatropium)
Subcutaneous beta agents (Epinephrine 1:1000, 0.1 to 0.3 mg SQ)
Bronchitis / Pneumonia
• Viral or bacterial
– Neonates: GBS, enterics
– 3 mo-3yr: Streptococcus pneumonia
– 4mo- Preschool: RSV / viral
• Fever, cyanosis + tachypnea,
cough, nasal flaring, retractions,
rales, decreased breath sounds
• Aggressive airway management
Acute Respiratory Distress (ARDS)
• Severe lung inflammation rapidly
results in hypoxia & respiratory
failure
• Frequency: 2-12/100,000
• Mortality: 15%
• Management:
– Aggressive airway control
– PEEP
– Fluid & cardiovascular resuscitation
Anaphylaxis
• Acute & life-threatening
• Release of inflammatory mediators after a trigger
– MEWS: Milk, eggs, wheat, soy
– Peanuts & shellfish most potent
– Others: preservatives, medications, insect venom,
blood products, environmental, animal, exercise
• Symptoms progress over minutes to days resulting
in respiratory failure, shock, multiorgan system
failure & DIC
– 5-20% experience recurrence of anaphylaxis >12 hrs
– Symptoms can last 3 days despite treatment
Anaphylaxis Management
• Early aggressive airway management
• Medications:
–
–
–
–
Diphenhydramine
Histamine blocker (pepcid, zantac)
Nebulized or MDI albuterol (2.5-5 mg/dose)
Epinephrine 1:1000 IM
• Anaphylactic Shock:
–
–
–
–
Beware of “compensated shock”
Trendelenburg position
20 mL/kg crystalloid bolus; repeat to 60-80 mL/kg prn
Vasopressors:
• Epinephrine (0.1-1 mcg/kg/min IV)
• Dopamine (2-20 mcg/kg/min IV)
• Norepinephrine (0.1-2 mcg/kg/min IV)
Pediatric Bronchospasm /
Respiratory Distress
•
EMS:
– ALS or rapid transport without ALS if potential delay
– Encourage or assist patient to self-administer MDI
– MDI contraindicated if max dose administered, pt cannot physically use device,
device not prescribed for patient
•
ALS:
– IV, O2, Monitor
– Albuterol / atrovent nebulizer or MDI
– Medical Control:
• Epinephrine 0.15-0.3 mg IM autoinjector
• Magnesium Sulfate 25 mg/kg IV over 5 min
– Treat for shock as needed
•
Notify receiving hospital
Special Patients
• Tracheostomy tubes, apnea monitors, ventilators
are common home-care devices
• Most common are trach-related emergencies
–
–
–
–
–
Obstruction
Tube dislodgement
Stoma bleeding
Tube reinsertion “false track”
Infection
• If ineffective ventilation/oxygenation:
–
–
–
–
Wipe stoma, suction tube
Remove tube if necessary
Once airway open, begin PPV
Attempt intubation if cannot oxygenate
• Consider rapid tube re-insertion
References
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Emergency Care & Transportation of the Sick and Injured, 9th ED
Massachusetts OEMS (www.dph.org)
Alameda County EMS
www.emsonline.com
Premier Health Care Services
Continuing Education and Training
Pediatric Advanced Life Support (PALS)
Pediatric Education for the Prehospital Provider (PEPP)
Pediatric Emergency Assessment, Recognition & Stabilization (PEARS)
[email protected]
NAEMT Emergency pediatric Care
www.emsc.org
E Humphreys PA-C, EMT-I “Pediatric Respiratory Emergencies” (2009)
J Reynolds MD “Pediatric Respiratory Emergencies” (2012)
S Villanueva MD, FACEP “Pediatric Respiratory Emergencies”. 2011.
“Management of acute lung injury & ARDS in children”. Critical Care. 2009.
Summary
• Pre-arrival preparation important
• Standardized approach to
assessment & management
• Knowledge of normal child
development and age-specific
physiology important
• “Sick/not sick” determination is
paramount in treatment & transport
decisions
Find me: Kingston ED
Email me: [email protected] / Website: www.PreparedRescuer.com
Text me: 513-255-1353