Download Pediatric Assessment

Maryland Pre-hospital
Protocol
for Croup
Maryland EMSC Program
Care for Children with Croup
Developed by
Hopkins Outreach for Pediatric Education
Written by
Elizabeth Berg, RN, BSN, EMT-B
Reviewed by Maryland PEMAG 7/2001
Objectives
Identify three signs and symptoms of croup
 State the treatment protocol for croup
 List two criteria for medical direction
 Identify three signs and symptoms of
pediatric respiratory failure
 List two criteria for BVM ventilations

Pediatric Medical Emergencies
Epidemiology of Croup
Common age range is 3 months to 4 years
 Most severe symptoms under 3 years
 More common in males
 Most common during the winter months
 Typical duration of illness is 5-6 days

Pediatric Medical Emergencies
Pathophysiology of Croup

Viral infection of the vocal cords
– Parainfluenza virus (75%)
– Adenovirus
– Respiratory syncytial virus (RSV)
– Influenza
– Measles
– Bacterial super infection
Pediatric Medical Emergencies
Pediatric Anatomical and
Physiological Differences
Airway shape: cone versus cylindrical
 Narrowest point at the cricoid ring
 Anterior vocal cords
 Tongue larger in proportion to the mouth

Pediatric Medical Emergencies
Airway Differences
Pediatric Medical Emergencies
Pediatric Anatomical and
Physiological Differences
Smaller, more collapsible
lower airways
 Diaphragm dependent
 Poorly developed intercostal
and accessory muscles

Pediatric Medical Emergencies
Clinical Presentation of Croup

Signs and symptoms
– Loud barking cough
– Hoarseness
– Respiratory distress
Nasal flaring
 Retractions
 Head-bobbing
 Inspiratory grunting or stridor

Pediatric Medical Emergencies
Clinical Presentation of Croup

Associated illnesses
– Ear infection
– Pneumonia
Pediatric Medical Emergencies
Neck X-rays
Normal Airway
Narrowed Airway
Other Causes of
Pediatric Airway Obstruction

Vascular Ring


Blood vessels compress the trachea
Tracheomalacia

Softening of the tracheal wall
Foreign body
 Epiglottitis

Pediatric Medical Emergencies
Epiglottitis

Clinical presentation
– Over 5 years of age
– Most common organism is Hemophilus influenza
– Rapid onset of stridor and drooling
– Associated with high fever
Pediatric Medical Emergencies
Epiglottitis

Interventions
– High flow oxygen
– Calm environment
– No manipulation of the upper airway
– Hospital notification
– Do not initiate croup protocol
Pediatric Medical Emergencies
EMS Protocol for Croup

Initiate General Patient Care
– Allow children to assume their own position of
comfort
– Semi-fowler’s position will promote diaphragm
expansion
– Allow parent to remain with child for emotional
support
Pediatric Medical Emergencies
EMS Protocol for Croup

Initiate General Patient Care
– Get down to child’s level
– Use age-appropriate words
– Give them choices, when able
– If stable, allow the child to set the pace of the
procedure
Pediatric Medical Emergencies
EMS Protocol for Croup

Initiate General Patient Care
– Foster trust by telling the truth
– Be aware of the capabilities of the local ED
– Consider risks and benefits of transporting the
child to a pediatric referral center
– Administer oxygen without increasing agitation
Pediatric Medical Emergencies
Oxygen Administration in Children

Infants/toddlers may not tolerate a face mask
– Have parent hold mask near patient’s face
– Place oxygen tubing set at 10 lpm in the bottom
of a paper cup with stickers inside
– Use commercially designed teddy-bears with
oxygen port; may also use for nebs
Pediatric Medical Emergencies
EMS Protocol for Croup

Presentation
– Severe: Priority 1
Unable to speak or cry
 Decreased LOC
 Bradycardia or tachycardia
 Hypertension or hypotension

Pediatric Medical Emergencies
EMS Protocol for Croup

Presentation
– Moderate: Priority 2
Slow onset of respiratory distress
 Barking cough
 Fever
 Audible stridor

Pediatric Medical Emergencies
EMS Protocol for Croup

Treatment
– Perform initial patient assessment
Patent airway
 Adequate respiratory effort

– Assign a treatment priority
– If patient > 40 kg (88 lbs) treat under adult
protocol
Pediatric Medical Emergencies
Continuum of Respiratory Failure
•Tachypnea
•Nasal flaring
•Pale
•Stridor
•Expiratory
wheezing
•Tachypnea
RR > 60
•Retractions,
grunting
•Mottled
•Head bobbing
•Insp/Exp
wheezing
•Bradypnea
•See saw
respirations
•Gray,
cyanotic
•No air
movement
•No wheezing
Pediatric Medical Emergencies
EMS Protocol for Croup

Treatment
– Place on cardiac monitor, pulse oximeter
– Record vital signs
– Initiate IV with LR at a KVO rate
Do not withhold epinephrine if IV not easily obtainable
 Over 75% of croup cases seen in ED have no IV
 If patient is unstable, establish IO access

Pediatric Medical Emergencies
EMS Protocol for Croup

Under 40 kilograms with S/S of croup
– Administer 3 cc of NS via nebulizer for 3-5 mins

Continue NS nebulization during transport if improved
– If no improvement, contact medical control
physician to administer inhaled epinephrine

All patients who receive nebulized epinephrine must
be transported by an ALS unit to the hospital
Pediatric Medical Emergencies
EMS Protocol for Croup

Obtain medical direction
– Give 2.5 ml of 1:1000 epinephrine via nebulizer
– A second dose may be given with medical
direction
– Other interventions, such as albuterol neb

Albuterol and epinephrine are compatible
Pediatric Medical Emergencies
Commercially Available Nebulizers
Pharmacological Actions of
Inhaled Epinephrine
Alpha-adrenergic receptor agonist
 Desired action

– Local vasoconstriction in the large airways, which
reduces airway edema and obstruction
– Caution: may have rebound edema
– Decreased systemic effects with inhalation
Pediatric Medical Emergencies
EMS Protocol for Croup

Imminent respiratory arrest
– Administer 0.01 mg/kg of 1:1000 epinephrine SC


Max dose is 0.3 mg
Interventions for pediatric respiratory failure
– Bag-valve-mask ventilations

May administer inhaled medications with BVM
– Endotracheal intubation
Pediatric Medical Emergencies
BVM with Multi-Dose Inhalor Port
BVM with In-line Nebulizer
Criteria for BVM Ventilations

Inadequate RR
– Infant/Toddler
– Child
– Adolescent

< 20
< 16
< 12
Bradycardia
– Infant
– Child
HR
HR
< 80
< 60
Pediatric Medical Emergencies
Criteria for BVM Ventilations

Inadequate respiratory effort
– Absent or diminished breath sounds
– Paradoxical breathing
– Cyanosis on 100% oxygen
Cardiac arrest
 Altered mental status

– GCS < 8
Pediatric Medical Emergencies
Complications of BVM Ventilations
Gastric distension
 Vomiting
 Increased ICP due to vagal stimulation

– Pressure over the eyes
Pediatric Medical Emergencies
Equipment for BVM Ventilations

Appropriate size mask
– Premature infants
– Newborn - 1 year
– 1 - 6 years
– 6 - 12 years
– 12 years - young adult
#0
#1
#2
#3
#4
Neonatal
Infant
Toddler
Pediatric
Small Adult
Pediatric Medical Emergencies
Equipment for BVM Ventilations
Suction
 Appropriate size airway adjunct
 Appropriate size bag

– Newborn - 3 mo
– Child < 30 kg
– Child > 30 kg
Neonatal
Pediatric
Adult
450 - 500 ml
750 ml
1000 - 1200 ml
Pediatric Medical Emergencies
Single Provider
Technique
Pediatric Medical Emergencies
Two
Provider
Technique
Pediatric Medical Emergencies
Respiratory Rates for
Assisted Ventilations
Infant/Toddler
 Child
 Adolescent

30 - 40
20 - 30
12 - 20
Pediatric Medical Emergencies
Evaluate BVM Ventilations
Chest rise and fall
 Presence of breath sounds
 Skin color
 Pulse oximeter reading
 Presence of end-tidal C02

Pediatric Medical Emergencies
Troubleshooting BVM Ventilations
Check size and seal of the mask
 Verify oxygen source
 Assure proper airway position

Pediatric Medical Emergencies
Troubleshooting BVM Ventilations
Disable the pressure pop-off valve
 Increase the size of the bag
 Treat gastric distension

– ALS providers: insertion of gastric tube
Pediatric Medical Emergencies
PRESENTATION

Paramedics responded to a call for trouble
breathing. Upon arrival they found a six
month old with audible inspiratory stridor.
– Mom reports that pt was recently discharged
after a work-up for a platelet disorder. He was
having stridor last night, but was much improved
this AM. No other past medical history or
allergies.
Pediatric Medical Emergencies
VITAL SIGNS
PULSE
 ECG
 RR
 O2 SAT
 BP
 SKIN
 WEIGHT

140-160
ST without ectopy
30-50, labored
90% on room air
84/45
Pale, warm, moist
Estimated at 10 kg
Pediatric Medical Emergencies
FIELD MANAGEMENT
Pt was kept calm in Mom’s arms for transport
 Inhaled saline at 6 LPM which brought the 02
sat up to 96%.
 Parents refused an IV due to pt’s low platelet
count.

Pediatric Medical Emergencies
E. D. MANAGEMENT
Upon arrival, chest x-ray done and pt placed
on humidified oxygen.
 Pt received two racemic epi nebs with no
improvement.

Pediatric Medical Emergencies
E. D. MANAGEMENT
Transport team contacted and recommended
another racemic epi neb, an albuterol neb,
and an IM dose of steroids.
 Parents finally consented to peripheral IV
insertion.

Pediatric Medical Emergencies
TRANSPORT TEAM MANAGEMENT
Upon arrival the pt was gray and gasping for
air with RR of 16.
 Transport RN and MD agreed pt needed
emergent intubation. Pt received IV sedation
with fentanyl and versed and was intubated
with #3.5 uncuffed ET tube.

Pediatric Medical Emergencies
TRANSPORT TEAM MANAGEMENT
CXR showed right mainstem intubation. ET
tube was pulled back.
 Pt transported to the PICU without incident.

Pediatric Medical Emergencies
DISPOSITION
Within twelve hours of admission pt
developed a leak around the ET tube and
was successfully extubated.
 He was discharged from the hospital three
days later with no ill effects.

Pediatric Medical Emergencies