Download Pediatric Respiratory Emergencies

Pediatric Respiratory
Emergencies
Amy Gutman MD
EMS Medical Director Tobey Hospital
[email protected]
Conflicts of Interest
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Sadly, I have no corporate sponsorships or private funding to declare
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Employed by Tobey Emergency Associates, a private EM group staffing Tobey Hospital
Emergency Department (Southcoast Hospitals Group)
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Medical Director for a bevy of awesome Fire & EMS Departments & training programs
for which I am paid an enormous amount of money (ahem)
Overview
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Review critical aspects of prehospital care of
pediatric respiratory emergencies
– Epidemiology
– Anatomy
– Specific disease processes
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Emphasizing children have unique
pathophysiology & respond differently to
respiratory illness than adults
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Most 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?
Pediatric Epidemiology
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26% US population, 10% EMS calls
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Respiratory distress #1 cause of admissions
& death during 1st year except for congenital abnormalities
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Most pediatric cardiac arrests begin as respiratory failure
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Minimal training, few ill pediatric patients makes it difficult to obtain & maintain skills
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Multiple sized pts, equipment sizes & drug dosages confusing in stressful situations
“External” Airway Anatomy
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Large head, large tongue, small mandible
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Narrowest at subglottic / cricoid area
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Relatively straight cervical spine
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Less rigid thoracic cage with poor accessory
muscle development
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Horizontal ribs, diaphragm breathers
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Increased metabolic rate, increased O2
consumption, limited O2 reserves
Smaller “Internal” Airway
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Epiglottis floppy, U shaped & anterior
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Larynx anterior
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Short floppy trachea
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Small soft airways in obligate nasal breathers
– Nose = 50% airway resistance
– Large tonsils, adenoids rapidly swell
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Pliable / floppy trachea collapses easily
(Poiseuille’s Law)
– Adult: 1 mm edema = 81% size
– Pedi: 1 mm edema = 44% size
Patient Needs
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Fear of separation, being hurt & the unknown
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Allow family to be with patient as long as it
does not distract you
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Never lie!
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Always explain your plan to the child
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Position at eye level, remain calm, speak slowly
Assessment
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Pre-arrival preparation & scene size-up
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General assessment (Pediatric Assessment Triangle)
Work of Breathing
– “Sick” vs “Not Sick” vs “Could Rapidly Become Sick”
– Clinical indicators reflect CV, respiratory & neurological status
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ABCDE & transport decision
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Ongoing assessment including more thorough history & exam
CUPS: Critical, Unstable, Potentially Unstable, Stable
HPI & Exam
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HPI
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How fast deteriorating?
Fever?
Noisy breathing?
What has been done so far?
PMH
– Prematurity, hospitalizations, Illnesses, intubations, immunizations?
– Allergies?
– Medications?
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Exam
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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
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Treat the symptoms, not the disease
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Every child with respiratory distress needs
oxygenation as uncorrected respiratory distress
deteriorates to bradycardia & cardiac arrest
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Priority is to support breathing effort
– Remember the basics!
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If pulse remains low or breathing inadequate,
re-evaluate airway, ventilations, O2 & tubing
15
Airway Management
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Use pediatric assessment triangle to determine
oxygenation status & O2 delivery device
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Neutral “sniffing” head position
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Towel under shoulders; do not flex head which
collapses trachea
Head-tilt chin lift or jaw-thrust
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<5 seconds to look, listen & feel
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Suction airway
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Appropriate ventilation volume & rate (4-6
mg/kg)
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Maintain optimal cardiac output, 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
• EMS adult success rate: 85%–95%
EMS pediatric success rate: 50%–80%
• 2005 AHA:
– Cuffed ETT effective & safe for all ages, but
un-cuffed ETT recommended in neonates
• Rapidly deoxygenate & decompensate
– Prepare to start compressions
– “Hail Mary” plan
ETT & Resuscitation
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Smartphone apps:
– RapiTube, Difficult Airway, PediStat , PediSafe
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Traditional Calculations:
– Un-cuffed = (Age / 4) + 4
– Cuffed = (Age / 4) + 3
– General = Age + 16/4
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[6yo + 16]/4 = 22; 22/4 = 5.5 ETT
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Ready ETT 0.5 mm smaller & larger
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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
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Upper Airway
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Foreign Body Obstruction
Retropharyngeal Abscess
Bacterial Tracheitis
Epiglottitis
Croup
Lower Airway
– RSV / Bronchiolitis
– Asthma
– Bronchitis / Pneumonia
Apparent Life Threatening Events (ALTE)
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Lifeless, pulseless or unresponsive infant
recovering spontaneously & “looks normal”
– 1-2% infants
– Most common at 2-3 mo, uncommon >2 yrs
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All require transport & admission
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DDX:
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Arrythmias
Congenital heart disease
Abuse / Trauma
GERD
Infectious / Metabolic / Neurological
disorders
– 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
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Able to talk or minimal distress, rapidly transport in position
of comfort
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Responsive but significant distress:
– Child: abdominal thrusts or Heimlich
– Infant: chest thrusts, back blows
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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
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Rapid transport & notify receiving hospital
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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
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URI complication
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Lymph nodes between posterior pharynx &
pre-vertebral fascia
– Soft palate bulging obstructs nose
– Posterior pharynx bulging obstructs trachea
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Abrupt fever, severe distress, painful
swallowing
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Head hyperextension
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Noisy respirations, drooling
Epiglottitis (H. Influenza)
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4-6 yo most common
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10 X decrease since H. flu vaccinations
– 10% are vaccinated, but exposed to virulent strain
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High fever, sore throat, stridor, drooling, tripoding &
severe respiratory distress
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Supraglottic edema completely obstructs airway
– DO NOT attempt to visualize (“Sniff Test”)
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Manage according to severity of condition but rapidly
transport in upright position with humidified O2
Respiratory Distress + Sore Throat + Drooling
Croup (Viral Parainfluenza)
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Nightly recurring fever, hoarseness,
“barking seal” cough from laryngeal &
tracheal edema
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6 mo to 4 yr
– Males > Females
– Fall, early winter
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Management:
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Reassurance
Humidified, cool air
Steroids
Racemic epinephrine
Rare advanced airway management;
consider alternative diagnoses
Bacterial Tracheitis
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Post URI
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Purulent sputum, high fever,
pseudomembrane
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Toxic appearance + stridor
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Croup-like symptoms responding
poorly to croup management
Bronchiolitis (RSV)
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Viral bronchiolar edema from air trapping
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>80% < 1 yo
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Epidemics January - May
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Recent URI with gradual onset of SOB
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Expiratory wheezing, tachypnea, cyanosis
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Management
– Humidified oxygen
– Bronchodilators
– Advanced airway as needed
Asthma
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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
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Important History
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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
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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)
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Severe lung inflammation rapidly resulting in
hypoxia & respiratory failure
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Frequency: 2-12/100,000
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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
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Airway
– Oxygen + adjuncts including CPAP
– Make early aggressive choices including advanced airway
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Medications:
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Diphenhydramine
Histamine blocker (pepcid, zantac)
Nebulized or MDI albuterol (2.5-5 mg/dose)
Epinephrine 1:1000 IM
Anaphylactic Shock:
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Beware of “compensated shock”
Trandelenburg position
20 mL/kg crystalloid bolus; repeat to 60-80 mL/kg as necessary
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
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Activate ALS intercept; rapidly transport without
ALS if necessary
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Mild Distress
– If not taken max dose of prescribed MDI, encourage or assist patient to self-administer
– Med Control for 2nd MDI dose if max not administered. MDI contraindicated if max dose
administered, pt cannot physically use device, device not prescribed for patient
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ALS:
– IV, O2, Monitor
– If not improving with O2, consider 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
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Notify receiving hospital
Special Patients
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Tracheostomy tubes, apnea monitors, ventilators
are common home-care devices
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Most common are trach-related emergencies
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If ineffective ventilation/oxygenation:
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Obstruction
Tube dislodgement
Stoma bleeding
Tube reinsertion “false track”
Infection
Wipe stoma, suction tube
Remove tube if necessary
Once airway open, begin PPV
Attempt intubation if cannot oxygenate
Med Control may order 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
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Pre-arrival preparation important
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Standardized approach to assessment &
management
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Knowledge of normal child development
and age-specific physiology important
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“Sick/not sick” determination is
paramount in treatment & transport
decisions
Find me: Nights at Tobey ED
Email me: [email protected] / Website: www.TEAEMS.com
Text me: 513-255-1353