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Pediatric Respiratory Emergencies

Pediatric Respiratory Emergencies. Amy Gutman MD prehospitalmd@gmail.com www.PreparedRescuer.com. R eview critical aspects of emergency care of pediatric respiratory emergencies Epidemiology Anatomy Specific disease processes

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Pediatric Respiratory Emergencies

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  1. Pediatric Respiratory Emergencies Amy Gutman MD prehospitalmd@gmail.com www.PreparedRescuer.com

  2. 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 Overview

  3. Sick or Not Sick?

  4. 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

  5. AHRQ Statistical Brief #52. Healthcare Cost and Utilization Project (HCUP); May 2010 • Majority of ED visits “treat-and-release” • However, 500,000 pediatric ED visits result in admission, with the most common cause being respiratory • Four of the ten most common admitted conditions: • Pneumonia, asthma, acute bronchitis, & URI • In 0-4 yrs, respiratory conditions = 1/3 ED visits resulting in admission

  6. “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 O2consumption, limited O2 reserves

  7. 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 • Pliable / floppy trachea collapses easily (Poiseuille’s Law) • Adult: 1 mm edema = 81% size • Pedi: 1 mm edema = 44% size Laminar Flow: Laminar flow directly related to the pressure difference between two ends of a vessel & inversely related to the resistance of flow through the vessel

  8. 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

  9. Appearance Skin Circulation Assessment Work of Breathing • Pre-arrival preparation & scene size-up • 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

  10. 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? HPI & Exam

  11. “Normal” Vitals AGE HR SB 0-3 mo 14060-9020-60 3 mo–2 yrs 14090–10555-65 2 yrs–5 yrs 9095–10555-65 6yrs–10 yrs 80100–11560-72 >10 yrs 75115–12565-85 AGE HR SBP DBP

  12. Appearance • Alertness • Distractibility • Consolability • Eye contact • Speech/cry • Spontaneous motor activity • Color

  13. 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

  14. 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 Failure Arrest Bradypnea Inefficient respirations Cyanosis / Grey No air movement Tachypnea Nasal Flaring / Pursed Lips Stridor / Wheezing AMS / Agitation Agitation Tachycardia Delayed Capillary Refill Pale RR > 60 Retractions Grunting Mottling Head Bobbing Severe Air Hunger Bradycardia Hypotension

  15. 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

  16. 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

  17. 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

  18. Sanders Jr RC, Ron M. Walls RM, et al. Level of Trainee & Tracheal Intubation Outcomes. NEAR for Children Investigators. Pediatrics. 131:3, March 2013 • METHODS: • 15 PICU Prospective multicenter observational cohort (7/2010 – 12/11) • Outcome measures: FPS, overall success, & adverse associated events • RESULTS: • 1265 primary ETI encounters by pediatric providers • 1st & overall attempt success Residents (37%, 51%) • 1st & overall attempt success Fellows (70%, 89%) • 1st & overall attempt success Attendings (72%, 94%) • OR 4.29; 95% CI (3.24–5.68) • Attending vs Fellow vs Resident assoc with fewer adverse events (OR 0.42; 95% CI, 0.31–0.57) • CONCLUSIONS: • Resident tracheal intubation success low with high adverse events • Necessary intensive resident procedural training before “live” ETIs Endotracheal Intubation • 2005 AHA: • Cuffed ETT effective & safe for all ages • Un-cuffed ETT recommended in neonates • Rapidly deoxygenate & decompensate • Prepare to start compressions • “Hail Mary” plan • Overall ETI FPS rate 68% • EM physicians FPS rate 74%* • EMS overall success rate: 50%–80% *Resuscitation. 2012 Nov;83(11):1363-8.

  19. 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

  20. 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

  21. Secure The Baby! Secure The Tube!

  22. Upper vs Lower Airway Diseases • Upper Airway • Foreign Body Obstruction • Retropharyngeal Abscess • Bacterial Tracheitis • Epiglottitis • Croup • Lower Airway • RSV / Bronchiolitis • Asthma • Bronchitis / Pneumonia

  23. 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

  24. 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

  25. 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

  26. 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

  27. 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 uprightposition with humidified O2 Respiratory Distress + Sore Throat + Drooling

  28. 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

  29. Bacterial Tracheitis • Post URI • Purulent sputum, high fever, pseudomembrane • Toxic appearance + stridor • Croup-like symptoms responding poorly to croup management

  30. 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

  31. 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)

  32. 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

  33. 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

  34. 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

  35. 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)

  36. 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

  37. 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

  38. References • 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) • healthtraining@inh.com • 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.

  39. 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: prehospitalmd@gmail.com / Website: www.PreparedRescuer.com Text me: 513-255-1353

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