Respiratory Emergencies in the Pediatric Population - wwwprsharma

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Respiratory Emergencies in the Pediatric Population - wwwprsharma Powered By Docstoc
					Respiratory Emergencies
in the

Pediatric Population

16 month old boy with wheeze
Initial Vitals: HR RR BP Temp O2sat on RA 160 60 88/50 38 89%

You do your pediatric assessment triangle:
Appearance Crying, distressed, looking around, moving all 4 limbs

Breathing (work of)

Laboured, chest caving in, +++indrawing
Colour OK, N cap refill


What would you like to do now?
Oxygen by mask applied, IV attempt started and pt now on cardiac monitor Airway Breathing No stridor audible, no obvious secretions +++ wheeze with little air entry bilat (inspiratory AND expiratory)

Circulation Warm extrem, PPP, cap refill 2 secs

What would you like to do now?
Oxygen CXR done / pending Ventolin Atrovent IV Access established – orders?

Blood work Doctor? Venous Gas pH pCO2 pO2 7.35 38 125

 Has had a “cold” for almost 2 days now
(mild fever, decreased energy / appetite with cough and runny nose)

 Started getting wheezy this morning  No history of exposure to allergens, inhalants or FB aspiration
Family History of Asthma / no smokers / no pets Otherwise healthy with no known allergies

Continuous Ventolin for 15 mins has little effect
 Still indrawing  RR 65  Still alert and looking around, crying Additional treatment? IV steroids Solucortef 1 mg/kg IV / IM Continue Ventolin Consider racemic Epinephrine (0.5 mls)

Repeat Venous Gas about 30 mins later pH 7.15 pCO2 55 pO2 120 Eyes rolling back, little crying now … What do you want to do?

Drugs? Tube Size?
4 – 4.5 tube
Ketamine 1-2 mg/kg IV Atropine 0.01 mg/kg IV (min 0.1 mg) Succinyl 1 mg/kg IV

Other Options
 IV Magnesium 25 mg/kg (max 2 gm)  IV Epinephrine  IV Ventolin  Inhalational Anesthetics  Methylxanthines  Heli - Ox

Differential Diagnosis of Wheezing
H+N Chest
Vocal cord dysfunction Asthma Bronchiolitis Foreign Body Aspiration Congestive Heart Failure Vascular Rings


CAEP Pediatric Asthma Guidelines
• Nocturnal cough • Exertional SOB • Increased Ventolin use • Good response to Ventolin

Pre - Treat

O2 sat > 95% PEF > 75% (predicted / personal best)
± O2 Ventolin Consider po Steroids


CAEP Pediatric Asthma Guidelines

• Normal mental status • Abbreviated speech • SOB at rest • Partial relief with Ventolin and required > than q 4h

Pre - Treat

O2 sat 92%-95% PEF 50-75% (predicted / personal best)
O2 100% Ventolin Systemic corticosteroids Consider anticholinergic


CAEP Pediatric Asthma Guidelines
• Altered mental status • Difficulty speaking • Laboured respirations • Persistant tachycardia • No prehospital relief with usual dose Ventolin

Pre - Treat

O2 saturation <92% PEF, FEV1 <50%

100% O2 (consider RSI) Continuous or frequent b-agonists Systemic corticosteroids & magnesium sulfate Consider anticholinergic & / or methylxanthines

CAEP Pediatric Asthma Guidelines

• Exhausted , Confused • Diaphoretic • Cyanotic, Decreased respiratory effort, APNEA • Falling heart rate

O2 saturation <80%
Pre - Treat
(spirometry not indicated)


As above PLUS RSI IV Ventolin Inhalational anesthetic, aminophylline Epinephrine

18 mo Girl with 24 hr Hx of coughing with drooling
Hx: Has had an URTI for about a week and was getting mildly better until yesterday. She developed a fever and the cough got harsher.
Still drinking but not interested in solids Vomited once last night Started drooling this morning

Physical Exam
T39.1 degrees rectally, P170, R28, BP 100/66
Appearance alert, awake, not toxic, in no acute distress Did not appear to prefer upright or a forward leaning position


Moist MM, slight erythema of oropharynx, nasal crusting, N TMs, no rash / petechiae, no drooling Supple neck


Clear when resting Mild inspiratory stridor with crying Rest of the exam N

DDx? • Croup • Epiglottitis • Bacterial tracheitis • RetroPharygeal abcess • Foreign Body aspiration

Other things on DDx of Inspiratory Stridor
Laryngeal Web TEF Diptheria Airway thermal injury Subglottic stenosis Peritonsillar abcess GERD Esophageal FB Laryngeal fracture Laryngeal cyst Lymphoma

Soft tissue lateral neck radiograph

Retropharyngeal Abscess
Lymph nodes between the posterior pharyngeal wall and the prevertebral fascia

• gone by 3 – 4 yrs of life • drain portions of the nasopharynx and the posterior nasal passages • may become infected and progress to breakdown of the nodes and to suppuration

Complication of bacterial pharyngitis Less frequently - extension of infection from vertebral osteomyelitis
Group A hemolytic streptococci, oral anaerobes, and S. aureus

Typically …
Recent or current history of an acute URTI

Abrupt onset:  High fever with difficulty in swallowing
 Refusal of feeding

 Severe distress with throat pain
 Hyperextension of the head  Noisy, often gurgling respirations  Drooling

On Exam …
Nasopharynx Oropharynx Bulging forward of the soft palate and nasal obstruction Bulging of posterior phyaryngeal wall or Not visualized

Soft Tissue Neck Film
Patient position – MILD EXTENSION

Positive Film - Retropharyngeal soft tissue > ½ the width of the adjacent vertebral body - may see air in the retropharynx

Abscess rupture - aspiration of pus. Lateral extension - present externally on the side of the neck Dissection along fascial planes into the mediastinum Death may occur with aspiration, airway obstruction, erosion into major blood vessels, or mediastinitis.

 Clindamycin 20-30 mg/kg/day divided Q8H (if pre-fluctuant phase)
 Decadron 0.6 mg/kg  Airway management

 Surgical decompression

17 month old male with a one-hour history of noisy and abnormal breathing
Normal now but at the time, parents thought he was quite distressed. Now, he is able to speak and drink fluids without difficulty

VS T36.8, P200 (crying), R28 (crying), O2 sat 99%

Alert with no signs of respiratory distress Able to speak, had no cyanosis, no drooling, no dyspnea H+N Chest
No obvious swelling, bleeding, FB seen Mild wheezing with ? mild inspiratory stridor

What would you like to do now???

Soft Tissue Neck View


Next? Expiratory CXR

Inspiratory View

Expiratory View

Right Decub View

Foreign Body Aspiration
 More common with food than toys  Highest risk between 1 and 3 years old
(immature dentition – no molars, poor food control)

 Common foods = peanuts, grapes, hard candies  Some foods swell with prolonged aspiration
(may even sprout)

Clinical Manifestations
Typically … Acute respiratory distress (now resolved or ongoing) Witnessed choking period Uncommonly … Cyanosis and resp arrest Symptoms: cough, gag, stridor, wheeze, drool, muffled voice

 Lateral neck  Chest – inspiratory, expiratory, decubitus views

Expiratory views
Overinflation (partial obstruction with inspiratory flow) Volume loss with mediastinal shift towards obstructed side (partial obstruction with expiratory flow) Atelectasis (complete obstruction)

Decubitus views
Normal Smaller volumes and elevated diaphragm on side down Hyperinflation or “normal” volumes in decub position


If suspected …
Need a bronchoscope to rule out or remove Foreign Body

2 yo Boy with Barky Cough for 2 days
 Runny nose, decreased appetite  Not himself

No PMHx / FHx of significance Shots UTD
Other sibs with similar URTIs

On Exam …
Temp 38.9 HR 140 O2 sat 98% (drops to 90% when he crys) RR 40 (mild indrawing)
Irritable, crying, good colour H&N sl erythema of throat, no pus N TMs, small cervical nodes


Barky cough, inspiratory stridor No wheeze noted

Racemic Epinephrine 0.5 ml dose

? Dexamethasone now or later

Re – Assess in 30 minutes
No improvement with 1st dose of epinephrine

What would you like to do now?

Re – Examine
Ongoing Inspiratory Stridor Cries when trachea is examined

IV Cefuroxime PLUS Cloxacillin
Consult Pediatric ICU / Pulmonary for Bronch / Intubation

Bacterial tracheitis
 An acute bacterial infection of the upper airway capable of causing life-threatening airway obstruction  Staph aureus most commonly
(parainfluenza, Moraxella catarrhalis, H. influenzae, anearobes)

 Most pts less than 3 years old  Usually follows an URTI (esp laryngotracheitis)  Mucosal swelling at the level of the cricoid cartilage, complicated by copious thick, purulent secretions

Brassy cough High fever “Toxicity" with respiratory distress
(may occur immediately or after a few days of apparent improvement)

Failed response to CROUP TREATMENT
(mist, intravenous fluid, racemic epinephrine)

Antibiotics (good Staph coverage)
Intubation or tracheostomy is usually necessary

? Decadron

Pediatric Pneumonia
Neonate 1 – 3 mo Bacteria more frequent E. coli, Grp B strep, Listeria, Kleb Chlamydia trachomatis (unique) Commonly viral (RSV, etc.) B. Pertussis S. pneumonia, Chlamydia pneum Mycoplasma pneumonia RSV Strep pneumonia, Mycoplasma, Chlam

1 – 24 mo 2 – 5 yrs

Severe Pneumonia:
Staph aureus Strep pneumonia Grp. A strep HIB Mycoplasma pneumonia
Pseudomonas if recently hospitalized

Infants < 3 months Tachypnea, cough, retractions, grunting, isolated fever or hypothermia, vomiting, poor feeding, irritability, or lethargy

As age increases, symptoms are more specific Fever and chills, headache Cough or wheezing Chest pain, abdominal distress, neck pain and stiffness

Physical Exam
Tachypnea is the best single indicator of pneumonia Age in months Upper limit of Normal RR

2-12 > 12

45 35

Neonates 1 – 3 mo 1 – 24 mo
Ampicillin + Gentamycin / Cefotaxime Erythromycin 10 mg/kg IV Q6H Cefuroxime 50 mg/kg IV Q8H (not ICU) Ceftriaxone 50-75 mg/kg IV Q24H and Cloxacillin 50 mg/kg IV Q6H (ICU)

3 mo – 5 yrs Cefuroxime / Erythro IV (admitted)
Clarithro / Azithro (outpt Tx)

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