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NWC EMSS CE May 2017 Peds Respiratory Emergencies

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Pediatric Respiratory Emergencies

Northwest Community EMSS CE May 2017Connie J. Mattera, M.S., R.N., EMT-P

So, where do you find?Peds dosing reference tables

By the numbers…

Peds patients responsible for ~7–13% of EMS calls

Pediatric Emergency Care Applied Research Network most common chief complaints

Traumatic injury (29%) Pain (combining abdominal and others) (10.5%) General illness (10%) Respiratory distress (9%) Behavioral disorder (8.6%) Seizure (7.45%) Asthma (3.9%)

Factors for successful outcomes

Define responsibilities in advance

Know physiologic and psychological differences in children

Be familiar with developmental stages

Know unique disease and injury patterns in children

Know where your resources are!

Essential pediatric knowledge/skills

Ability to establish therapeutic relationships and communicate effectively with children/caregivers

Sequencing a pediatric assessment; correctly interpreting data; rapidly intervening with evidence-based care per peds SOPs

Caring, supportive and patient-sensitive interactions

Critical thinking/problem solving

COMMUNICATION EXERCISE – Pair up!


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There is no average sized child

One of our challenges? Pediatric age classifications

Newly born: First minutes to hrs after birthNeonate: Birth to 1 monthInfant: 1 to 12 monthsToddler: 1 to 3 yearsSchool age: 6 to 12 yearsAdolescent: Puberty - adult (18 yrs)

How can EMS estimate child’s size to treat?

Broselow Tape (2017) incorporates revised length weight zones based on most recent National Health and Nutrition

Examination Survey data

Weight

Alternatives to tape? Use scale if availableAsk parents / caregiverUse formula:

2 X age in years + 8 = wt. in kgLook up age/height/weight charts

How does the difference in pediatric anatomy impact our management of children?

The number one cause of cardiac arrest and death in

pediatric patients is…

HYPOXIA


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Obligate nose breather until 6 mos

How do young infants breathe?What is the impact to airway patency

and EMS care due to their large tonsils and adenoids?

Airways more easily obstructed Tend not to use NPAs in children < 4

Tongue is large in proportion to oral cavityIn what child is this

particularly true?

Why does neck flex when supine?

Large occiput

Why is hyperextension also contraindicated?

Can crimp and close off the airway

Nose to ceiling

Pad under torso

What position is just right?


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Jaw is posteriorly smaller in young children

Epiglottis wafer thin

Larynx is higher (C2-C3), more anterior

So what?

May make visualization more difficult

Allows for simultaneous feeding and breathing

Large and omega (Ω) shaped in infants

Extends at a 45° angle into airway

Epiglottic fold shorter and stiffer

Susceptible to swelling

So what?

Makes it more difficult to manipulateTend to use straight blade when intubating

Pediatric epiglottis

Vocal cords

Adult Peds

Steve Cole, CCEMT-P

Anterior attachment of peds cords is lower than posterior -creates an upward slant; adult cords are horizontal

Concave shape may affect ventilation; important to use jaw-lift maneuver to open arytenoids

What is the narrowest point of a child’s airway?

Speed of deterioration mathematical

Diameter = πR2

↓ diameter by ½ = 16 fold ↑ in resistance

Implications for care?

Even a mm of edema narrows airway considerably

Edema or infection more severe threat

↑ chance of obstruction

Trachea & mainstem bronchiTrachea cartilage softer, shorter

Mainstem bronchi: More symmetrical Split off at 55° angles

Implications for care?Increases likelihood of mainstem intubation

Aspiration or intubation can occur on either side


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Pediatric alveolation10-70 million primitive alveoli at birthAlveolar surface ↑ from 2.8 m2 (14% BSA) to 70 m2 (25% BSA)

Pulmonary SystemSmaller lung capacity and ↓ pulmonary reserve

Fewer pores of Kohn; ↓collateral ventilation

Implications for care?

Becomes hypoxic more quickly

↑ risk for atelectasis

Lung tissue more fragile; ↑ risk for pneumothorax

High resistance ↑ respiratory effort

Requires more time to fill & empty alveoli

If rapid RR does not allow adequate expiration, alveoli may overdistendand rupture

Rib/lung differences

Infant: chest has cylindrical shape; ribs horizontal

Ribs softer, more pliant -offer less protection

Fewer accessory muscles

Little leverage to ↑ A-P diameter

Diaphragm dependent ventilation (Belly breathers) until age 3

Abdomen rises & falls w/ each breath

Adult

Infant

Extremely soft & pliableLittle stability for chest wall

Sternum What are the implications of chest & lung differences?

Lung tissue is more fragile – more prone to pneumothorax from barotrauma

Ribs less likely to fracture

Significant internal injury can be present without external injury

Pulmonary contusion more common


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Heart Proportionally takes up more room in chestMediastinum more mobile; shifts greater

Put it all together…why doesn’t a child have pulmonary reserve?

Horizontal ribs; soft sternumWeak intercostal musclesLarge heart and abdomen↓ functional reserve capacityPoor ability to create negative intrathoracic

pressureCannot ↑ VT so ↑ RR when stressed

Beware RR>60

Hypoxia develops easily!

Breath sounds easily transmitted through thin chest wall

Implications?

Easy to miss a pneumothorax or misplaced ETT

Need to listen laterally to posteriorly on both sides of chest

Basal metabolic rate higherO2 consumption 50% higher/unit of body wt

in early childhood Implications?

↑ Risk for hypoxia

Implications for care?Will maintain BP until > 25-30% volume lossMay be in shock despite normal BPAssessments must be based on signs of tissue hypoperfusion

Children vasoconstrict and shut down to periphery well when stressed

What part of body is important to asses?

DehydrationWt loss of 10% = 15% fluid loss

ECF turnover rate up to 3 X > adultPreemies 60% turnover of water/day

Infants 15%Adults 9%

What is the leading cause of childhood

death worldwide?


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Assess volume/hydration status

Dry skin, poor skin turgor - tenting Absence of sweating, tearsHypotension (postural), tachycardiaDry mouth, furrowed tongueTachypnea, feverConfusionThirstAcute wt. loss

Palpate anterior fontanelle if < 15 mos; quiet vs crying

Fontanelles

Allow rapid growth of brain

Permit skull to change shape

Posterior close: 3 mos

Anterior close 9-18 mos

Pulsations reflect HR

Bulge: cry, cough, vomiting, ↑ ICP

Depressed: dehydration, malnourished

Immune SystemImmature in first 3-6 mosMore susceptible to severe infectionsLimited to passive immunity from mom

General approach to the pediatric patient

From the AAP’s Pediatric Education for Prehospital Professionals (PEPP) course. www.PEPPsite.com


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Airway Listen for any gasping

or choking noises Ask if the child can speak

Breathing If labored ventilations – determine cause If hypoxic administer oxygen

Circulation Check general pulse rate and quality Assess for uncontrolled external bleeding

Primary AssessmentCerebral function: Level of consciousness

Plus…Appearance, behavior,

cooperation (ability to follow simple

commands)

Language

Quality and rapidity of responses

Social response: Responsiveness to family members - do they recognize parents, toys?

Attention span

Unconcerned and allowing invasive procedures without protest?

Emotional status: Consolable vs. inconsolable?

Paradoxic irritability?

Response to environment If responsive: Is child crying or talking without difficulty or noise?

Yes: Go to breathing

No: Continue to assess airway

Inspection

PositionFace & neck for symmetry, wounds,

burns, edemaF/B; secretions

Loose teeth, emesisTongue obstruction

Symmetry of chest expansion & depth

InspectionDrooling; hoarseness

Listen for audible soundsWheezing, grunting Tripod position Tachypnea Retractions Accessory muscle use: nasal flaring, head bobbing

Altered mental status https://www.youtube.com/watch?v=q0bH

wMayCJY


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Diminished breath soundsTachy/bradycardia

AMS

Peds airway

adjuncts SOPp. 70

https://www.youtube.com/watch?v=Zkau4yHsLLM&list=PL7EA9354BC2DD8B67&index=2

Regardless of chief complaint, early and appropriate airway management is important first step

Allow responsive child w/o shock or spine concerns to assume most comfortable position to move air

<12 yrs: BLS adjuncts & interventionsUnsuccessful: 1 attempt at advanced

airway per OLMC onlyAdolescents > 12 yrs: per adult SOP

Possible indications for advanced airway in children

Persistent airway impairment, ventilatory failure (apnea, RR <10 or >40; shallow/labored effort; SpO2 92; increased WOB (retractions, nasal flaring, grunting) fatigue

Inability to ventilate/oxygenate adequately after insertion of OP/NP airway and/or via BVM

Need for inspiratory or positive end expiratory pressures to maintain gas exchange or sedation to control ventilations

Sedation prior to DAI in childrenKETAMINE 2 mg/kg slow IVP (over 1 min) or 4 mg/kg IN/IM (not for TBI)

Monitor VS, level of consciousness, skin color and SpO2 q. 5 min. during procedure.Interrupt DAI if HR < 60 or SpO2 < 94% Ventilate w/ O2 15 L//Peds BVM at 12 BPM until condition improves

Allow at least 1-2 minutes for clinical response before DAI (if possible)


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Peds ketamine dosing

Align tube markings with vocal cordsNote marking on

proximal tube end

Depth of insertion:TT diameter X 3

If > 2 yrs:(Age in yrs / 2) + 12

If intubated - On-going monitoring

Never leave an intubated child aloneIf condition deteriorates after tube is placed

assess for:Displacement of tube

from tracheaObstruction of the tubePneumothoraxEquipment failure

BREATHING/GAS EXCHANGE Pliable thoracic cage

Less protection of upper abdominal organs

Mobile mediastinum

Less aortic disruption –more tracheobronchial injuries

Earlier compromise from tension pneumo

Pulmonary contusion common

Ventilatory attempts: Spontaneous?

Generally fast or slow?

Tachypnea: Metabolic acidosis, fever

Bradypnea: Impending respiratory arrest

Work of breathingMore informative in peds than absolute RR

Reflects resistance in small air passages, dependence on diaphragm and weakness of chest wall muscles

Assess RR while child is quiet

Respiratory effort: obvious distress or pain, head bobbing, retractions, nasal flaring, stridor, audible wheezing, grunting

https://www.youtube.com/watch?v=vvgTCG18oZo


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Assess chest/abdominal contour

Children should easily maintain SpO2 > 96% with O2

Readings < 94% suggest impaired pulmonary function

Target SpO2: 94%-98%

Central vs. peripheral cyanosisAdequacy of ventilations: Quantitative waveform capnography

AuscultateImmediately if in distress – note if sounds are

Present Diminished Absent Asymmetrical Adventitious

Lung sounds

Can be very difficult to hear (noise, crying)Snoring (usually tongue obstruction)Stridor (Croup, epiglottitis, F/B, edema)

Wheezing (asthma, bronchiolitis, allergic reaction)

Crackles (pneumonia)


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Anticipate deterioration or imminent respiratory arrest if:

↑ RR, esp. if S & S of distress & ↑ effort

Inadequate RR effort or chest excursion

↓ peripheral BS

Gasping or grunting respirations

↓ LOC or response to pain

Poor skeletal muscle tone

Cyanosis

Correct hypoxia/assure adequate ventilations:

O2 1-6 L/Peds NC: Adequate rate/depth; minimal distress; SpO2 92%-94%

O2 12-15 L/Peds NRM: Adequate rate/depth: mod/severe distress; SpO2 < 92%

O2 15 L/ Peds BVM: Apnea and/or shallow/inadequate rate/depth with mod/severe distress; unstable

Ventilate 1 breath q. 3 to 5 sec; just to visible chest rise

If hypoxia/inadequate ventilations

Circulation Pulse assessment

Presence

Location

General rate

Volume/strength

Rhythmicity

Signs of poor perfusion

Cool extremities

Altered mental status

Weak pulse;

prolonged cap refill

Skin: pale, mottling

then cyanosis

Capillary refill should be < 2 sec in a warm environment in a child <6 years

Skin color: pink, pale, mottled, cyanotic, flushed

Mottling of extremities (knee caps), caused by hypoxemia, hypovolemia, or shock, is due to extreme vasoconstriction


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PR & QRS intervals are shorter T waves normally inverted V1-V3 up to 8 yrsAsystole & bradyarrhythmias are 90% of rhythms in peds cardiac arrests

ECG monitoring if unstableUse standard size electrodes in children > 10 kg Vascular access site

Selected based on Purpose & duration of infusion Patient’s clinical status Age Health history Vein location,

condition, relation to other structures, physical path along extremity, size

Assess glucose if AMS GCS for childrenEye opening Points

Spontaneous 4To voice 3To pain 2None 1

Verbal response PointsCoos, babbles 5Irritable, cries 4Cries to pain 3Moans to pain 2None 1

Motor response PointsNormal movement 6Withdraws to touch 5Withdraws to pain 4Abnormal flexion 3Abnormal extension 2None 1

Transport decision

Do NOT delay transport to perform assessments or procedures that can be done enroute if time sensitive condition:

Poor general impression

Apnea, pulselessness

Immediate life threats

Obvious severe distress

Secondary assessment


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Resting respiratory ratesNatural hyperventilators

RR decreases as body size increases

Infants 30-60 (40)

Toddlers 22-40 (35)

Pre-school 22-34 (30)

School age 18-30 (20)

Adolescent 12-20 (16)

Count pulse for 30-60 sec Heart rate averages

Newborn – 3 mos 1403 mos – 2 yrs 120-1302 - 10 yrs 80> 10 yrs 75

Blood pressure5th% (lower limits) of norms

Newborn to 1 month 60 mmHg1 month to 1 year 70 mmHg1 to 10 years 70 + 2 X age in yrs> 10 years 90 mmHg

Methods of temperature measurement

OralAxillaryTympanic membrane

Temporal arteryRectal –Not for EMS


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Case #1 - Dispatch Information

A 5 y/o male presents with a history of fever, noisy breathing, and drooling. Mom states that the fever began this morning and has spiked this afternoon.

The noisy breathing was alarming to the child’s parents so 911 was called.

Mom states that the child has not taken anything by mouth since he became ill.

Case #1 – H&PVS: BP 100/66; P 144; RR 32 & shallow; SpO2 90% on RA; T 103° F

Alert, awake, in acute respiratory distress, and prefers an upright or forward leaning position

Skin: hot and moist without a rashOropharynx: clear; mucosa is moistLung sounds: clear bilaterally; inspiratory stridor with retractions

What can cause peds resp distress?

Bronchiolitis 90,000 children hospitalized/yr 4,500 deaths/yr from RSV

Croup: 90% of stridor cases in children older than neonates

Epiglottis: 25% < 2 yrs

FBAO: 90% < 4 yrs

Differential cont.

Pneumonia 40 in 1,000 preschool children 9 in 1,000 10-year-olds Mortality rate < 1%

Asthma Most common chronic peds disease

4.8 million < 18 years old 50-80% develop S&S < age 5

Other differentials: Infectious processes

MononucleosisDiphtheriaPertussisTonsillitisLudwig’s angina with retropharyngeal abscess

Subglottic laryngitis

Other differentials: non-infectious processes

Allergic reactionAngioneurotic edemaForeign body aspirationReflex laryngospasmLaryngeal tumorHydrocarbon aspirationSystemic lupus erythematosusInhalation of toxic fumes or super-heated steam


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Need to determine acuity

Respiratory distress: Compensated state of dysfunction with increased rate and effort. Adequate levels of O2and CO2 maintained.

Respiratory failure: Inadequate elimination of CO2 and inadequate blood oxygenation

Course1.winona.edu/golsen/N422/Present/respdistr.htm

https://www.youtube.com/watch?v=VQiqgLZVUK4

Essential video to watch

Upper respiratory

emergencies

More serious than adults

Significant obstruction can occur due to small size of Eustachian tubes, larynx and bronchi

Poor cough reflex and minimal pulmonary reserves

Partial obstruction of upper airways is evidenced by stridor

Seriousness of URIs in children

BSI/PPEIf fever and cough: Contact and

droplet precautions, hand washing, gloves, masks

Stridor Most prominent symptom of partial airway obstruction

in pediatric patient

Sound heard w/o a stethoscope due to collapsing airways

from pressure changes

Can be misdiagnosed as asthma, bronchiolitis, bronchitis


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StridorProduced by rapid, turbulent airflow through narrowed segment of respiratory tract

High or low pitched, loud or soft, inspiratory or expiratory Inspiratory: obstruction at or above larynx Expiratory: obstruction below carina

Acute stridor usually results from infection Croup: 90% of infectious stridor Epiglottitis: most of the rest

Stuffy noseNasopharyngeal massBase of tongue massNeurologic lesions (CN IX, X, XI)

Enlarged tonsils & adenoids

Retropharyngeal abscess or tumor

Peri-tonsilar or para-pharyngeal space abscess

DiphtheriaFB in larynx or tracheobronchial tree

Asthma (expiratory)Bronchiolitis (expiratory)Pneumonia

Differential for stridor

Croup Epiglottitis Croup (Laryngotracheobronchitis)

Semi-acute URI90% of URI in childrenEtiology: parainfluenza A most common, RSV, adenovirus, influenza A

Usually occurs during winterClinical diagnosis based on Hx and PE

https://www.youtube.com/watch?v=7xDM8vuVEPo

Causes swelling of larynx & subglottic tissuesNormal epiglottis“Steeple sign” of subglottic trachea

Croup S&SHoarse voice & barking coughDyspnea, tachypneaStridor: if severe inspiratory & expiratoryLow grade feverFlaring/retractions if severeTachycardia; mild cyanosisHolds head backLOC: normal, restless to lethargicIf toxic appearing: consider bacterial tracheitis or epiglottitis

Great Neck public schools


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Croup – No CR compromisePosition of comfort: Do NOT irritate child by forcing exam; avoid visual exam of pharynx

ABCs

Lower acuity: NONE TO MILD CR compromise:

Peds IMC & transport

CroupEmergent to CRITICAL: Moderate to severe CR compromise: Cyanosis, marked stridor or respiratory distress. If toxic-appearing, consider bacterial tracheitis or epiglottitis.

EPINEPHRINE (1 mg/10mL) 0.5 mg (5 mL) w/ 6 L O2/HHN/mask (aim mist at child's face) or /BVM

Do not delay transport Consider possible epiglottitis 1/2

EpiglottitisLife-threatening; usually caused by bacterial infection; associated w/ septicemia

Rapid onset

Swollen epiglottis and supraglottic tissues can obstruct airway in hours

2-7 years formerly most common age group affected – now adults

Decreasing with Hib vaccine

Epiglottitis S&Sc/o severe sore throatDrooling; DysphagiaDysphonia; muffled speechHolds mouth openDistressed inspiratory efforts; stridor, retractions

Sniffing positionAnxiousHigh fever (>102° F)Tachycardia

Consider in determining impressionPossible allergic reactionForeign body aspirationMost recent oral intakeTime of onsetPrior recent illnessHeadache/stiff neck

Treatment

Avoid any stimulation of childMinimize touchingKeep child calm

EMERGENT: None to mild cardio-respiratory compromise: No cyanosis, effective air exchange:Peds IMC only. Sit up; anticipate rapid deterioration


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Epiglottitis Rx

DO NOT…Lay child flatUndress childExamine child’s throatPut anything in child’s mouthTake an oral temperatureSeparate child from parentsLeave child unattended

Epiglottitis – Treatment cont.

ABC’s – time sensitive patientCRITICAL: Moderate to severe CR compromise:Bradycardia, AMS, marked ventilatory distress, retractions, ineffective air exchange, and/or actual or impending respiratory arrest.

Nebulize EPINEPHRINE (1 mg/10mL) 0.5 mg(5 mL) w/ 6 L O2/HHN/mask (aim mist at child's face) or /BVM. Position to optimize air exchange (upright); do not delay transport setting up medication.

Epiglottitis – Treatment cont.

If continued inadequate ventilations/oxygenation:Position supine (sniffing); O2/high flow NC/mask

If ventilatory failure: 15L O2/Peds BVM at age-appropriate rate using slow compressions of bag

If unable to ventilate: Temporarily stop ambulance; provide airway per Peds Airway Adjuncts SOP: Least invasive way possible

Be prepared for airway status to worsen after unsuccessful intubation attempt

International Journal of Pediatric Otorhinolaryngology Volume 74, Issue 2 ,

Characteristics Croup Epiglottitis

Age 6 mos – 4 yrs 2 – 7 yrs

Organism Viral H. Influenza type b

Incidence Common Rare

Presentation

Gradual onsetMild URI S&SLoud stridorHoarse voiceBarky cough

Low fever

Sudden onset Drooling dysphagia

Soft stridor Muffled speechSitting forward

High fever

Case #2

An 8-y/o male is brought to school nurse after developing increased WOB while in the cafeteria. The patient has red blotchy hives on his face and neck.

The nurse learns he has a peanut allergy and may have ingested a cookie with peanuts.

Patient’s voice is becoming slightly hoarse and the hives are becoming more pronounced including on the hands.


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Realizing the patient’s condition is worsening and having no diphenhydramine or epinephrine on hand, the RN calls 9-1-1.

EMS arrives on scene four minutes later and finds the patient anxious and pale with difficulty breathing, beginning retractions and complaining of intense itching on his face, lips, throat and hands.

VS: BP 85/40; HR 120, RR 30, SpO2 92% on RA; ETCO2 30. Urticaria is now widespread, his lips are swollen, and his cap refill is 3 seconds.

What are the EMS priorities of management right now?

Need pt size (weight) and PMH from school nurse OR

Measure w/ Broselow tape

He weighs 55 lbs (25 kg) and is 50” tall (Orange zone)

SIMULTANEOUSLY

Apply O2 while preparing epinephrine – how?

15L/NRM

Drug dose and route?

SOP

EPINEPHRINE (1mg/1mL) 0.01 mg/kg (max single dose 0.3 mg) IM (vastus lateralus muscle) [BLS]

May repeat X 1 in 5-10 min prn; DO NOT DELAY TRANSPORT waiting for a response

THIS PATIENT by weight-based dosing?

0.25 mg (0.25 mL) IM

Also prepare long-acting antihistamine

Drug, dose and route?

DIPHENHYDRAMINE 1 mg/kg (50 mg max) IVP [ALS]; if no IV give IM [BLS]

Packaged (50 mg / 1 mL)

This patient? 25 mg

Set up for IV attempt

Size of catheter?

18-20 g

Why?


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Volume to infuse

Predetermined amount based on weight & condition

If hypovolemic: 20 mL/kg

Draw up into a syringe

Rapid infusion or push over < 20 min

May repeat X 2 prn

THIS PATIENT?

500mL

Apply ECG electrodes to chest

Switch to administering positive-pressure ventilations via BVM with 15L O2

Place defib pads

Repeat epi if not done already; move to the unit for transport

The child’s level of consciousness and respiratory effort rapidly deteriorate, what intervention is needed now?

Begin quality CPR;Prolonged CPR indicated while S&S of anaphylaxis resolve

Defibrillate – how many Joules? 50 J

Start 2nd vascular access line (IO); give IVF as rapidly as possible (up to 20 mL/kg) (use pressure infusers if available)

Once inside the ambulance, the patient becomes completely unresponsive and apneic. Pulseless V-Fib is apparent. What interventions are indicated now?

What drug is now indicated?EPINEPHRINE (1mg/10mL) 0.01 mg/kg (0.1 mL/kg) up to 1 mg IVP/IO q. 2 min; treat dysrhythmias per appropriate SOP. Repeat q. 3-5 min as long as CPR continues.

What is the dose for THIS patient?0.25 mg – 2.5 mL

122

What drug is indicated next?

AMIODARONE 5 mg/kg IVP/IO Max single dose 300 mg

What is the dose for THIS patient?

125 mg = 2.5 mL


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What drug is indicated next?

After 5 min: AMIODARONE 2.5 mg/kg (max 150 mg) IVP/IO

What is the dose for THIS patient?

63 mg = 1.25 mL

Due to poor BVM compliance, the patient is intubated using a 5.5 cuffed ET tube, noting obvious laryngeal swelling and difficult insertion. Continuous waveform capnography confirms tube placement with a CO2 of 80. After advanced airway: child was ventilated at 1 breath every 3-5 sec with no compression pause for breaths.

After next two minutes of CPR, patient is found to have a strong central pulse and some ventilatory effort. Upon arrival in the ED, a physician immediately confirms tube placement and orders 2 mg/kg of methylprednisolone via IV. This time…happy outcome!

Of the 16-18 million people who suffer

from asthma, an estimated

4.5 million are school aged

children

Due to small airway diameters, even incremental edema/ bronchoconstriction may cause severe air exchange problems & distress

WebMD

Asthma S&SInability of peds pts to increase their tidal volumes results in markedly ↑ RR that rapidly dehydrate airways and accelerates mucous production

Asthma S&SProlonged expiration; nasal flaring, use of accessory muscles ( WOB), retractions

Audible wheezing; sub-q emphysema between neck and navel

Itchy, tingly skin (especially younger kids)

Sudden, sharp chest pain (pneumothorax)

Hypoxemia and hypercarbia lead to acidosis and bradycardia

Kids die more from acidosis than hypoxia


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Cough Variant AsthmaChild may not wheeze but may continuously cough for 20 – 30 min after excitement or exercise

May abruptly vomit Treat like classic asthma

www.asthmacenter.com/

Severe asthma S&SBreath sounds: Severe = ↓ or absent

HR: Severe - bradycardia

O'Brien's Triad: Cyanosis, severe retractions and minimal or absent wheezing indicates impending respiratory failure

Silent chest = bad sign

Goals of therapy

Early recognition of deteriorationRapid relief of airflow obstructionPrevent/correct hypoxemia & acidosisReduce WOBBronchodilationReduce inflammation

https://www.youtube.com/watch?v=EK8nzKzdnIM

IMC special considerationsEvaluate ventilation (EtCO2)/oxygenation (SpO2), WOB, accessory muscle use, degree of airway obstruction/ resistance, speech/cry, cough, lung sounds, mental status, fatigue, and cardiac status

IMCPosition of comfort; ABCs

Airway/O2 per Peds Airway Adjuncts SOP if near apnea, AMS, fatigue, hypoxia, or failure to improve with maximal initial therapy


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Supplemental oxygenGive to all with moderate to severe attacksQuick relief drugs induce ventilation/perfusion mismatches that are offset by O2

Reduces respiratory muscle fatigue

O2 at 12-15 L/NRMAttempt to keep SpO2 > 94%

IMC special considerations

http://facs.med.cuhk.edu.hk/site/ANA/Reference.asp?topic=STANDARD%20PATIENT%20SET%20UP%20FOR%20ANAESTHESIA

IV access: Mild distress: No IV usually necessary Moderate to severe distress: IV NS

titrated to maintain hemodynamic stabilityMonitor ECG. Bradycardia signals deterioration of pt status

Wheezing and/or cough variant asthma; SpO2 > 95%:

ALBUTEROL 2.5 mg (3 mL) & IPRATROPIUM 0.5 mg via HHN or mask

Supplement w/O2 6 L/NC if patient is hypoxic and using a HHN

Begin transport as soon as started. Do not wait for a response.

Continue/repeat while enroute to hospital

Lower Acuity to EMERGENTMILD to MODERATE distress

Critical: SEVERE distress

Severe SOB, orthopnea, use of accessory muscles, speaks in syllables, tachypnea, lung sounds diminished or absent; exhausted; HR & BP may be dropping; SpO2 ≤94%

Time sensitive patient

EPINEPHRINE (1 mg/mL) 0.01 mg/kg (0.01 mL/kg) to a max of 0.3 mg (0.3 mL) IM

Typical dosing: 15 to 29 kg (33–65 lbs): 0.15 mg; ≥ 30 kg (66 lbs): 0.3 mg

Critical: SEVERE distress

Caution: Experiencing significant side effects (tachycardia) to Albuterol

Begin transport as soon as Epi is given Do not wait for a response

May repeat X 1 in 10 minutes if minimal response

Follow immediately withALBUTEROL 2.5 mg & IPRATROPIUM 0.5 mg via HHN, mask, or BVM

Cont. enroute; May repeat X 1 as needed


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Severe Asthma Rx cont.

MAGNESIUM (50%) 25 mg/kg (max 2 Gm) mixed with NS to total volume of 20 mL (slow IVP) over 10 min or

(Alt. in 50 mL IVPB on mcgtt tubing) over 10 min (Max 1 Gm/5 min) if premix bags stocked during a drug shortage

Put gauze moistened in cold water or cold pack over IV site to relieve burning

Go to appropriate SOP if HR < 60 or patient becomes pulseless or apneic

How can you tell the difference between an asthma attack and an allergic reaction?

History and physical exam

Allergic reaction has Hx of allergen exposure

Often begins with GI (N/V) or skin (hives, itching, flushed) S&S

Progresses to respiratory (SOB, wheezes) and cardiovascular (hypotension) S&S

A child with asthma has Hx of asthma but may also have a Hx of allergies

A 3-month-old infant presents with paroxysmal cough and increased respiratory effort progressively getting worse over the past 2 days. On exam, the child has a fever and is wheezing in all lung fields.

What should you suspect?

A. Pneumonia

B. Bronchiolitis

C. Aspiration

D. Asthma

RSV/Bronchiolitis

p. 75

RSV is the most important cause of lower respiratory tract disease in infants and children

It can present like a cold that gets worse

Respiratory Syncytial Virus (RSV) RSV: (Respiratory Syncytial Virus)

Produces yearly epidemics lasting 4-6 mos during late fall, winter or early spring

Timing and severity of outbreaks vary from year to year


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RSVSpread from respiratory secretions via contact with infected persons or contaminated surfaces

Infection occurs after virus contacts mucous membranes of eyes/mouth/nose

1st infection severe; 25-40% have S&S of Bronchiolitis or pneumonia; 0.5-2% require hospitalization

BronchiolitisMost common wheezing-associated illness in children under 2 years of age

Acute wheezing, cough, & respiratory distress prominently seen at night

Hx of otitis media in > 50% of cases

RSVMost recover in 8-15 days

Most have evidence of RSV exposure by 2 yrs

Reinfection common, but clinically milder

40% infants with RSV develop reactive airway disorders such as wheezing or asthma as adults

RSV: Clinical S&SEarly same as URI: runny nose, coughWithin 1-2 days, breathing labored; retractionsFeverApnea in young infantsProlonged expiratory phase with air trapping and wheezing

Tachypnea (50-60+), shallowWith severe exhaustion, infant may arrest

Position to optimize air exchange (upright)

ABCs: Clear nasal passages; O2

Nebulize EPINEPHRINE (1 mg/10mL) 0.5 mg(5 mL) w/ 6 L O2/HHN/mask (aim mist at child's face) or /BVM.

Do not delay transport setting up medication.

Usually poorly responsive to bronchodilators

If severe viral syndrome may need ETI, ventilation and IVF for dehydration

Treatment RSV cont. A febrile (105° F) 6-month-old infant presents with a poor appetite and decreased activity over the past 3 days.

On exam, the patient appears lethargic, is warm to the touch, and is taking rapid shallow breaths at a rate of 70 breaths/min. He has crackles in the right lower lung field.

What should you suspect?

Pneumonia


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Differential diagnosesCroup Epiglottitis FBAO

Age 6 mos – 3 yrs 1 – 7 yrs 6 mos – 5 yrsOnset 1 – 5 days Rapid; hrs Immed.

Position None Prefer erect None

Stridor I & E I Variable

Lung sounds Normal/wheeze Normal Absent/wheezeCough Seal-like bark No Possible

Voice change Hoarse Muffled Variable

Drool No Yes No

Dysphagia No Yes No

Temperature Low grade Yes None

Differential diagnosis cont.

Pneumonia Asthma Bronchiolitis

Age Birth- 10 yrs 1 & up 6 mos – 2 yrsOnset Gradual/weeks Rapid 3 – 5 days

Position None Prefer erect Prefer erect

Stridor None None None

Lung sounds Crackles Wheeze/absent Wheeze/absentCough Yes Yes or no Yes

Voice change No Possible No

Drool No No No

Dysphagia No No No

Temperature Yes None Yes

Hypoxia & Acidosis

Lead to…

Bottom line…

DEATH!

Outcome of case #1…

Recap: 5 year-old male Noisy breathing Fever Drooling VS

HR: 144RR: 32 and shallowBP: 100/66SpO2: 90% RA

EMS providers believed this child was in acute respiratory distress and attempted to ventilate w/ a BVM.

Upon putting the mask on the child, he became agitated and the paramedic thought he needed to be intubated immediately for the hypoxia.

After lying the child flat, he went into respiratory arrest.

When attempting intubation, the paramedic stated that he was unable to visualize the airway structures.


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While attempting to intubate, the child went into cardiac arrest while enroute to the ED.

The patient remained apneic and was pronounced dead 30 minutes after arrival in the ED.

…and a mother cries.

"Life isn't about how to survive the storm, but how to dance in the rain."

NWC EMSS CE May 2017 Peds Respiratory Emergencies · NWC EMSS CE May 2017 Peds Respiratory...

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