Respiratory Emergencies in the Pediatric Population Respiratory Emergencies in the Pediatric...

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  • Respiratory Emergenciesin thePediatric Population

  • 16 month old boy with wheezeInitial Vitals:HR 160 RR 60BP88/50Temp38O2sat on RA89%CASE 1

  • You do your pediatric assessment triangle:AppearanceCrying, distressed, lookingaround, moving all 4 limbs

    Breathing (work of)Laboured, chest caving in, +++indrawing

    CirculationColour OK, N cap refill

  • What would you like to do now?Oxygen by mask applied, IV attempt started and pt now on cardiac monitor

    AirwayNo stridor audible, no obvious secretions

    Breathing+++ wheeze with little air entry bilat(inspiratory AND expiratory)

    CirculationWarm extrem, PPP, cap refill 2 secs

  • What would you like to do now?Oxygen VentolinAtroventIV Access established orders?CXR done / pendingBlood work Doctor?Venous GaspH 7.35pCO2 38pO2125

  • History:

    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, inhalantsor FB aspirationFamily History of Asthma / no smokers / no petsOtherwise healthy with no known allergies

  • Continuous Ventolin for 15 mins has little effect

    Still indrawing RR 65 Still alert and looking around, cryingAdditional treatment?

    IV steroidsSolucortef 1 mg/kg IV / IMContinue VentolinConsider racemic Epinephrine (0.5 mls)

  • Repeat Venous Gas about 30 mins laterpH 7.15pCO2 55pO2120

    Eyes rolling back, little crying now

    What do you want to do?Drugs? Tube Size?Ketamine 1-2 mg/kg IV Atropine 0.01 mg/kg IV (min 0.1 mg)Succinyl 1 mg/kg IV4 4.5 tube

  • Other Options

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

  • Differential Diagnosis of WheezingH + NVocal cord dysfunction

    ChestAsthmaBronchiolitis Foreign Body Aspiration

    CVSCongestive Heart FailureVascular Rings

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

    O2 sat > 95%PEF > 75% (predicted / personal best)

    O2VentolinConsider po SteroidsSymptoms

    Pre - Treat


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

    O2 sat 92%-95%PEF 50-75% (predicted / personal best)

    O2 100%VentolinSystemic corticosteroidsConsider anticholinergic


    Pre - Treat

    TreatmentCAEP Pediatric Asthma Guidelines

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

    O2 saturation

  • CAEP Pediatric Asthma GuidelinesSymptoms

    Pre - Treat


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

    O2 saturation

  • 18 mo Girl with 24 hr Hx of coughing with droolingHx: 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 solidsVomited once last night

    Started drooling this morning

    CASE 2

  • T39.1 degrees rectally, P170, R28, BP 100/66Appearance alert, awake, not toxic, in no acute distressDid not appear to prefer upright or a forward leaning positionEENTMoist MM, slight erythema of oropharynx, nasal crusting, N TMs, no rash / petechiae, no droolingSupple neck

    ChestClear when restingMild inspiratory stridor with cryingRest of the exam NPhysical Exam

  • DDx?

    Croup Epiglottitis Bacterial tracheitis RetroPharygeal abcess Foreign Body aspirationOther things on DDx of Inspiratory Stridor

    Laryngeal WebTEFDiptheriaAirway thermal injurySubglottic stenosisPeritonsillar abcessGERDEsophageal FBLaryngeal fractureLaryngeal cystLymphoma

  • Soft tissue lateral neck radiograph

  • 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 suppurationRetropharyngeal Abscess


    Complication of bacterial pharyngitisLess frequently - extension of infection from vertebral osteomyelitis

    Group A hemolytic streptococci, oral anaerobes, and S. aureus

  • 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


  • Soft Tissue Neck Film

    Patient position MILD EXTENSION

    Positive Film - Retropharyngeal soft tissue > the width of the adjacent vertebral body - may see air in the retropharynxOn Exam Nasopharynx Bulging forward of the soft palate and nasal obstruction OropharynxBulging of posterior phyaryngeal wallorNot visualized

  • Complications

    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.

  • Treatment

    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 breathingNormal now but at the time, parents thought he was quite distressed.

    Now, he is able to speak and drink fluids without difficultyCASE 3

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

    Alert with no signs of respiratory distressAble to speak, had no cyanosis, no drooling, no dyspnea

    H+NNo obvious swelling, bleeding, FB seenChest Mild wheezing with ? mild inspiratory stridor

    What would you like to do now???

  • Soft TissueNeck View

  • CXR (PA)

  • Next?ExpiratoryCXR

  • Inspiratory ViewExpiratory View

  • Right DecubView

  • 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 ManifestationsTypically Acute respiratory distress (now resolved or ongoing)Witnessed choking period

    Uncommonly Cyanosis and resp arrest

    Symptoms: cough, gag, stridor, wheeze, drool, muffled voice

  • InvestigationsXrays

    Lateral neck Chest inspiratory, expiratory, decubitus views

    Expiratory viewsOverinflation (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 diaphragmon side down

    AbnormalHyperinflation or normal volumes indecub positionIf suspected Need a bronchoscope to rule out orremove Foreign Body

  • CASE 42 yo Boy with Barky Cough for 2 days Runny nose, decreased appetite Not himself

    No PMHx / FHx of significanceShots UTD

    Other sibs with similar URTIs

  • Temp 38.9HR 140O2 sat98% (drops to 90% when he crys)RR40 (mild indrawing)On Exam Irritable, crying, good colour

    H & Nsl erythema of throat, no pusN TMs, small cervical nodes

    ChestBarky cough, inspiratory stridorNo wheeze noted

  • Diagnosis? Racemic Epinephrine 0.5 ml dose

    ? Dexamethasone now or laterRe Assess in 30 minutes

    No improvement with 1st dose of epinephrineWhat would you like to do now?

  • IV Cefuroxime PLUS Cloxacillin Consult Pediatric ICU / Pulmonary for Bronch / IntubationRe ExamineOngoing Inspiratory StridorCries when trachea is examined

  • 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 coughHigh 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)CLINICAL MANIFESTATIONS

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

  • Pediatric PneumoniaNeonateBacteria more frequentE. coli, Grp B strep, Listeria, Kleb

    1 3 moChlamydia trachomatis (unique)Commonly viral (RSV, etc.)B. Pertussis

    1 24 moS. pneumonia, Chlamydia pneumMycoplasma pneumonia

    2 5 yrsRSVStrep pneumonia, Mycoplasma, Chlam

  • Severe Pneumonia:

    Staph aureusStrep pneumoniaGrp. A strepHIBMycoplasma pneumonia

    Pseudomonas if recently hospitalized

  • History:Infants < 3 months Tachypnea, cough, retractions, grunting, isolated fever or hypothermia, vomiting, poor feeding, irritability, or lethargyAs age increases, symptoms are more specificFever and chills, headacheCough or wheezingChest pain, abdominal distress, neck pain and stiffness

  • Physical Exam Tachypnea is the best single indicator of pneumoniaAge in monthsUpper limit of Normal RR

    < 255


    > 1235

  • TreatmentNeonatesAmpicillin + Gentamycin / Cefotaxime

    1 3 moErythromycin 10 mg/kg IV Q6H

    1 24 moCefuroxime 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 yrsCefuroxime / Erythro IV (admitted)Clarithro / Azithro (outpt Tx)