Respiratory Emergenciesin the

Pediatric Population

16 month old boy with wheeze

Initial Vitals: HR 160 RR 60

BP 88/50Temp 38O2sat on RA 89%

CASE 1

You do your pediatric assessment triangle:

Appearance Crying, distressed, lookingaround, moving all 4 limbs

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

Circulation 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 No stridor audible, no obvious secretions

Breathing +++ 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 VentolinAtroventIV Access established – orders?

CXR done / pending

Blood work Doctor?

Venous Gas pH 7.35pCO2 38pO2 125

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, inhalants

or FB aspiration

Family 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, crying

Additional treatment?

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

Repeat Venous Gas about 30 mins laterpH 7.15pCO2 55pO2 120

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 IV

4 – 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 Wheezing

H + N Vocal cord dysfunction

Chest AsthmaBronchiolitis Foreign Body Aspiration

CVS Congestive 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 Steroids

Symptoms

Pre - Treat

Treatment

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

Symptoms

Pre - Treat

Treatment

CAEP 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 <92%PEF, FEV1 <50%

100% O2Continuous or frequent b-agonistsSystemic corticosteroids & magnesium sulfateConsider anticholinergic & / or methylxanthines

Symptoms

Pre - Treat

Treatment(consider RSI)

CAEP Pediatric Asthma Guidelines

Symptoms

Pre - Treat

Treatment

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

O2 saturation <80% (spirometry not indicated)

As above PLUSRSIIV VentolinInhalational anesthetic, aminophyllineEpinephrine

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

CASE 2

T39.1 degrees rectally, P170, R28, BP 100/66

Appearance alert, awake, not toxic, in no acute distressDid not appear to prefer upright or a forward leaning position

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

Chest Clear when restingMild inspiratory stridor with crying

Rest of the exam N

Physical Exam

DDx?

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

Other 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 suppuration

Retropharyngeal Abscess

ETIOLOGY

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

Typically …

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

On Exam …Nasopharynx Bulging forward of the soft palate and

nasal obstruction Oropharynx Bulging of posterior phyaryngeal wall

orNot 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 breathing

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

Now, he is able to speak and drink fluids without difficulty

CASE 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+N No obvious swelling, bleeding, FB seen

Chest Mild wheezing with ? mild inspiratory stridor

What would you like to do now???

Soft TissueNeck View

CXR (PA)

Next?

ExpiratoryCXR

Inspiratory View Expiratory 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 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

Investigations

Xrays 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 diaphragmon side down

Abnormal Hyperinflation or “normal” volumes indecub position

If suspected …Need a bronchoscope to rule out or

remove Foreign Body

CASE 4

2 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 sat 98% (drops to 90% when he crys)RR 40 (mild indrawing)

On Exam …

Irritable, crying, good colour

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

Chest Barky cough, inspiratory stridorNo wheeze noted

Diagnosis?

Racemic Epinephrine 0.5 ml dose

? Dexamethasone now or later

Re – Assess in 30 minutesNo improvement with 1st dose of epinephrine

What would you like to do now?

IV Cefuroxime PLUS Cloxacillin Consult Pediatric ICU / Pulmonary

for Bronch / Intubation

Re – 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 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)

CLINICAL MANIFESTATIONS

Antibiotics (good Staph coverage)

Intubation or tracheostomy is usually necessary

? Decadron

Treatment

Pediatric Pneumonia

Neonate Bacteria more frequentE. coli, Grp B strep, Listeria, Kleb

1 – 3 mo Chlamydia trachomatis (unique)Commonly viral (RSV, etc.)B. Pertussis

1 – 24 mo S. pneumonia, Chlamydia pneumMycoplasma pneumonia

2 – 5 yrs RSVStrep 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 lethargy

As age increases, symptoms are more specific

Fever and chills, headacheCough or wheezingChest 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 55

2-12 45

> 12 35

TreatmentNeonates Ampicillin + Gentamycin / Cefotaxime

1 – 3 mo Erythromycin 10 mg/kg IV Q6H

1 – 24 mo 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)