Post on 15-Oct-2020
transcript
8/29/16
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Tips & tricks to Pediatric Respiratory
Distress
Joelle Donofrio, DO, FAAP RCHSD EMS Medical Director
Pediatric Emergency Medicine Assistant Professor UCSD
EDAP by the Sea 9.7.16
Parental consent (and child assent
if possible) obtained in all
videos
No children were harmed in the making
of these videos
Basics in Peds Airway
Tips and tricks
for the pediatric airway
Step 2: ID problem
Step 3: Solve/Improve Problem
Step 1: Stabilize
Pediatric Assessment Triangle - Only need your eyes -
Breathing
Circulation
Appearance T- Tone I- Interactive C- Consolable L- Look/Gaze S- Speech/Cry
Airway Sounds Airway Positioning Retractions
Pallor Mottling Cyanosis
Respiratory Distress Respiratory Failure Life Threatening Event A- Airway: patent? Position? BVM?
B- Breathing: lung sounds? Need O2?
C- Circulation: HR & central pulses?
D- Disability/Dextrose: AVPU?
E- Exposure: look then wrap back up
ABC’s
Kids-
* Breathe faster
* Higher heart rates
* Lower blood pressure
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Tips and tricks
for the pediatric airway
Step 2: ID problem
Step 3: Solve/Improve Problem
Step 1: Stabilize
Anatomy Lesson: upper or lower
Croup FB
Epiglottitis
Pneumonia Asthma
Anaphylaxis Bronchiolitis
Problem:
Big head = kinked airway
EMS Solution: Sniffing position
Problem: Obligate nose breathers Clear the Airway
EMS Solution:
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Problem: Big tongue = Airway Obstruction Jaw Thrust
Solution 1:
A good jaw thrust can save a life Airway Adjuncts
Solution 2:
OPA mouth to angle of jaw
NPA nose to ear
Problem: Small upper airways = inc resistance
Problem Increased: Narrow Subglottic region
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Remove secretions EMS Solution 1:
Inhaled epinephrine EMS Solution 2:
5 mL of 1:10,000 epi Nebulized
Stridor at Rest Mod-Severe Resp Distress
SC/IM epinephrine EMS Solution 3:
0.01 mg/kg of 1:1000 IM
Anaphylaxis or Impending resp failure
Steroids ED Solution
Dex 0.6 mg/kg (max 10mg) PO/IM Prednisolone 1 mg/kg PO
Methylprednisone 2 mg/kg IV
Problem: Small lower airways = inc resistance
Bronchioli
Bronchioli
Worse mucous plugging
Albuterol (Beta agonist) EMS Solution 1:
2.5 -5mg nebulized or 6 puffs MDI
Wheezing, Retractions
Bronchiolitis?
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Ipratropium (anticholinergic)
EMS Solution 2:
0.25-0.5 mg nebulized
Wheezing, Retractions
Asthmatics, Not bronchiolitis
SC/IM epinephrine EMS Solution 3:
0.01 mg/kg of 1:1000 IM
Anaphylaxis or Impending resp failure
Steroids ED Solution 4
Dex 0.6 mg/kg (max 10mg) PO/IM Prednisolone 1 mg/kg PO
Methylprednisone 2 mg/kg IV
Magnesium Sulfate ED Solution 5:
25-75 mg/kg IV over 20 min
Severe asthma
Positive Pressure ED Solution 6:
Nasal CPAP
High flow
BiPAP
Problem: Respiratory Failure
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Bag Mask Ventilation Solution: Bag Mask Ventilation
C to E hold Good jaw thrust
Watch your
fingers
Now let’s go save some kids
Case 1 10 year old
asthmatic male with SOB.
Problem: upper/lower? Problem: Lower airway dz
PAT: Respiratory Distress
More info please S/S- Wheezing, SOB Allergies- Peanuts Meds- Albuterol, epipen Pertinent Med hx- H/o asthma, allergic rhinitis. Had appendix removed at age 6y
Last meal- cookies 10 minutes ago Events leading up to event- Started having cough and wheeze. Family tried albuterol x2 with only minimal improvement.
Exam A- Airway patent B- Wheezing bilat C- Strong pulses, CR < 2sec D- AVPU: Alert E- …
Dx?
Anaphylaxis
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Assessment 1st
Protocol 2nd
Epi IM = #1 for peds Stridor = Epi IM not on protocol!
Wheeze = Epi IM after base contact
Poor perfusion = Epi not on protocol!
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check skin, BP/perfusion, and GI
Think of exposure
If wheezing/stridor
Case 2
12 month old with stridor Problem: Lower/upper? Problem: Upper airway dz
PAT: Respiratory Failure
More info please S/S- Barky cough, runny nose, fever, stridor
Allergies- PCN (rash)
Meds- Ranitidine
Pertinent Med hx- Developmentally delayed G-tube dependent, h/o laryngomalasia and reflux
Last meal- pedialyte 1 hour ago, G-tube feed 3 hours ago
Events leading up to event- Recent cold, bark cough x 2 days, fever x 1 day, got worse at 10pm tonight
Exam A- Airway patent but with stridor B- Insp & exp stridor, retracting C- Strong pulses, CR < 2sec D- AVPU: lethargic E- No rash
Dx? Resp failure with stridor
Croup?
Other Things to Consider
Swollen Epiglottis
Croup
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Historical Croup Bacterial Croup = Bacterial tracheitis
Viral Croup = modern day croup
Ill appearing Non responsive to racemic epi & steroids
Racemic epi, steroids Antibiotics & IV hydration +/- heliox & intubation
Responds to racemic epi & steroids
Case 3
2 Month Old ALTE
Problem: Lower/upper? Problem: Lower airway dz
PAT: Respiratory Distress
Exam A- Airway patent B- Mild retractions C- Strong pulses, CR < 2sec D- AVPU: Smiling E- No rash
Dx? Bronchiolitis
Bronchiolitis Treatment
Suction Nose O2 if < 90%
Albuterol? Steroids?
Nebulized 3% saline hint: Not all
respiratory distress is a respiratory problem
What type of breathing is this?
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Questions, Concerns, Comments,
Jokes ?
Remember
1. Stabilize 2. ID problem 3. Solve problem
*** Don’t forget to Expose***
Thank You!
References Basics of Pediatric Anesthesia: http://basicsofpediatricanesthesia.com
Cone D, Brice JH, Delbridge TR, Myers JB. Emergency Medical Services: Clinical Practice and Systems Oversight. ISBN: 978-1-118-86530-9
NPA: http://centegra.org/wp-content/uploads/2013/06/Nasal-Pharyngeal-Airway.pdf
KNUTSON D, ARING A. Viral Croup. Am Fam Physician. 2004 Feb 1;69(3):535-540.
Campbell RL, Li JT, Nicklas RA, Sadosty AT. Emergency department diagnosis and treatment of anaphylaxis: a practice parameter. Ann Allergy Asthma Immunol 113 (2014) 599e608
(2014-12-15). Strange and Schafermeyer's Pediatric Emergency Medicine, Fourth Edition (Strange, Pediatric Emergency Medicine) (Kindle Location 1531). McGraw-Hill Education. Kindle Edition.
References Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulisers for delivery of beta-agonist relievers in the treatment of an asthma attack. Cochrane Review September 2013. http://www.cochrane.org/CD000052/AIRWAYS_holding-chambers-spacers-versus-nebulisers-for-delivery-of-beta-agonist-relievers-in-the-treatment-of-an-asthma-attack
Teoh L, Cates CJ, Hurwitz M, Acworth JP, van Asperen P, Chang AB. Anticholinergic therapy for acute asthma in children. April 2012. http://www.cochrane.org/CD003797/AIRWAYS_anticholinergic-therapy-for-acute-asthma-in-children
Schafermeyer, Robert; Tenenbein, Milton; Macias, Charles; Sharieff, Ghazala; Yamamoto, Loren (2014-12-15). Strange and Schafermeyer's Pediatric Emergency Medicine, Fourth Edition (Strange, Pediatric Emergency Medicine) (Kindle Location 1531). McGraw-Hill Education. Kindle Edition.
Fleisher, Gary R. (2011-01-01). Textbook of Pediatric Emergency Medicine 6e (Textbook of Fleisher, Gary R. (2011-01-01). Textbook of Pediatric Emergency Medicine 6e (Textbook of Pediatric Medicine (Fleisher)) Lippincot (Wolters Kluwer Health). Kindle Edition.
Picture References http://wikieducator.org/Lesson_12:_Acute_Respiratory_Disease
http://commons.wikimedia.org/wiki/File:Diagrama_de_los_pulmones.svg
http://basicsofpediatricanesthesia.com/section-iii-anesthetic-management/chapter-16-routine-airway-management/anatomic-differences/
http://www.miami-allergy.com/skin/hives/
http://www.ultrasoundpodcast.com/2014/07/bedside-tee-arntfield-part-1-yes-heard-right-point-care-providers-tee-just-got-real-foamed/
http://theconversation.com/health-check-what-you-need-to-know-about-mucus-and-phlegm-33192
http://www.washingtonpost.com/wp-dyn/content/gallery/2010/08/06/GA2010080603650.html
http://www.rch.org.au/kidsinfo/fact_sheets/Pierre_Robin_Sequence_PRS/
http://www.japantimes.co.jp/news/2013/07/25/asia-pacific/abbott-use-military-on-boat-people/
http://www.rcecs.com/MyCE/PDFDocs/course/V7110.pdf
https://www.flickr.com/photos/mbradbury/4433619952/
https://www.flickr.com/photos/mbradbury/4433619952/
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Picture References Cont
https://www.flickr.com/photos/mbradbury/4433619952/
http://www.beautyhows.com/nose/stuffy-nose/home-remedies-for-stuffy-nose-best-baby-kids-natural-remedies/
http://www.brooksidepress.org/Products/ed2/Enhanced/Newborn.htm
http://www.curiousmitch.com/2011/04/this-weekends-adventures-in-parenting/
http://www.aimhigh-training.co.uk/firstaid/anaphylaxis/
http://www.moviecricket.com/steroids-hollywood-actors-pressure-23779/
http://ajplung.physiology.org/content/303/11/L953
http://store.mcguff.com/products/4218.aspx
https://matthewmanuelnel.wordpress.com/author/zitaveronica/page/2/
http://commons.wikimedia.org/wiki/File:Premature_infant_CPAP.jpg
http://www.carefusion.com/medical-products/respiratory/consumables/airlife-high-flow-oxygen-therapy-and-noninvasive-ventilation.aspx
Picture References Cont
http://hubpages.com/hub/C-Pap-Masks-for-Children-C-Pap-and-BiPap-Mask-Review
https://foodallergyproject.wordpress.com/2013/02/01/epinephrine-a-life-saving-drug/
http://www.medicinesforchildren.org.uk/search-for-a-leaflet/adrenaline-for-anapylaxis/
http://firstaidcoursesperth.net/anaphylaxis/how-to-use-an-epipen-safely
http://www.seattlechildrens.org/content.aspx?id=1980
http://en.wikipedia.org/wiki/Diphtheria
http://www.britannica.com/EBchecked/topic/121404/Grover-Cleveland
http://www.drmkotb.com/EN/index.php?page=students&case=&A=3&B=4&C=1
http://www.lookfordiagnosis.com/mesh_info.php?term=airway+obstruction&lang=1
http://www.radiologyassistant.nl/en/p4718c7f2eb7cc/vascular-anomalies-of-aorta-pulmonary-and-systemic-vessels.html
http://app1.unmc.edu/medicine/heywood/laryngealdisease/Data/benignlesions.htm
http://www.rocketcitymom.com/socks-4-surgery/
Picture References Cont
http://www.rocketcitymom.com/socks-4-surgery/
https://www.pinterest.com/unaartista/keep-calm-and/