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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/