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
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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."