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Amy Gutman MD EMS Medical Director Tobey Hospital Pediatric Respiratory Emergencies.

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Presentation on theme: "Amy Gutman MD EMS Medical Director Tobey Hospital Pediatric Respiratory Emergencies."— Presentation transcript:

1 Amy Gutman MD EMS Medical Director Tobey Hospital Pediatric Respiratory Emergencies

2 Conflicts of Interest Sadly, I have no corporate sponsorships or private funding to declare Employed by Tobey Emergency Associates, a private EM group staffing Tobey Hospital Emergency Department (Southcoast Hospitals Group) Medical Director for a bevy of awesome Fire & EMS Departments & training programs for which I am paid an enormous amount of money (ahem)

3 Overview Review critical aspects of prehospital care of pediatric respiratory emergencies – Epidemiology – Anatomy – Specific disease processes Emphasizing children have unique pathophysiology & respond differently to respiratory illness than adults Most importantly: – How to recognize “sick” – Management strategies for respiratory distress – Timely recognition of respiratory distress & appropriate intervention key to preventing progression to cardiac arrest

4 Sick or Not Sick?

5 Pediatric Epidemiology 26% US population, 10% EMS calls Respiratory distress #1 cause of admissions & death during 1 st year except for congenital abnormalities Most pediatric cardiac arrests begin as respiratory failure Minimal training, few ill pediatric patients makes it difficult to obtain & maintain skills Multiple sized pts, equipment sizes & drug dosages confusing in stressful situations

6 “External” Airway Anatomy Large head, large tongue, small mandible Narrowest at subglottic / cricoid area Relatively straight cervical spine Less rigid thoracic cage with poor accessory muscle development Horizontal ribs, diaphragm breathers Increased metabolic rate, increased O 2 consumption, limited O 2 reserves

7 Smaller “Internal” Airway Epiglottis floppy, U shaped & anterior Larynx anterior Short floppy trachea Small soft airways in obligate nasal breathers – Nose = 50% airway resistance – Large tonsils, adenoids rapidly swell Pliable / floppy trachea collapses easily (Poiseuille’s Law) – Adult: 1 mm edema = 81% size – Pedi: 1 mm edema = 44% size

8 Patient Needs Fear of separation, being hurt & the unknown Allow family to be with patient as long as it does not distract you Never lie! Always explain your plan to the child Position at eye level, remain calm, speak slowly

9 Assessment Pre-arrival preparation & scene size-up General assessment (Pediatric Assessment Triangle) – “Sick” vs “Not Sick” vs “Could Rapidly Become Sick” – Clinical indicators reflect CV, respiratory & neurological status ABCDE & transport decision Ongoing assessment including more thorough history & exam Skin Circulation Appearance Work of Breathing CUPSCUPUS CUPS: Critical, Unstable, Potentially Unstable, Stable

10 HPI & Exam HPI – How fast deteriorating? – Fever? – Noisy breathing? – What has been done so far? PMH – Prematurity, hospitalizations, Illnesses, intubations, immunizations? – Allergies? – Medications? Exam – Sick or Not Sick? – Rate? – Noisy? – Position? – Color? – Symmetric?

11 AGEHRSB 0-3 mo mo–2 yrs14090– yrs–5 yrs9095– yrs–10 yrs80100– >10 yrs75115– “Normal” Vitals AGE HR SBP DBP

12 Appearance Alertness Distractibility Consolability Eye contact Speech/cry Spontaneous motor activity Color

13 Stridor – High pitched sound heard on inspiration – Indicates upper airway obstruction Grunting – Short, low pitched sound heard in expiration – Auto-PEEP to keep small airways open as progresses towards respiratory failure Wheezing – High-pitched whistling sound heard expiration > inspiration – Indicates lower airway obstruction Crackles – Crackling sounds heard on inspiration – Associated with cardio-vascular disease, lung disease, infection Abnormal Breathing Sounds

14 Respiratory Distress vs Failure Distress – Maintain oxygenation only by increasing work of breathing Failure – Cannot compensate for inadequate oxygenation despite extra respiratory effort & rate – Circulatory & respiratory system collapse Tachypnea Nasal Flaring / Pursed Lips Stridor / Wheezing AMS / Agitation Agitation Tachycardia Delayed Capillary Refill Pale RR > 60 Retractions Grunting Mottling Head Bobbing Severe Air Hunger Bradycardia Hypotension Bradypnea Inefficient respirations Cyanosis / Grey No air movement Distress Failure Arrest

15 15 Management Strategies Treat the symptoms, not the disease Every child with respiratory distress needs oxygenation as uncorrected respiratory distress deteriorates to bradycardia & cardiac arrest Priority is to support breathing effort – Remember the basics! If pulse remains low or breathing inadequate, re-evaluate airway, ventilations, O 2 & tubing

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17 Airway Management Use pediatric assessment triangle to determine oxygenation status & O 2 delivery device Neutral “sniffing” head position – Towel under shoulders; do not flex head which collapses trachea – Head-tilt chin lift or jaw-thrust <5 seconds to look, listen & feel Suction airway Appropriate ventilation volume & rate (4-6 mg/kg) – Maintain optimal cardiac output, venous return, cerebral blood flow & coronary perfusion – Limits regurgitation & aspiration

18 7 Ps…Not Just For RSI 1. Preparation 2. Pre-oxygenation 3. Premedication 4. Paralyze 5. Pass tube 6. Placement proof 7. Post-intubation care

19 Endotracheal Intubation EMS adult success rate: 85%–95% EMS pediatric success rate: 50%–80% 2005 AHA: – Cuffed ETT effective & safe for all ages, but un-cuffed ETT recommended in neonates Rapidly deoxygenate & decompensate – Prepare to start compressions – “Hail Mary” plan

20 ETT & Resuscitation Smartphone apps: – RapiTube, Difficult Airway, PediStat, PediSafe Traditional Calculations: – Un-cuffed = (Age / 4) + 4 – Cuffed = (Age / 4) + 3 – General = Age + 16/4 [6yo + 16]/4 = 22; 22/4 = 5.5 ETT Ready ETT 0.5 mm smaller & larger Use blade you like: – In very young Miller directly lifts floppy epiglottis – In older children Macintosh slides into vallecula & indirectly lifts epiglottis

21 Alternative Airways Supraglottic, LMA, videoscope Supraglottics & LMAs placed blindly with insertion times approximately 5 secs even during compressions Confirm BL lung sounds, ETCO 2, tube fog, rising O 2 sat & HR

22 Secure The Baby! Secure The Tube!

23 Upper vs Lower Airway Diseases Upper Airway – Foreign Body Obstruction – Retropharyngeal Abscess – Bacterial Tracheitis – Epiglottitis – Croup Lower Airway – RSV / Bronchiolitis – Asthma – Bronchitis / Pneumonia

24 Apparent Life Threatening Events (ALTE) Lifeless, pulseless or unresponsive infant recovering spontaneously & “looks normal” – 1-2% infants – Most common at 2-3 mo, uncommon >2 yrs All require transport & admission DDX: – Arrythmias – Congenital heart disease – Abuse / Trauma – GERD – Infectious / Metabolic / Neurological disorders – Respiratory compromise – Munchausen’s

25 Foreign Body Aspiration / Obstruction (FBAO) >90% respiratory deaths in <5 yo; 65% infant deaths from respiratory causes Suspect in sudden respiratory distress, choking / coughing, stridor or wheezing DDX: seizure, syncope, arrhythmia or overdose Large objects lodge in upper airway & trachea – 20% FBAO – Acute dyspnea, drooling, stridor & cyanosis Small objects lodge in bronchus / terminal airway

26 Choking / FBAO Able to talk or minimal distress, rapidly transport in position of comfort Responsive but significant distress: – Child: abdominal thrusts or Heimlich – Infant: chest thrusts, back blows Unresponsive, open airway & only remove object if visible / accessible – Begin CPR with airway check – Look for FB prior to starting each ventilation; if visible attempt removal with Magill’s – Airway management via PPV or advanced airway attempt Rapid transport & notify receiving hospital Medical Control for needle cricothyroidotomy if unable to clear obstruction, unable to intubate or ventilate Even If obstruction clears prior to your arrival, still transport

27 Retropharyngeal Abscess URI complication Lymph nodes between posterior pharynx & pre-vertebral fascia – Soft palate bulging obstructs nose – Posterior pharynx bulging obstructs trachea Abrupt fever, severe distress, painful swallowing Head hyperextension Noisy respirations, drooling

28 Epiglottitis (H. Influenza) 4-6 yo most common 10 X decrease since H. flu vaccinations – 10% are vaccinated, but exposed to virulent strain High fever, sore throat, stridor, drooling, tripoding & severe respiratory distress Supraglottic edema completely obstructs airway – DO NOT attempt to visualize (“Sniff Test”) Manage according to severity of condition but rapidly transport in upright position with humidified O 2 Respiratory Distress + Sore Throat + Drooling

29 Croup (Viral Parainfluenza) Nightly recurring fever, hoarseness, “barking seal” cough from laryngeal & tracheal edema 6 mo to 4 yr – Males > Females – Fall, early winter Management: – Reassurance – Humidified, cool air – Steroids – Racemic epinephrine – Rare advanced airway management; consider alternative diagnoses

30 Bacterial Tracheitis Post URI Purulent sputum, high fever, pseudomembrane Toxic appearance + stridor Croup-like symptoms responding poorly to croup management

31 Bronchiolitis (RSV) Viral bronchiolar edema from air trapping >80% < 1 yo Epidemics January - May Recent URI with gradual onset of SOB Expiratory wheezing, tachypnea, cyanosis Management – Humidified oxygen – Bronchodilators – Advanced airway as needed

32 Asthma Lower airway hypersensitivity causing bronchospasm, edema & mucus production – Varying degrees of respiratory distress – All that wheezes is not asthma – Non-wheezers often in severe respiratory distress Important History – Prior ICU admission / intubations – >3 ED visits or >2 admissions in past yr – >1 MDI used in past mo or every 4 hrs – Symptom progression despite aggressive treatment Management is aggressive airway, pharmacology & fluid resuscitation – Position of comfort, humidified O2 – Beta-2 agents (Albuterol) – Anticholinergics (Atropine, Ipatropium) – Subcutaneous beta agents (Epinephrine 1:1000, 0.1 to 0.3 mg SQ)

33 Bronchitis / Pneumonia Viral or bacterial – Neonates: GBS, enterics – 3 mo-3yr: Streptococcus pneumonia – 4mo- Preschool: RSV / viral Fever, cyanosis + tachypnea, cough, nasal flaring, retractions, rales, decreased breath sounds Aggressive airway management

34 Acute Respiratory Distress (ARDS) Severe lung inflammation rapidly resulting in hypoxia & respiratory failure Frequency: 2-12/100,000 Mortality: 15% Management: – Aggressive airway control – PEEP – Fluid & cardiovascular resuscitation

35 Anaphylaxis Acute & life-threatening Release of inflammatory mediators after a trigger – MEWS: Milk, eggs, wheat, soy – Peanuts & shellfish most potent – Others: preservatives, medications, insect venom, blood products, environmental, animal, exercise Symptoms progress over minutes to days resulting in respiratory failure, shock, multiorgan system failure & DIC – 5-20% experience recurrence of anaphylaxis >12 hrs – Symptoms can last 3 days despite treatment

36 Anaphylaxis Management Airway – Oxygen + adjuncts including CPAP – Make early aggressive choices including advanced airway Medications: – Diphenhydramine – Histamine blocker (pepcid, zantac) – Nebulized or MDI albuterol (2.5-5 mg/dose) – Epinephrine 1:1000 IM Anaphylactic Shock: – Beware of “compensated shock” – Trandelenburg position – 20 mL/kg crystalloid bolus; repeat to mL/kg as necessary – Vasopressors: Epinephrine (0.1-1 mcg/kg/min IV) Dopamine (2-20 mcg/kg/min IV) Norepinephrine (0.1-2 mcg/kg/min IV)

37 Pediatric Bronchospasm / Respiratory Distress Activate ALS intercept; rapidly transport without ALS if necessary Mild Distress – If not taken max dose of prescribed MDI, encourage or assist patient to self-administer – Med Control for 2 nd MDI dose if max not administered. MDI contraindicated if max dose administered, pt cannot physically use device, device not prescribed for patient ALS: – IV, O2, Monitor – If not improving with O 2, consider albuterol / atrovent nebulizer or MDI – Medical Control: Epinephrine mg IM autoinjector Magnesium Sulfate 25 mg/kg IV over 5 min – Treat for shock as needed Notify receiving hospital

38 Special Patients Tracheostomy tubes, apnea monitors, ventilators are common home-care devices Most common are trach-related emergencies – Obstruction – Tube dislodgement – Stoma bleeding – Tube reinsertion “false track” – Infection If ineffective ventilation/oxygenation: – Wipe stoma, suction tube – Remove tube if necessary – Once airway open, begin PPV – Attempt intubation if cannot oxygenate Med Control may order tube re-insertion

39 References Emergency Care & Transportation of the Sick and Injured, 9th ED Massachusetts OEMS (www.dph.org) Alameda County EMS Premier Health Care Services Continuing Education and Training Pediatric Advanced Life Support (PALS) Pediatric Education for the Prehospital Provider (PEPP) Pediatric Emergency Assessment, Recognition & Stabilization (PEARS) NAEMT Emergency pediatric Care E Humphreys PA-C, EMT-I “Pediatric Respiratory Emergencies” (2009) J Reynolds MD “Pediatric Respiratory Emergencies” (2012) S Villanueva MD, FACEP “Pediatric Respiratory Emergencies” “Management of acute lung injury & ARDS in children”. Critical Care

40 Summary Pre-arrival preparation important Standardized approach to assessment & management Knowledge of normal child development and age-specific physiology important “Sick/not sick” determination is paramount in treatment & transport decisions Find me: Nights at Tobey ED me: / Website: Text me:


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