Pediatrics

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Presentation Transcript

Pediatrics : 

Pediatrics Respiratory Emergencies

Respiratory Emergencies : 

Respiratory Emergencies #1 cause of Pediatric hospital admissions Death during first year of life except for congenital abnormalities

Respiratory Emergencies : 

Respiratory Emergencies Most pediatric cardiac arrest begins as respiratory failure or respiratory arrest

Pediatric Respiratory System : 

Pediatric Respiratory System Large head, small mandible, small neck Large, posteriorly-placed tongue High glottic opening Small airways Presence of tonsils, adenoids

Pediatric Respiratory System : 

Pediatric Respiratory System Poor accessory muscle development Less rigid thoracic cage Horizontal ribs, primarily diaphragm breathers Increased metabolic rate, increased O2 consumption

Pediatric Respiratory System : 

Pediatric Respiratory System Decrease respiratory reserve + Increased O2 demand = Increased respiratory failure risk

Respiratory Distress : 

Respiratory Distress

Respiratory Distress : 

Respiratory Distress Tachycardia (May be bradycardia in neonate) Head bobbing, stridor, prolonged expiration Abdominal breathing Grunting--creates CPAP

Respiratory Emergencies : 

Respiratory Emergencies Croup Epiglottitis Asthma Bronchiolitis Foreign body aspiration Bronchopulmonary dysplasia

Laryngotracheobronchitis : 

Laryngotracheobronchitis Croup

Croup: Pathophysiology : 

Croup: Pathophysiology Viral infection (parainfluenza) Affects larynx, trachea Subglottic edema; Air flow obstruction

Croup: Incidence : 

Croup: Incidence 6 months to 4 years Males > Females Fall, early winter

Croup: Signs/Symptoms : 

Croup: Signs/Symptoms “Cold” progressing to hoarseness, cough Low grade fever Night-time increase in edema with: Stridor “Seal bark” cough Respiratory distress Cyanosis Recurs on several nights

Croup: Management : 

Croup: Management Mild Croup Reassurance Moist, cool air

Croup: Management : 

Croup: Management Severe Croup Humidified high concentration oxygen Monitor EKG IV tko if tolerated Nebulized racemic epinephrine Anticipate need to intubate, assist ventilations

Epiglottitis : 

Epiglottitis

Epiglottitis: Pathophysiology : 

Epiglottitis: Pathophysiology Bacterial infection (Hemophilus influenza) Affects epiglottis, adjacent pharyngeal tissue Supraglottic edema Complete Airway Obstruction

Epiglottitis: Incidence : 

Epiglottitis: Incidence Children > 4 years old Common in ages 4 - 7 Pedi incidence falling due to HiB vaccination Can occur in adults, particularly elderly Incidence in adults is increasing

Epiglottitis: Signs/Symptoms : 

Epiglottitis: Signs/Symptoms Rapid onset, severe distress in hours High fever Intense sore throat, difficulty swallowing Drooling Stridor Sits up, leans forward, extends neck slightly One-third present unconscious, in shock

Epiglottitis : 

Epiglottitis Respiratory distress+ Sore throat+Drooling = Epiglottitis

Epiglottitis: Management : 

Epiglottitis: Management High concentration oxygen IV tko, if possible Rapid transport Do not attempt to visualize airway

Epiglottitis : 

Epiglottitis Immediate Life Threat Possible Complete Airway Obstruction

Asthma : 

Asthma

Asthma: Pathophysiology : 

Asthma: Pathophysiology Lower airway hypersensitivity to: Allergies Infection Irritants Emotional stress Cold Exercise

Asthma: Pathophysiology : 

Asthma: Pathophysiology Bronchospasm Bronchial Edema Increased Mucus Production

Asthma: Pathophysiology : 

Asthma: Pathophysiology

Asthma: Pathophysiology : 

Asthma: Pathophysiology Cast of airway produced by asthmatic mucus plugs

Asthma: Signs/Symptoms : 

Asthma: Signs/Symptoms Dyspnea Signs of respiratory distress Nasal flaring Tracheal tugging Accessory muscle use Suprasternal, intercostal, epigastric retractions

Asthma: Signs/Symptoms : 

Asthma: Signs/Symptoms Coughing Expiratory wheezing Tachypnea Cyanosis

Asthma: Prolonged Attacks : 

Asthma: Prolonged Attacks Increase in respiratory water loss Decreased fluid intake Dehydration

Asthma: History : 

Asthma: History How long has patient been wheezing? How much fluid has patient had? Recent respiratory tract infection? Medications? When? How much? Allergies? Previous hospitalizations?

Asthma: Physical Exam : 

Asthma: Physical Exam Patient position? Drowsy or stuporous? Signs/symptoms of dehydration? Chest movement? Quality of breath sounds?

Asthma: Risk Assessment : 

Asthma: Risk Assessment Prior ICU admissions Prior intubation >3 emergency department visits in past year >2 hospital admissions in past year >1 bronchodilator canister used in past month Use of bronchodilators > every 4 hours Chronic use of steroids Progressive symptoms in spite of aggressive Rx

Asthma : 

Asthma Silent Chest equals Danger

Golden Rule : 

Golden Rule Pulmonary edema Allergic reactions Pneumonia Foreign body aspiration ALL THAT WHEEZES IS NOT ASTHMA

Asthma: Management : 

Asthma: Management Airway Breathing Sitting position Humidified O2 by NRB mask Dry O2 dries mucus, worsens plugs Encourage coughing Consider intubation, assisted ventilation

Asthma: Management : 

Asthma: Management Circulation IV TKO Assess for dehydration Titrate fluid administration to severity of dehydration Monitor ECG

Asthma: Management : 

Asthma: Management Obtain medication history Overdose Arrhythmias

Asthma: Management : 

Asthma: Management Nebulized Beta-2 agents Albuterol Terbutaline Metaproterenol Isoetharine

Asthma: Management : 

Asthma: Management Nebulized anticholinergics Atropine Ipatropium

Asthma: Management : 

POSSIBLE BENEFIT IN PATIENTS WITH VENTILATORY FAILURE Asthma: Management Subcutaneous beta agents Epinephrine 1:1000--0.1 to 0.3 mg SQ Terbutaline--0.25 mg SQ

Asthma: Management : 

Asthma: Management Use EXTREME caution in giving two sympathomimetics to same patient Monitor ECG

Asthma: Management : 

Asthma: Management Avoid Sedatives Depress respiratory drive Antihistamines Decrease LOC, dry secretions Aspirin High incidence of allergy

Status Asthmaticus : 

Status Asthmaticus Asthma attack unresponsive to -2 adrenergic agents

Status Asthmaticus : 

Status Asthmaticus Humidified oxygen Rehydration Continuous nebulized beta-2 agents Atrovent Corticosteroids Aminophylline (controversial) Magnesium sulfate (controversial)

Status Asthmaticus : 

Status Asthmaticus Intubation Mechanical ventilation Large tidal volumes (18-24 ml/kg) Long expiratory times Intravenous Terbutaline Continuous infusion 3 to 6 mcg/kg/min

Bronchiolitis : 

Bronchiolitis

Bronchiolitis: Pathophysiology : 

Bronchiolitis: Pathophysiology Viral infection (RSV) Inflammatory bronchiolar edema Air trapping

Bronchiolitis: Incidence : 

Bronchiolitis: Incidence Children < 2 years old 80% of patients < 1 year old Epidemics January through May

Bronchiolitis: Signs/Symptoms : 

Bronchiolitis: Signs/Symptoms Infant < 1 year old Recent upper respiratory infection exposure Gradual onset of respiratory distress Expiratory wheezing Extreme tachypnea (60 - 100+/min) Cyanosis

Asthma vs Bronchiolitis : 

Asthma vs Bronchiolitis Asthma Age - > 2 years Fever - usually normal Family Hx - positive Hx of allergies - positive Response to Epi - positive Bronchiolitis Age - < 2 years Fever - positive Family Hx - negative Hx of allergies - negative Response to Epi - negative

Bronchiolitis: Management : 

Bronchiolitis: Management Humidified oxygen by NRB mask Monitor EKG IV tko Anticipate order for bronchodilators Anticipate need to intubate, assist ventilations

Foreign Body Airway Obstruction : 

Foreign Body Airway Obstruction FBAO

FBAO: High Risk Groups : 

FBAO: High Risk Groups > 90% of deaths: children < 5 years old 65% of deaths: infants

FBAO: Signs/Symptoms : 

FBAO: Signs/Symptoms Suspect in any previously well, afebrile child with sudden onset of: Respiratory distress Choking Coughing Stridor Wheezing

FBAO: Management : 

FBAO: Management Minimize intervention if child conscious, maintaining own airway 100% oxygen as tolerated No blind sweeps of oral cavity Wheezing Object in small airway Avoid trying to dislodge in field

FBAO: Management : 

FBAO: Management Inadequate ventilation Infant: 5 back blows/5 chest thrusts Child: Abdominal thrusts

Bronchopulmonary Dysplasia : 

Bronchopulmonary Dysplasia BPD

BPD: Pathophysiology : 

BPD: Pathophysiology Complication of infant respiratory distress syndrome Seen in premature infants Results from prolonged exposure to high concentration O2 , mechanical ventilation

BPD: Signs/Symptoms : 

BPD: Signs/Symptoms Require supplemental O2 to prevent cyanosis Chronic respiratory distress Retractions Rales Wheezing Possible cor pulmonale with peripheral edema

BPD: Prognosis : 

BPD: Prognosis Medically fragile, decompensate quickly Prone to recurrent respiratory infections About 2/3 gradually recover

BPD: Treatment : 

BPD: Treatment Supplemental O2 Assisted ventilations, as needed Diuretic therapy, as needed