PediatricAirway

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Presentation Description

Review of pediatric airway anatomy as well as common ailments and treatments for prehospital care providers.

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Pediatric Airway Management:

Pediatric Airway Management Jennifer L. Knapp NREMT-P, PI

Objectives:

Objectives Review pediatric airway anatomy Discuss airway variances from adults Discuss common pediatric airway problems Review lung sounds and abnormal sounds Review prehospital pediatric airway maintenance Address the emotional aspect of pediatric care

Just Smaller Adults?:

Just Smaller Adults? Pediatric patients are NOT just small adults Anatomy varies Pediatric specific problems Caregiver concerns

Airway:

Airway Upper Airway Nasopharynx Oropharynx Laryngopharynx Includes epiglottis Larynx Everything above the glottic opening Lower Airway Trachea Bronchial tree Carina Bronchioles Lungs Alveoli

Pediatric vs Adult Airway:

Pediatric vs Adult Airway Larger head Larger tongue proportionately Funnel shaped larynx Cricoid cartilage is narrowest point Structures less rigid Epiglottis more superior and anterior

Slide 6:

Airway Differences Adapted from Walls et al. Manual of Emergency Airway Management. 2 nd Ed. 2004.

Common Airway Problems:

Common Airway Problems FBAO Epiglottitis Croup Bronchiolitis RSV Asthma

FBAO:

FBAO Foreign Body Airway Obstruction Toilet paper tube Common problem in pediatrics “Hand to Mouth” issues

FBAO Continued:

FBAO Continued Incomplete obstruction Some breathing or coughing Stridor Can progress to complete obstruction Complete obstruction Apneic, possibly stridor True emergency

FBAO Treatment Infants:

FBAO Treatment Infants Less than 1 year age Conscious 5 back blows then 5 chest thrusts Repeat, checking for obstruction NO blind finger sweeps Unconscious CPR Checking for obstruction on breaths

FBAO Treatment Pediatrics:

FBAO Treatment Pediatrics 1 year to adolescent Conscious Abdominal Thrusts/Heimlich Maneuver Appropriate positioning Use one hand on smaller children Unconscious CPR Checking for obstruction on breaths

FBAO Treatments Invasive:

FBAO Treatments Invasive Needle cricothyrotomy Surgical cricothyrotomy Intubation – ventilating unaffected side Surgical removal of obstruction

Epiglottitis:

Epiglottitis Supraglottitis Inflammation of epiglottis Epiglottis is more anterior and superior More “floppy” Greater angle with the trachea Drooling Rapid onset Bacterial typically

Epiglottitis Continued:

Epiglottitis Continued Rare now (Hib vaccine) Was seen in ages 2 to 6 Swelling of epiglottis blocks airway

Epiglottitis Symptoms:

Epiglottitis Symptoms Onset high fever and sore throat Stridor Chills and shaking Drooling Cyanosis Tripod positioning Hoarseness

Epiglottitis Treatment:

Epiglottitis Treatment Field Do NOT upset child Do NOT place anything in child’s mouth Humidified oxygen or racemic epi neb Rapid, calm transport Hospital Intubation Antibiotics and anti-inflammatory Fluids via IV

Epiglottitis Complications:

Epiglottitis Complications Airway swell shut Airway spasms Death in minutes

Croup:

Croup Viral Barking cough Typical age range 3 months to 5 years Most common between October and March May develop stridor, labored breathing Lasts 5 to 6 days Worse overnight

Croup Concerns:

Croup Concerns Labored breathing Narrowing airways Atelectasis Dehydration Respiratory Arrest

Croup Treatment:

Croup Treatment Cool, moist air Tylenol for fever Steroids Oxygen Inhaled medications Bacterial infections - Antibiotics

Bronchiolitis:

Bronchiolitis Viral Typically <2 years old Peak age range 3 to 6 months Most often in the fall and winter Minor for adults, severe for infants

Bronchiolitis Risk Factors:

Bronchiolitis Risk Factors Exposure to cigarette smoking Less than 6 months old Living in crowded conditions Lack of breastfeeding Premature birth (before 37 weeks gestation)

Bronchiolitis Signs and Symptoms:

Bronchiolitis Signs and Symptoms Onset is mild respiratory cold Fever Increase in difficulty over 2 to 3 days Wheezing Tachypnea and anxiety Severe – cyanosis, retractions and nasal flaring

Bronchiolitis Treatment:

Bronchiolitis Treatment Chest clapping Fluids – PO or IV Humidified Air Severe cases – Antiviral and oxygen assistance Usually improve in a week Mortality less than 1%

Bronchiolitis Complications:

Bronchiolitis Complications Respiratory failure Pneumonia Airway disease, ex. Asthma, later in life Respiratory Arrest

RSV:

RSV Respiratory Syncytial Virus Most common virus in children Most exposed by 2 years of age Common in fall and winter Common cause of Bronchiolitis Spread via droplets in air Live for ½ to 1 hour on hands Live for 5 hours on surfaces

RSV Symptoms:

RSV Symptoms Fever Cough, possibly even barking Tachypnea Shortness of breath Wheezing Cyanosis Nasal flaring and retractions

RSV Treatment:

RSV Treatment Humidified oxygen Fluids via PO or IV Humidified medications

RSV Complications:

RSV Complications Croup Ear Infections Bronchiolitis Pneumonia Lung Failure Respiratory Arrest Increased risk of developing Asthma

Asthma:

Asthma Swelling and narrowing of the airways Triggers Increasing in occurrence in children Already small airways narrow = major event

Asthma Symptoms:

Asthma Symptoms Difficulty breathing Tightness in chest Cough – often persistent overnight Severe – cyanosis, altered mental status

Asthma Treatment:

Asthma Treatment Avoid triggers Monitor symptoms Medication compliance Asthma Action Plans

Asthma Medications:

Asthma Medications Fast, short acting Short acting bronchodilators (Proventil, Xopenex) Corticosteroids via PO or IV Long term treating Inhaled steroids Long acting Bronchodilators (Serevent)

Asthma Complications:

Asthma Complications Persistent cough Difficulty sleeping Decreased ability for physical exertion Missed school and work (parents) ER visits/Hospital stays Lung function changes Death

Lung Sounds:

Lung Sounds Clear (goal) Stridor Wheezing Rhonchi Rales Decreased Absent

Lung Sounds Clear:

Lung Sounds Clear Good air movement Good chest rise and fall No abnormal sounds Listen over all lobes, front and back Systematic auscultation

Lung Sounds Stridor:

Lung Sounds Stridor High pitched sound Fairly loud Upper airway Obstruction of some kind

Lung Sounds Wheezing:

Lung Sounds Wheezing Whistle sound More often expiratory Lower airway obstruction Causes: Asthma, Bronchiolitis, Inhalation injury, Pneumonia

Lung Sounds Rhonchi:

Lung Sounds Rhonchi Large, lower airways Snoring like sound Often a decline from wheezing

Lung Sounds Rales:

Lung Sounds Rales Clicking, bubbling or rattle sounds May be moist, dry, fine or coarse

Lung Sounds Decreased:

Lung Sounds Decreased Reduced airflow Pneumonia Over-inflation of part of lung Air or fluid in or around lungs

Lung Sounds Absent:

Lung Sounds Absent Progressively worse than decreased No chest rise and fall …… Apneic

What are We to Do?:

What are We to Do? First and foremost ……. REMAIN CALM

Then What?:

Then What? Use assessment skills PAT – Pediatric Assessment Triangle Determine – Sick or not sick (or not yet sick) Airway concerns Find it and fix it Vigilance and positioning are crucial

And Then?:

And Then? Breathing? Find it and fix it Use appropriate methods If an infant or toddler tolerates oxygen mask SICK KID Remember the blow-by option Caregiver assistance

And …..:

And ….. Circulation Find it and fix it Uncommon unless secondary to respiratory Dehydrated? Medications needed?

ALS or BLS?:

ALS or BLS? Differential Diagnosis …… BLS Not sick ALTE without history or signs ALS Not yet sick Sick ALTE with coexisting history Apparent Life Threatening Event

Considerations:

Considerations Caregiver presence Positioning – comfort Age appropriate behaviors and needs

How do you feel?:

How do you feel? Emotional calls Less than 10% of EMS calls Only 1% of that 10% are critical Lack of exposure increases discomfort Added pressure from family members

Things to Remember:

Things to Remember We don’t make them sick We don’t hurt them We have a job to do Calm the situation Thoroughly assess Manage ABC’s Transport to appropriate facility

References:

References http://www.chems.alaska.gov/EMS/Assets/EMSC/pediatric_airway.pdf http://www.emsworld.com/publication/article.jsp?pubId=1&id=3347 http://www.paramedicsofmanitoba.ca/admin/CMS/storage/08-09ARML/Pediatric%20Emergencies.pdf PEPP

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