Maryland Pre-hospital Protocol for Croup

1. Maryland Pre-hospital Protocolfor Croup Maryland EMSC Program

2. Care for Children with Croup Developed by Hopkins Outreach for Pediatric Education Written by Elizabeth Berg, RN, BSN, EMT-B Reviewed by Maryland PEMAG 7/2001

3. Pediatric Medical Emergencies Objectives • Identify three signs and symptoms of croup • State the treatment protocol for croup • List two criteria for medical direction • Identify three signs and symptoms of pediatric respiratory failure • List two criteria for BVM ventilations

4. Pediatric Medical Emergencies Epidemiology of Croup • Common age range is 3 months to 4 years • Most severe symptoms under 3 years • More common in males • Most common during the winter months • Typical duration of illness is 5-6 days

5. Pediatric Medical Emergencies Pathophysiology of Croup • Viral infection of the vocal cords • Parainfluenza virus (75%) • Adenovirus • Respiratory syncytial virus (RSV) • Influenza • Measles • Bacterial super infection

6. Pediatric Medical Emergencies Pediatric Anatomical and Physiological Differences • Airway shape: cone versus cylindrical • Narrowest point at the cricoid ring • Anterior vocal cords • Tongue larger in proportion to the mouth

7. Pediatric Medical Emergencies Airway Differences

8. Pediatric Medical Emergencies Pediatric Anatomical and Physiological Differences • Smaller, more collapsible lower airways • Diaphragm dependent • Poorly developed intercostal and accessory muscles

9. Pediatric Medical Emergencies Clinical Presentation of Croup • Signs and symptoms • Loud barking cough • Hoarseness • Respiratory distress • Nasal flaring • Retractions • Head-bobbing • Inspiratory grunting or stridor

10. Pediatric Medical Emergencies Clinical Presentation of Croup • Associated illnesses • Ear infection • Pneumonia

11. Neck X-rays Normal Airway NarrowedAirway

12. Pediatric Medical Emergencies Other Causes of Pediatric Airway Obstruction • Vascular Ring • Blood vessels compress the trachea • Tracheomalacia • Softening of the tracheal wall • Foreign body • Epiglottitis

13. Pediatric Medical Emergencies Epiglottitis • Clinical presentation • Over 5 years of age • Most common organism is Hemophilus influenza • Rapid onset of stridor and drooling • Associated with high fever

14. Pediatric Medical Emergencies Epiglottitis • Interventions • High flow oxygen • Calm environment • No manipulation of the upper airway • Hospital notification • Do not initiate croup protocol

15. Pediatric Medical Emergencies EMS Protocol for Croup • Initiate General Patient Care • Allow children to assume their own position of comfort • Semi-fowler’s position will promote diaphragm expansion • Allow parent to remain with child for emotional support

16. Pediatric Medical Emergencies EMS Protocol for Croup • Initiate General Patient Care • Get down to child’s level • Use age-appropriate words • Give them choices, when able • If stable, allow the child to set the pace of the procedure

17. Pediatric Medical Emergencies EMS Protocol for Croup • Initiate General Patient Care • Foster trust by telling the truth • Be aware of the capabilities of the local ED • Consider risks and benefits of transporting the child to a pediatric referral center • Administer oxygen without increasing agitation

18. Pediatric Medical Emergencies Oxygen Administration in Children • Infants/toddlers may not tolerate a face mask • Have parent hold mask near patient’s face • Place oxygen tubing set at 10 lpm in the bottom of a paper cup with stickers inside • Use commercially designed teddy-bears with oxygen port; may also use for nebs

19. Pediatric Medical Emergencies EMS Protocol for Croup • Presentation • Severe: Priority 1 • Unable to speak or cry • Decreased LOC • Bradycardia or tachycardia • Hypertension or hypotension

20. Pediatric Medical Emergencies EMS Protocol for Croup • Presentation • Moderate: Priority 2 • Slow onset of respiratory distress • Barking cough • Fever • Audible stridor

21. Pediatric Medical Emergencies EMS Protocol for Croup • Treatment • Perform initial patient assessment • Patent airway • Adequate respiratory effort • Assign a treatment priority • If patient > 40 kg (88 lbs) treat under adult protocol

22. Tachypnea • RR > 60 • Bradypnea • See saw • respirations • Gray, • cyanotic • No air • movement • No wheezing • Tachypnea • Nasal flaring • Pale • Stridor • Expiratory • wheezing • Retractions, • grunting • Mottled • Head bobbing • Insp/Exp • wheezing Pediatric Medical Emergencies Continuum of Respiratory Failure

23. Pediatric Medical Emergencies EMS Protocol for Croup • Treatment • Place on cardiac monitor, pulse oximeter • Record vital signs • Initiate IV with LR at a KVO rate • Do not withhold epinephrine if IV not easily obtainable • Over 75% of croup cases seen in ED have no IV • If patient is unstable, establish IO access

24. Pediatric Medical Emergencies EMS Protocol for Croup • Under 40 kilograms with S/S of croup • Administer 3 cc of NS via nebulizer for 3-5 mins • Continue NS nebulization during transport if improved • If no improvement, contact medical control physician to administer inhaled epinephrine • All patients who receive nebulized epinephrine must be transported by an ALS unit to the hospital

25. Pediatric Medical Emergencies EMS Protocol for Croup • Obtain medical direction • Give 2.5 ml of 1:1000 epinephrine via nebulizer • A second dose may be given with medical direction • Other interventions, such as albuterol neb • Albuterol and epinephrine are compatible

27. Pediatric Medical Emergencies Pharmacological Actions of Inhaled Epinephrine • Alpha-adrenergic receptor agonist • Desired action • Local vasoconstriction in the large airways, which reduces airway edema and obstruction • Caution: may have rebound edema • Decreased systemic effects with inhalation

28. Pediatric Medical Emergencies EMS Protocol for Croup • Imminent respiratory arrest • Administer 0.01 mg/kg of 1:1000 epinephrine SC • Max dose is 0.3 mg • Interventions for pediatric respiratory failure • Bag-valve-mask ventilations • May administer inhaled medications with BVM • Endotracheal intubation

29. BVM with Multi-Dose Inhalor Port

30. BVM with In-line Nebulizer

31. Pediatric Medical Emergencies Criteria for BVM Ventilations • Inadequate RR • Infant/Toddler < 20 • Child < 16 • Adolescent < 12 • Bradycardia • Infant HR < 80 • Child HR < 60

32. Pediatric Medical Emergencies Criteria for BVM Ventilations • Inadequate respiratory effort • Absent or diminished breath sounds • Paradoxical breathing • Cyanosis on 100% oxygen • Cardiac arrest • Altered mental status • GCS < 8

33. Pediatric Medical Emergencies Complications of BVM Ventilations • Gastric distension • Vomiting • Increased ICP due to vagal stimulation • Pressure over the eyes

34. Pediatric Medical Emergencies Equipment for BVM Ventilations • Appropriate size mask • Premature infants #0 Neonatal • Newborn - 1 year #1 Infant • 1 - 6 years #2 Toddler • 6 - 12 years #3 Pediatric • 12 years - young adult #4 Small Adult

35. Pediatric Medical Emergencies Equipment for BVM Ventilations • Suction • Appropriate size airway adjunct • Appropriate size bag • Newborn - 3 mo Neonatal 450 - 500 ml • Child < 30 kg Pediatric 750 ml • Child > 30 kg Adult 1000 - 1200 ml

36. Pediatric Medical Emergencies Single Provider Technique

37. Pediatric Medical Emergencies Two Provider Technique

38. Pediatric Medical Emergencies Respiratory Rates for Assisted Ventilations • Infant/Toddler 30 - 40 • Child 20 - 30 • Adolescent 12 - 20

39. Pediatric Medical Emergencies Evaluate BVM Ventilations • Chest rise and fall • Presence of breath sounds • Skin color • Pulse oximeter reading • Presence of end-tidal C02

40. Pediatric Medical Emergencies Troubleshooting BVM Ventilations • Check size and seal of the mask • Verify oxygen source • Assure proper airway position

41. Pediatric Medical Emergencies Troubleshooting BVM Ventilations • Disable the pressure pop-off valve • Increase the size of the bag • Treat gastric distension • ALS providers: insertion of gastric tube

42. Pediatric Medical Emergencies PRESENTATION • Paramedics responded to a call for trouble breathing. Upon arrival they found a six month old with audible inspiratory stridor. • Mom reports that pt was recently discharged after a work-up for a platelet disorder. He was having stridor last night, but was much improved this AM. No other past medical history or allergies.

43. Pediatric Medical Emergencies VITAL SIGNS • PULSE 140-160 • ECG ST without ectopy • RR 30-50, labored • O2 SAT 90% on room air • BP 84/45 • SKIN Pale, warm, moist • WEIGHT Estimated at 10 kg

44. Pediatric Medical Emergencies FIELD MANAGEMENT • Pt was kept calm in Mom’s arms for transport • Inhaled saline at 6 LPM which brought the 02 sat up to 96%. • Parents refused an IV due to pt’s low platelet count.

45. Pediatric Medical Emergencies E. D. MANAGEMENT • Upon arrival, chest x-ray done and pt placed on humidified oxygen. • Pt received two racemic epi nebs with no improvement.

46. Pediatric Medical Emergencies E. D. MANAGEMENT • Transport team contacted and recommended another racemic epi neb, an albuterol neb, and an IM dose of steroids. • Parents finally consented to peripheral IV insertion.

47. Pediatric Medical Emergencies TRANSPORT TEAM MANAGEMENT • Upon arrival the pt was gray and gasping for air with RR of 16. • Transport RN and MD agreed pt needed emergent intubation. Pt received IV sedation with fentanyl and versed and was intubated with #3.5 uncuffed ET tube.

48. Pediatric Medical Emergencies TRANSPORT TEAM MANAGEMENT • CXR showed right mainstem intubation. ET tube was pulled back. • Pt transported to the PICU without incident.

49. Pediatric Medical Emergencies DISPOSITION • Within twelve hours of admission pt developed a leak around the ET tube and was successfully extubated. • He was discharged from the hospital three days later with no ill effects.