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Respiratory Emergencies in the Pediatric Population

Respiratory Emergencies in the Pediatric Population. OBJECTIVES. Common upper airway obstruction including :- Croup Epiglottises Retropharyngeal Abscess F.B.A Bacterial Tracheaitis Pneumonia Lower airway obstruction(ASTHMA) ,.

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Respiratory Emergencies in the Pediatric Population

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  1. Respiratory Emergencies in the Pediatric Population

  2. OBJECTIVES • Common upper airway obstruction including :- • Croup • Epiglottises • Retropharyngeal Abscess • F.B.A • Bacterial Tracheaitis • Pneumonia • Lower airway obstruction(ASTHMA) • ,

  3. What is the difference between pedsand adult airways? • The tongue is larger, easily displaced, and the most common cause of airway obstruction in the obtunded child. • • The narrowest portion of the pediatric airway is at the cricoid ring, making obstruction with subglottic pathology more likely than adults.

  4. Croup • • Also called laryngotracheobronchitis • • Most common cause of infectious acute upper airway obstruction. • • Approx. 10% of children seen with croup require admission, 1-5% require intubation, and 10 cases are seen for each case of epiglottitis.

  5. Croup • • Viral etiologies include parainfluenza virus type1, influenza, respiratory syncytial virus (RSV),rhinoviruses and measles. • • Mean age of affected patients is 18 months, with a slight male predominance, and there is a seasonal increase in cases in autumn and early winter.

  6. Croup • • May have elevated temperature. • • Drooling is uncommon. • • May have mild expiratory wheezing • • Inspiratory stridor at rest with nasal flaring, suprasternal • and intercostal retractions. • • Poor air entry • • Lethargy + agitation = HYPOXIA • • Dehydration

  7. Treatment of Croup • Racemic epinephrine • Steroids(dexamethasone)

  8. Epiglottitis • • Also known as supraglottitis • • First described in 1878, was thought to be • disease of adults. “angina epiglottidea anterior” • • 60% male dominance

  9. Epiglottitis • • Occurs in children from 3-7 yrs in age with only 4% • under the age of 1. • • Hemophilus influenzae (bacterial infection) is the most common etiology. (some viruses, allergic reactions and physical and thermal injuries can play a part also) • • 1985 – vaccine….but things mutate.

  10. Epiglottis Signs and symptoms • • Very sudden onset and progresses rapidly • • Muffled voice or cry (in croup it is more hoarse) • • Minimal cough • • Sore throat, fever, hoarseness • • Drooling caused by difficulty swallowing saliva • • Intercostal muscle retractions • • Noisy, high-pitched, squeaky inhalations • • Purple skin and nails • • Odd head posture. (sniffing position), tripod position

  11. Why do children with epiglottitishave airway obstruction? • • Fatigue • • Laryngospasm • • Progressive swelling of the supraglottic structures • • Pooled secretions

  12. Treatment of epiglottitis • • DO NOT AGITATE THE CHILD IN ANY WAY • • Airway mgmt. Done in OR • • Administer high flow humidified oxygen in order to • obtain maximal alveoli oxygen saturation. • • If there is an obstruction – BVM ventilation. • • Position of comfort • • Run like hell………………

  13. Review Epiglottitis • Voice – muffled • Cough – usually none • Fever – yes • Saliva – lots • Neck swelling – lots • Begins – suddenly • Season – all year • Time – all day • • Croup • • Voice – hoarse • • Cough – barking • • Fever – yes • • Saliva – minimal • • Neck swelling – little • • Begins – slowly • • Season – autumn • • Time – evening/night

  14. Upper airway obstruction Other things on DDx of Inspiratory Stridor Laryngeal Web TEF Diptheria Airway thermal injury Subglottic stenosis Peritonsillar abcess GERD Esophageal FB Laryngeal fracture Laryngeal cyst Lymphoma • Croup • Epiglottitis • Bacterial • tracheitis • RetroPharygeal • abcess • Foreign Body • aspiration

  15. Retropharyngeal Abscess • Lymph nodes between the posterior pharyngeal wall • and the prevertebral fascia • gone by 3 – 4 yrs of life • drain portions of the nasopharynx and the posterior • nasal passages • may become infected and progress to breakdown • of the nodes and to suppuration

  16. ETIOLOGY Retropharyngeal absces • Complication of bacterial pharyngitis • Less frequently • - extension of infection from vertebral osteomyelitis • Group A hemolytic streptococci, oral anaerobes, • and S. aureus

  17. Typically …Retropharyngeal absces • Recent or current history of an acute URTI • Abrupt onset: • High fever with difficulty in swallowing • Refusal of feeding • Severe distress with throat pain • Hyperextension of the head • Noisy, often gurgling respirations • Drooling

  18. On Exam Retropharyngeal absces Nasopharynx Bulging forward of the soft palate and nasal obstruction Oropharynx Bulging of posterior phyaryngeal wall or Not visualized Soft Tissue Neck Film Patient position – MILD EXTENSION Positive Film - Retropharyngeal soft tissue > ½ the width of the adjacent vertebral body - may see air in the retropharynx

  19. Complications of Retroph.absces Abscess rupture - aspiration of pus. Lateral extension - present externally on the side of the neck Dissection along fascial planes into the mediastinum Death may occur with aspiration, airway obstruction, erosion into major blood vessels, or mediastinitis.

  20. Treatment of Retroph.absces • Clindamycin 20-30 mg/kg/day divided Q8H (if pre-fluctuant phase) • Decadron 0.6 mg/kg • Airway management • Surgical decompression

  21. Foreign Body Aspiration • More common with food than toys • Highest risk between 1 and 3 years old (immature dentition – no molars, poor food control) • Common foods = peanuts, grapes, hard candies • Some foods swell with prolonged aspiration • (may even sprout)

  22. Clinical Manifestations Typically … Acute respiratory distress (now resolved or ongoing) Witnessed choking period Uncommonly … Cyanosis and resp arrest Symptoms: cough, gag, stridor, wheeze, drool, muffled voice

  23. Investigations • Xrays • Lateral neck • Chest – inspiratory, expiratory, decubitus views • Expiratory views • Overinflation (partial obstruction with inspiratory flow) • with mediastinal shift towards opposite obstructed • side (partial obstruction with expiratory flow) • Atelectasis (complete obstruction) with mediastinal shift • towerds obstructed side

  24. Decubitus views Normal Smaller volumes and elevated diaphragm on side down Abnormal Hyperinflation or “normal” volumes in decub position If suspected …fluoroscopy …then… Need a bronchoscope to rule out or remove Foreign Body

  25. Bacterial tracheitis • An acute bacterial infection of the upper airway capable of causing life-threatening airway obstruction • Staph aureus most commonly ( Moraxella catarrhalis, H. influenzae, anearobes) • Most pts less than 3 years old • Usually follows an URTI (esp laryngotracheitis) • Mucosal swelling at the level of the cricoid cartilage, • complicated by copious thick, purulent secretions

  26. CLINICAL MANIFESTATIONS Brassy cough High fever “Toxicity" with respiratory distress (may occur immediately or after a few days of apparent improvement) Failed response to CROUP TREATMENT (mist, intravenous fluid, racemic epinephrine)

  27. Treatment Antibiotics (good Staph coverage) Intubation or tracheostomy is usually necessary Dexamethasone?

  28. Pediatric Pneumonia Neonate Bacteria more frequent E. coli, Grp B strep, Listeria, Kleb 1 – 3 mo Chlamydia trachomatis (unique) Commonly viral (RSV, etc.) B. Pertussis 1 – 24 mo S. pneumonia, Chlamydia pneum Mycoplasma pneumonia 2 – 5 yrs RSV Strep pneumonia, Mycoplasma, Chlam

  29. Severe Pneumonia: Staph aureus Strep pneumonia Grp. A strep HIB Mycoplasma pneumonia Pseudomonas if recently hospitalized

  30. History: Infants < 3 months Tachypnea, cough, retractions, grunting, isolated fever or hypothermia, vomiting, poor feeding, irritability, or lethargy As age increases, symptoms are more specific Fever and chills, headache Cough or wheezing Chest pain, abdominal distress, neck pain and stiffness pallor and leukocytosis

  31. Physical Exam Tachypnea is the best single indicator of pneumonia Age in monthsUpper limit of Normal RR < 2 60 2-12 50 12-60 40

  32. Treatment Neonates Ampicillin + Gentamycin / Cefotaxime 1 – 3 mo Erythromycin 10 mg/kg IV Q6H 1 – 24 mo Cefuroxime 50 mg/kg IV Q8H (not ICU) Ceftriaxone 50-75 mg/kg IV Q24H and Cloxacillin 50 mg/kg IV Q6H (ICU) 3 mo – 5 yrs Cefuroxime / Erythro IV (admitted) Clarithro / Azithro (outpt Tx)

  33. Differential Diagnosis of Wheezing H + N Vocal cord dysfunction Chest Asthma Bronchiolitis Foreign Body Aspiration CVS Congestive Heart Failure Vascular Rings

  34. CAEP Pediatric Asthma Guidelines • MILD • Nocturnal cough • Exertional SOB • Increased Ventolin use • Good response to Ventolin • O2 sat > 95% • PEF > 75% (predicted / personal best) • ± O2 • Ventolin • Consider po Steroids Symptoms Pre - Treat Treatment

  35. CAEP Pediatric Asthma Guidelines • MODERATE • Normal mental status • Abbreviated speech • SOB at rest • Partial relief with Ventolin and required > than q 4h • O2 sat 92%-95% • PEF 50-75% (predicted / personal best) • O2 100% • Ventolin • Systemic corticosteroids • Consider anticholinergic Symptoms Pre - Treat Treatment

  36. CAEP Pediatric Asthma Guidelines • SEVERE • Altered mental status • Difficulty speaking • Laboured respirations • Persistant tachycardia • No prehospital relief with usual dose Ventolin • O2 saturation <92% • PEF, FEV1 <50% • 100% O2 • Continuous or frequent b-agonists • Systemic corticosteroids & magnesium sulfate • Consider anticholinergic & / or methylxanthines Symptoms Pre - Treat Treatment (consider RSI)

  37. CAEP Pediatric Asthma Guidelines • NEAR DEATH • Exhausted , Confused • Diaphoretic • Cyanotic, Decreased respiratory effort, APNEA • Falling heart rate • O2 saturation <80% • (spirometry not indicated) • As above PLUS • RSI • IV Ventolin • Inhalational anesthetic, aminophylline • Epinephrine Symptoms Pre - Treat Treatment

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