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Pediatrics

Pediatrics. Respiratory Emergencies. Respiratory Emergencies. #1 cause of Pediatric hospital admissions Death during first year of life except for congenital abnormalities. Respiratory Emergencies. Most pediatric cardiac arrest begins as respiratory failure or respiratory arrest.

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Pediatrics

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  1. Pediatrics Respiratory Emergencies

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

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

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

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

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

  7. Respiratory Distress

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

  9. Respiratory Emergencies • Croup • Epiglottitis • Asthma • Bronchiolitis • Foreign body aspiration

  10. Laryngotracheobronchitis Croup

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

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

  13. 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

  14. Croup: Management • Mild Croup • Reassurance • Moist, cool air

  15. Croup: Management • Severe Croup • Humidified high concentration oxygen • Monitor EKG • IV tko iftolerated • Nebulized racemic epinephrine • Anticipate need to intubate, assist ventilations

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

  17. 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

  18. 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

  19. Epiglottitis Respiratory distress+ Sore throat+Drooling = Epiglottitis

  20. Epiglottitis: Management • High concentration oxygen • IV tko, ifpossible • Rapid transport • Do not attempt to visualize airway

  21. Epiglottitis Immediate Life Threat Possible Complete Airway Obstruction

  22. Asthma

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

  24. Asthma: Pathophysiology Bronchospasm Bronchial Edema Increased Mucus Production

  25. Asthma: Pathophysiology

  26. Asthma: Pathophysiology Cast of airway produced by asthmatic mucus plugs

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

  28. Asthma: Signs/Symptoms • Coughing • Expiratory wheezing • Tachypnea • Cyanosis

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

  30. 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?

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

  32. 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

  33. Asthma • SILENT CHEST= DANGER OF RESPIRATORY FAILURE

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

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

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

  37. Asthma: Management • Obtain medication history • Overdose • Arrhythmias

  38. Asthma: Management • Nebulized Beta-2 agents • Albuterol

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

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

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

  42. Status Asthmaticus Asthma attack unresponsive to -2 adrenergic agents

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

  44. 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

  45. Bronchiolitis

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

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

  48. 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

  49. 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 Asthma vs Bronchiolitis

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

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