CROUP

1. CROUP Prepared by: South West Education Committee

2. South West Education Committee Croup Protocol

3. OBJECTIVES • Identify the anatomical differences in pediatrics which impact croup patients. • Review of pediatric assessment • Identify common presentations for croup. • Distinguish croup from Epliglottitis. • Describe the treatment for croup. • Explain the indications for treatment.

4. ANATOMICAL DIFFERENCES • Anatomy is smaller and proportioned differently. • Head proportionately larger on a weak neck. • Obligatory nose breathers. (Infants)

5. AIRWAY - Pediatric vs. Adult • Narrower at all levels • The mandible is proportionally smaller in young children • The tongue is proportionally larger than adults • Larynx is more anterior and superior than an adults’ (C3-C4)

6. AIRWAY - Pediatric vs. Adult

7. AIRWAY • Cricoid ring is the narrowest part of the airway in young children • Tracheal cartilage is softer • Trachea is smaller in both length and diameter

8. A Picture is Worth….. • Small, hypotonic jaw, large tongue, tonsils, adenoids, arytenoids, uvula, long floppy epiglottis. (prone to swelling) • Excessive secretions. (requires suctioning) • Gums are more delicate, bleed easily, softer teeth which dislodge easily

9. Anatomical Differences • Why is this difficult? • The larynx: • 3-3-2 • More anterior. • More superior. thyromental distance • Big teeth or no teeth. • Cone shaped.

10. AIRWAY • BLS first • Open & maintain a/w • Ensure patency • Suction & insert oral &/or nasal a/w • ORAL or NASAL ETT? • Assist/prep for intubation

11. HUMAN ERROR • Most preventable deaths that happen in the pre-hospital care setting are STILL attributed to poor airway management practices. • It has been found that upwards of 86% of preventable deaths of inhospital patients with airway complications were attributed to human error.

12. PEDIATRIC REVIEWCHEST AND LUNGS • Ribs are positioned horizontally • Ribs are more pliable and offer less protection to organs • Chest muscles are immature and fatigue easily • Lung tissue is more fragile • Mediastinum is more mobile • Thin chest wall allows for easily transmitted breath sounds

13. PEDIATRIC REVIEW ABDOMEN • Immature abdominal muscles offer less protection • Abdominal organs are closer together • Liver and spleen are proportionally larger and more vascular

14. PEDIATRIC REVIEW RESPIRATORY SYSTEM • Tidal volume is proportionally smaller to that of adolescents and adults • Metabolic oxygen requirements of infants and children are about double those of adolescents and adults • Children have proportionally smaller functional residual capacity, and therefore proportionally smaller oxygen reserves

15. PEDIATRIC REVIEW CARDIOVASCULAR SYSTEM • Cardiac output is rate dependent in infants and small children • Vigorous but limited cardiovascular reserve • Bradycardia is a response to hypoxia • Children can maintain blood pressure longer than adults • Circulating blood volume is proportionally larger than adults • Absolute blood volume is smaller than adults

16. WRAP UP! • Smaller chest and respiratory reserve, belly breathers. • Poorly developed accessory and abdominal muscles. ( prone to fatigue / injury) • Poorly developed rib cage. (prone injury) • Excessive air swallowing. (large stomach) • Poor gastric emptying. (vomit) • Immature temperature regulatory system. • Higher metabolic rate requires a higher respiratory and circulatory rate. Conversely they have a much lower blood pressure due to the lack of plaque, arteriosclerosis and muscle development in arteries.

17. ASSESSMENT - PEDIATRICS

18. SCENE ASSESSMENT • Observe the scene for hazards or potential hazards • Observe the scene for mechanism of injury/illness • Ingestion • Pills, medicine bottles, household chemicals, etc. • Child abuse • Injury and history do not coincide, bruises not where they should be for mechanism of injury, etc. • Position patient found

19. INITIAL ASSESSMENT • General impression • General impression of environment • General impression of parent/guardian and child interaction • General impression of the patient/pediatric assessment triangle • A structure for assessing the pediatric patient • Focuses on the most valuable information for pediatric patients • Used to ascertain if any life-threatening condition exists • Components

20. GCS / LOA • Determine level of consciousness • AVPU scale • Alert • Responds to verbal stimuli • Responds to painful stimuli • Unresponsive • Modified Glasgow Coma Scale • Signs of inadequate oxygenation

21. Pediatric Glasgow Coma Scale 0-1 year old >1 year old Score Eye Opening Spontaneous spontaneous 4 To shout To command 3 To pain To pain 2 No response No response 1 Verbal Cry, smiles, coos Appropriate words 5 Cries Disorientated 4 Inappropriate cry Cries/screams or inappropriate 3 Grunts Grunts or incomprehensible 2 No response No response 1 Motor Obeys Command 6 Localizes pain Localizes pain 5 Withdraws Withdraws 4 Flexion Flexion 3 Extension Extension 2 None None 1

22. AIRWAY AND BREATHING • Airway – determine patency • Breathing should proceed with adequate chest rise and fall. Visualize/Expose chest. • Signs of respiratory distress • Tachypnea • Use of accessory muscles • Nasal flaring • Grunting • Bradypnea • Irregular breathing pattern • Head bobbing • Absent breath sounds • Abnormal breath sounds

23. CIRCULATION • Pulse • Central • Peripheral • Quality of pulse • Blood pressure • 2 x Age + 80 = systolic • 2/3 the systolic = diastolic • Skin color • Active hemorrhage

24. TRANSITION PHASE • Used to allow the infant or child to become familiar with you and your equipment • Use depends on the seriousness of the patient's condition • For the conscious, non-acutely ill child • For the unconscious, acutely ill child do not perform the transition phase but proceed directly to treatment and transport

25. APPROACH TO PEDIATRICS • Always remember there are 2 patients. • Stay CALM, reassure parents and child. • remain calm but be attentive and willing to act aggressively to reduce morbidity and mortality. • Handle child gently & explain before doing. • Try to examine small children on parents lap when appropriate. • If child or parents are extremis to the point they endanger resuscitation efforts, separate. • Prevent heat stress and preserve Child’s body heat.

26. PATIENT COMMUNICATION • Try to never be alone with a pediatric patient. • Sit close, eye level, but do not overcrowd. • Use toys to aid your exam. • Demonstrate on parents. • Offer rewards. • Be direct, do not lie!!!!!!! • Parents sometimes feel guilty even if they did nothing wrong.

27. HISTORY TAKING • Parents of chronically ill children know the disease better than most care givers - ask them. • Ask if child has had a fever / are they hot. • Hx of laboured breathing or excessive drooling. • Lethargy. (A very quiet child is a scary thing) • Blank staring, twitching other bizarre behavior. • Poor appetite, refusal to eat, vomiting or diarrhea recently. • Increase or decrease in wet diapers. • Inconsolable crying / screaming does not recognize parents.

28. Chief complaint Nature of illness/injury How long has the patient been sick/injured Presence of fever Effects on behavior Bowel/urine habits Vomiting/diarrhea Frequency of urination Past medical history Infant or child under the care of a physician Chronic illnesses Medications Allergies FOCUSED HISTORY–CONTENT

29. DETAILED PHYSICAL EXAMINATION • Should proceed from head-to-toe in older children • Should proceed from toe-to-head in younger children (less than 2 years of age) • Depending on the patient’s condition, some or all of the following assessments may be appropriate: • Pupils - Hydration • Capillary refill - Pulse oximetry • ECG monitoring • Is patient hypoglycemic?

30. ON-GOING ASSESSMENT • Appropriate for all patients • Should be continued throughout the patient care encounter • Purpose is to monitor the patient for changes in: • Respiratory effort • Skin color and temperature • Mental status • Vital signs (including pulse oximetry measurements) • Measurement tools should be appropriate for size of child

31. RESPIRATORY COMPROMISE • Several conditions manifest chiefly as respiratory distress in children including: • Upper and lower foreign body airway obstruction • Upper airway disease (croup, bacterial tracheitis, and epiglottitis) • Lower airway disease (asthma, bronchiolitis, and pneumonia) • Most cardiac arrests in children are secondary to respiratory insufficiency thus, respiratory emergencies require rapid prehospital assessment and management

32. CROUP • Laryngotracheobronchitis • Common inflammatory respiratory illness in children • Viral infection of the upper airway • Differentiation between croup and epiglottitis in the prehospital setting may be difficult

33. Upper Respiratory Distress • CROUP • upper airway infection with “barking” cough. • mild to moderate respiratory distress with predominant stridor. • may be relieved by cold air. (mist) • usually 2 - 7 years of age, Rapid onset. • Epiglottitis DEADLY EMERGENCY!!!!! • Rarely have Stridor. (inspiratory when they do) • Excessive drooling. • Absence of a “barking seal cough.”. • Preference for sitting in “sniffing position.” • Very “eerie”, quiet & obtunded look. • High grade fever.

34. Upper Respiratory Distress

35. CROUP PROTOCOLINDICATIONS • Any patient who is <8 years old . • A current Hx of upper respiratory infection. • Barking cough (seal-like) • Stridor at rest and/or • Altered level of consciousness and/or • Cyanosis.

36. PROCEDURE • Monitor heart rate • Attach cardiac monitor • Assess pulse rate. • Pulse rate must be <200 bpm.

37. PROCEDURE • Nebulized Epinephrine will not exceed 2 doses.

38. WHY EPINEPHRINE? • Epi. acts on the subglottic swollen area to vasoconstrict blood vessels and reduce the swelling with the alpha 1 effects. • Salbutamol has no vasoconstrictive effects and only acts on the smooth muscles of the bronchioles with its beta 2 effects.

39. PROCEDURE • Allow patient to assume position of comfort. • Reassure the patient and parents. • Administer 100% oxygen, via blow-by if needed, while preparing equipment

40. PROCEDURE • Nebulize Epinephrine 1:1000 based on patients weight and age.

41. <1y/o and <5kg 0.5 mg(0.5 ml) in 2 ml of normal saline. <1y/o and >5kg 2.5 mg(2.5 ml) 2 ml of normal saline may be added. EPINEPHRINE DOSING Age and WeightDose >1y/o and <8y/o 5.0 mg (5.0 ml)

42. REPEAT • Repeat treatment if no improvement is observed. • Max Epinephrine treatments is 2! • No exceptions.

43. TRANSPORT • ALL PATIENTS MUST BE TRANSPORTED WITHOUT DELAY.

44. REASSESS - ENROUTE • Reassess every 5 minutes. • Airway • Breathing • Circulation • Vitals • And document it all.

45. QUESTIONS?