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Recognition and Initial Management of Pediatric Shock and Respiratory Failure

Critical Concepts:. Recognition and Initial Management of Pediatric Shock and Respiratory Failure. Shock. Inadequate peripheral perfusion where oxygen delivery does not meet metabolic demand Adult vs Pediatric Shock - Same causes/different frequencies. Pediatric Shock. Hypovolemia

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Recognition and Initial Management of Pediatric Shock and Respiratory Failure

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  1. Critical Concepts: Recognition and Initial Management of Pediatric Shock and Respiratory Failure

  2. Shock • Inadequate peripheral perfusion where oxygen delivery does not meet metabolic demand • Adult vs Pediatric Shock - Same causes/different frequencies

  3. Pediatric Shock • Hypovolemia • Most common cause of pediatric shock • Small blood volumes (80cc/kg) • Sepsis • Second most common cause of pediatric shock • Immature immune system

  4. Pediatric Shock • Cardiogenic • Primary pump failure – congenital heart disease • Secondary failure from: • Hypoxia • Acidosis • Hypoglycemia • Hypothermia • Drug toxicity

  5. Pediatric Shock • Neurogenic • Rare • Low incidence associated with low pediatric spinal cord trauma rates

  6. Pediatric Shock • Early shock - Very difficult to detect • Pediatric cardiovascular system compensates well • Early Signs/Symptoms • Tachycardia - carry chart of normals • Slow capillary refill ( > 2 seconds) • Pale or mottled skin, cool extremities • Tachypnea

  7. Pediatric Shock • Late Signs/Symptoms • Weak or absent peripheral pulses • Decreasing level of consciousness • Hypotension • Hypotension = Pre-arrest State

  8. Pediatric Shock Management • Initial assessment may detect shock, but not its cause • When in doubt, treat for hypovolemia

  9. Shock Management • Airway • Open, clear, maintain • Non-invasive (chin lift, jaw thrust) • Invasive (endotracheal intubation) • Trauma patient - ? C-spine injury

  10. Shock Management • Breathing • 100% oxygen indicated for all shock • Ventilation • Reduce work of breathing • Do not “fight” patient

  11. Shock Management • Circulation • Apply cardiac monitor • Control obvious hemorrhage • Elevate lower extremities

  12. Shock Management • Fluid Resuscitation • Obtain Access quickly • Consider intraosseous access • Fluid bolus: 20 ml/kg isotonic fluid • Most common error--Too LITTLE fluid • Reassess for: • Improved perfusion • Respiratory distress • Check blood glucose • Give D25W if D-stick < 40 - 60

  13. Disorders of Hydration • Causes • Vomiting • Diarrhea • Fever • Poor oral intake • Diabetes mellitus

  14. Disorders of Hydration • Mild dehydration ( <5% weight loss) • Mild increased thirst • Slight mucous membrane dryness • Slight decrease in urinary frequency • Slight increase in pulse rate

  15. Disorders of Hydration • Moderate dehydration (5 - 10% weight loss) • Moderate increase in thirst • Very dry, “beefy red” mucous membranes • Decrease in skin turgor • Tachycardia • Oliguria, concentrated urine • Sunken eyes

  16. Disorders of Hydration • Severe dehydration (10 - 15% weight loss) • Severe thirst • Tenting of skin • No tears when crying • Weak, thready pulses • Marked tachycardia • Sunken fontanelle • Hypotension • Decrease in LOC

  17. Disorders of Hydration • Management • Oxygen • 20 cc/kg boluses LR • Repeat boluses as needed to • Restore peripheral pulses • Decrease tachycardia • Improve LOC • Remember that hypotension is a late and ominous finding! • Reassess frequently

  18. Tonsils Epiglottis Esophagus Tongue Trachea Larynx Normal upper airway anatomy ACCT4Kids

  19. Typical causes of distress • Upper airway • Croup • Retropharyngeal abscess • Epiglottitis • Foreign body aspiration • Lower airway • Reactive airway disease / asthma • Bronchiolitis • Pneumonia • Pneumothorax ACCT4Kids

  20. Obligate nose-breathers Tongue relatively larger Higher larynx (C3-C4 versus C6) Narrowing of airway causes exponential rise of airway resistance Less elasticity of alveoli Lower FRC Diaphragm Flatter Muscle fibers more vulnerable to fatigue Chest wall More compliant Ribs more horizontal Why are kids different? ACCT4Kids

  21. Nasal flaring Hypoventilation, apnea Stridor Grunting Wheezing Pallor, ashen color  WOB Tachypnea Cyanosis Head bobbing Tripod positioning Retractions  Level of consciousness  Air movement Acidosis Hypercapnea Signs & symptoms of distress ACCT4Kids

  22. Croup (LaryngoTracheoBronchitis) • Most severe in kids 6 mo - 3 years old • Males • Winter months • Associated illnesses • Ear infection • Pneumonia • Organisms: parainfluenza types 1, 2 & 3, adenovirus, RSV, influenza ACCT4Kids

  23. Croup symptoms • URI symptoms X 1-3 days • Low grade fever • “Barking” cough, hoarseness • Inspiratory stridor • Worse at night • Prefer to sit up • Aggravated by agitation & crying ACCT4Kids

  24. Croup diagnosis • Clinical diagnosis • Does not require neck X-ray • Consider X-ray in patients with atypical presentation or clinical course • “Steeple sign” Steeple sign ACCT4Kids

  25. Hypopharnyx Narrow air column Trachea Steeple sign Croup treatment • Position of comfort, with parent • Dexamethasone 0.6 mg/kg IV/IM • Epi neb • Heliox • SQ Epi • Cool mist ACCT4Kids

  26. Retropharyngeal abscess • Deep, potential, space of the neck • Children age 6 months to 6 years • Other deep neck abscesses more frequent in older children & adults • Parapharyngeal • Peritonsillar • Potential for airway compromise • Complications secondary to mass effect, rupture of the abscess, or spread of infection ACCT4Kids

  27. Fever, chills, malaise Decreased appetite Irritability Sore throat Difficulty or pain swallowing Jaw stiffness Neck stiffness Muffled voice “Lump” in the throat Pain in the back & shoulders upon swallowing Difficulty breathing is an ominous complaint that signifies impending airway obstruction Retropharyngeal abscess - symptoms ACCT4Kids

  28. Retropharyngeal abscess ACCT4Kids

  29. Retropharyngeal abscess • Polymicrobial infection typical • Gram-positive organisms and anaerobes predominating • Gram-negative bacteria possible • Oropharyngeal flora • Most common cause is group A beta-hemolytic streptococci ACCT4Kids

  30. Retropharyngeal abscess - Treatment • Position airway - comfort • Avoid unnecessary manipulation • Monitor, CT of neck, possible OR • Sedation & paralytics can relax airway muscles, leading to complete obstruction • Endotracheal intubation is dangerous • Abx: clindamycin, cefoxitin, Timentin, Zosyn, or Unasyn ACCT4Kids

  31. Epiglottitis • Acute, rapidly progressive cellulitis of the epiglottis and adjacent structures • Before immunization - peak incidence at 3.5 years of age • Danger of airway obstruction - medical emergency • Prompt diagnosis and airway protection required ACCT4Kids

  32. Epiglottitis - signs & symptoms • More acute presentation in young children than in adolescents or adults • Symptoms for <24 hrs • High fever, severe sore throat, tachycardia, systemic toxicity, drooling, tripod position • Moderate or severe respiratory distress with inspiratory stridor & retractions ACCT4Kids

  33. Epiglottitis - lateral neck film ACCT4Kids

  34. Epiglottitis ACCT4Kids

  35. Epiglottitis - etiology • Group A Streptococcus • Other pathogens seen less frequently include: • Strep pneumoniae • Haemophilus parainfluenza • Staph aureus ACCT4Kids

  36. Epiglottitis - Treatment • Position of comfort, with parent • Minimize manipulation • Intubation under controlled circumstances • O2 prn, blow-by if not tolerating mask • Avoid agitation (Do not try to start IV, obtain blood or examine airway!) • Consult anesthesia & ENT • IV for antibiotics, after airway secure ACCT4Kids

  37. Foreign body (FB) aspiration • Toddler through preschool age common • No molar teeth for thorough chewing • Talking, laughing, and running while eating • Nuts, raisins, sunflower seeds, pieces of meat and small smooth (grapes, hot dogs, & sausages) • Dried foods absorb water ACCT4Kids

  38. Foreign Body aspiration • Sudden episode of coughing / choking while eating with subsequent wheezing (sometimes unilateral), coughing, or stridor • Tragic cases occur with total or near-total occlusion of the airway • Frequent sites of FB lodgement: • Usually below vocal cords • Mainstem bronchi • Trachea • Lobar bronchi ACCT4Kids

  39. Foreign Body aspiration • Extrathoracic FB: • Breath sounds are inspiratory • Intrathoracic FB • Noises are symmetric but more prominent in central airways • If FB is beyond the carina, the breath sounds are usually asymmetric • Kid chest transmits sounds well • Stethoscope head may be bigger than lung lobes • Lack of asymmetry should not dissuade you from considering the FB diagnosis ACCT4Kids

  40. Foreign Body aspiration • Hyperinflation & air-trapping of the affected lobe(s) is typical • Best seen with X-ray taken at expiration • Difficult in little kids • May see soft tissue opacity in proximal airway ACCT4Kids

  41. Foreign bodies ACCT4Kids

  42. FB aspiration • Position of comfort • Heimlich maneuver, back blows • BVM prn • Magill forceps (if object above cords) • Intubation prn • Needle cricothyrotomy • Surgical cricothyrotomy • Rigid bronchoscopy for FB removal ACCT4Kids

  43. Reactive airway disease / Asthma ACCT4Kids

  44. RAD / Asthma - children • <3 years - small intrapulmonary airways • Poor collateral ventilation • Decreased elastic recoil pressure • Partially developed diaphragm ACCT4Kids

  45. RAD / Asthma • Identify and remove asthma triggers • Albuterol, nebulized • Ipratopium bromide (Atrovent) • Methylprednisolone (Solumedrol) • Magnesium sulfate • CPAP / BiPAP • Heliox • Epinephrine or terbutaline infusion • May require inubation • At risk for pnuemothorax due to hyperinflation ACCT4Kids

  46. Bronchiolitis • Organisms: RSV most common • Others: parainfluenza, influenza, human metapneumovirus (hMPV), adenovirus, mycoplasma • Winter & spring • Males • Typically <2 years old, peak 2-8 mos • Disease more severe in babies 1-3 mo old • Risk factors: Heart disease, BPD, prematurity, smoking in home ACCT4Kids

  47. Bronchiolitis ACCT4Kids

  48. Bronchiolitis - symptoms • Apnea, bradycardia • Desaturations • Cough, copious secretions • Tachypnea, tachycardia • Crackles, wheezing • Increased WOB, retractions • Flaring, grunting • Pallor, cyanosis ACCT4Kids

  49. Bronchiolitis - diagnosis • No diagnostic tests needed, but possibly: • Rapid viral panel (antigen or FA panel) • Viral cultures • CXR - hyperinflation, peribronchial cuffing, patchy atelectasis • Tachypnea, WOB, wheezing • Hx URI • fever, cough, runny nose, appetite • Apnea (may occur w/o other symptoms) • May be complicated by secondary bacterial infection ACCT4Kids

  50. Bronchiolitis • Isolation - contact, droplet • O2, keep sats ≥92% • Pulmonary toilet, suctioning! • CPAP / BiPAP • No steroids • Nebs largely unhelpful (<1/3) • Chest PT prolongs hospitalization • Antibiotics depend on other sxs ACCT4Kids

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