Transcript Document

Respiratory Emergencies
in the
Pediatric Population
CASE 1
16 month old boy with wheeze
Initial Vitals:
HR
RR
BP
Temp
O2sat on RA
160
60
88/50
38
89%
You do your pediatric assessment triangle:
Appearance
Crying, distressed, looking
around, moving all 4 limbs
Breathing (work of)
Laboured, chest caving in,
+++indrawing
Circulation
Colour OK, N cap refill
What would you like to do now?
Oxygen by mask applied, IV attempt started and
pt now on cardiac monitor
Airway
No stridor audible, no obvious secretions
Breathing
+++ wheeze with little air entry bilat
(inspiratory AND expiratory)
Circulation Warm extrem, PPP, cap refill 2 secs
What would you like to do now?
Oxygen
CXR done / pending
Ventolin
Atrovent
IV Access established – orders?
Blood work Doctor?
Venous Gas
pH
pCO2
pO2
7.35
38
125
History:
 Has had a “cold” for almost 2 days now
(mild fever, decreased energy / appetite with cough
and runny nose)
 Started getting wheezy this morning
 No history of exposure to allergens, inhalants
or FB aspiration
Family History of Asthma / no smokers / no pets
Otherwise healthy with no known allergies
Continuous Ventolin for 15 mins has little effect
 Still indrawing
 RR 65
 Still alert and looking around, crying
Additional treatment?
IV steroids
Solucortef 1 mg/kg IV / IM
Continue Ventolin
Consider racemic Epinephrine (0.5 mls)
Repeat Venous Gas about 30 mins later
pH
7.15
pCO2
55
pO2
120
Eyes rolling back, little crying now …
What do you want to do?
Drugs? Tube Size?
4 – 4.5 tube
Ketamine 1-2 mg/kg IV
Atropine 0.01 mg/kg IV (min 0.1 mg)
Succinyl 1 mg/kg IV
Other Options
 IV Magnesium 25 mg/kg (max 2 gm)
 IV Epinephrine
 IV Ventolin
 Inhalational Anesthetics
 Methylxanthines
 Heli - Ox
Differential Diagnosis of Wheezing
H+N
Vocal cord dysfunction
Chest
Asthma
Bronchiolitis
Foreign Body Aspiration
CVS
Congestive Heart Failure
Vascular Rings
CAEP Pediatric Asthma Guidelines
MILD
Symptoms
• Nocturnal cough
• Exertional SOB
• Increased Ventolin use
• Good response to Ventolin
Pre - Treat
O2 sat > 95%
PEF > 75%
(predicted / personal best)
Treatment
± O2
Ventolin
Consider po Steroids
CAEP Pediatric Asthma Guidelines
MODERATE
Symptoms
• Normal mental status
• Abbreviated speech
• SOB at rest
• Partial relief with Ventolin and required > than q 4h
Pre - Treat
O2 sat 92%-95%
PEF 50-75% (predicted / personal best)
Treatment
O2 100%
Ventolin
Systemic corticosteroids
Consider anticholinergic
CAEP Pediatric Asthma Guidelines
SEVERE
Symptoms
Pre - Treat
• Altered mental status
• Difficulty speaking
• Laboured respirations
• Persistant tachycardia
• No prehospital relief with usual dose Ventolin
O2 saturation <92%
PEF, FEV1 <50%
100% O2
(consider RSI) Continuous or frequent b-agonists
Systemic corticosteroids & magnesium sulfate
Consider anticholinergic & / or methylxanthines
Treatment
CAEP Pediatric Asthma Guidelines
Symptoms
NEAR DEATH
• Exhausted , Confused
• Diaphoretic
• Cyanotic, Decreased respiratory effort, APNEA
• Falling heart rate
O2 saturation <80%
Pre - Treat
Treatment
(spirometry not indicated)
As above PLUS
RSI
IV Ventolin
Inhalational anesthetic, aminophylline
Epinephrine
CASE 2
18 mo Girl with 24 hr Hx of coughing with drooling
Hx:
Has had an URTI for about a week and was
getting mildly better until yesterday. She
developed a fever and the cough got harsher.
Still drinking but not interested in solids
Vomited once last night
Started drooling this morning
Physical Exam
T39.1 degrees rectally, P170, R28, BP 100/66
Appearance alert, awake, not toxic, in no acute distress
Did not appear to prefer upright or a forward leaning position
EENT
Chest
Moist MM, slight erythema of oropharynx,
nasal crusting, N TMs, no rash / petechiae,
no drooling
Supple neck
Clear when resting
Mild inspiratory stridor with crying
Rest of the exam N
DDx?
• Croup
• Epiglottitis
• Bacterial
tracheitis
• RetroPharygeal
abcess
• Foreign Body
aspiration
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
Soft tissue lateral
neck radiograph
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
ETIOLOGY
Complication of bacterial pharyngitis
Less frequently
- extension of infection from vertebral osteomyelitis
Group A hemolytic streptococci, oral anaerobes,
and S. aureus
Typically …
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
On Exam …
Nasopharynx
Oropharynx
Bulging forward of the soft palate and
nasal obstruction
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
Complications
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.
Treatment
 Clindamycin 20-30 mg/kg/day divided Q8H
(if pre-fluctuant phase)
 Decadron 0.6 mg/kg
 Airway management
 Surgical decompression
CASE 3
17 month old male with a one-hour history
of noisy and abnormal breathing
Normal now but at the time, parents thought he was
quite distressed.
Now, he is able to speak and drink fluids without difficulty
VS T36.8, P200 (crying), R28 (crying), O2 sat 99%
Alert with no signs of respiratory distress
Able to speak, had no cyanosis, no drooling,
no dyspnea
H+N
No obvious swelling, bleeding, FB seen
Chest
Mild wheezing with ? mild inspiratory stridor
What would you like to do now???
Soft Tissue
Neck View
CXR (PA)
Next?
Expiratory
CXR
Inspiratory View
Expiratory View
Right
Decub
View
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)
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
Investigations
Xrays
 Lateral neck
 Chest – inspiratory, expiratory, decubitus views
Expiratory views
Overinflation (partial obstruction with inspiratory flow)
Volume loss with mediastinal shift towards obstructed
side (partial obstruction with expiratory flow)
Atelectasis (complete obstruction)
Decubitus views
Normal
Smaller volumes and elevated diaphragm
on side down
Abnormal
Hyperinflation or “normal” volumes in
decub position
If suspected …
Need a bronchoscope to rule out or
remove Foreign Body
CASE 4
2 yo Boy with Barky Cough for 2 days
 Runny nose, decreased appetite
 Not himself
No PMHx / FHx of significance
Shots UTD
Other sibs with similar URTIs
On Exam …
Temp 38.9
HR
140
O2 sat
98% (drops to 90% when he crys)
RR
40 (mild indrawing)
Irritable, crying, good colour
H&N
sl erythema of throat, no pus
N TMs, small cervical nodes
Chest
Barky cough, inspiratory stridor
No wheeze noted
Diagnosis?
Racemic Epinephrine
0.5 ml dose
? Dexamethasone now or later
Re – Assess in 30 minutes
No improvement with 1st dose of epinephrine
What would you like to do now?
Re – Examine
Ongoing Inspiratory Stridor
Cries when trachea is examined
IV Cefuroxime PLUS Cloxacillin
Consult Pediatric ICU / Pulmonary
for Bronch / Intubation
Bacterial tracheitis
 An acute bacterial infection of the upper airway capable
of causing life-threatening airway obstruction
 Staph aureus most commonly
(parainfluenza, 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
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)
Treatment
Antibiotics (good Staph coverage)
Intubation or tracheostomy is usually necessary
? Decadron
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
Severe Pneumonia:
Staph aureus
Strep pneumonia
Grp. A strep
HIB
Mycoplasma pneumonia
Pseudomonas if recently hospitalized
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
Physical Exam
Tachypnea is the best single indicator of pneumonia
Age in months
Upper limit of Normal RR
<2
55
2-12
45
> 12
35
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)