Caring for the Critical Infant and Child
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Transcript Caring for the Critical Infant and Child
Caring for the Critical Infant and
Child
John Camuso RN, BSN, CCRN
Flight Nurse
Life Net of New York
Overview
Discuss the anatomic and physiologic
differences in children that impact
resuscitation
Review the relevant pre-hospital literature
on pediatric resuscitation
Review pediatric specific emergencies
likely to be encountered by EMS personnel
Pediatric Differences
Size
Anatomy
Physiology
Environment/Psychosocial
Pediatric Differences-Size
Implications for
equipment
Chubby short necks
Large occiputs
Picture Joe Andruzzi’s
head on Troy Brown’s
body
Pediatric Differences-Anatomy
Can make
immobilization and
intubation challenging
Pediatric Differences-Size
Cervical spine
immobilization
No true infant collar
Most kids not actually
in neutral position
when immobilized
Pediatric Differences-Size
If the correct cervical
spine collar is
unavailable use towel
rolls
Pediatric Differences-Anatomy
Large occiput requires optimal head
positioning
Rapid desaturation with apnea
Limited ability to perform awake/sedated
intubations
Intravenous access
Pediatric Differences
Pediatric Differences-Anatomy
Tongue relatively large
Epiglottis floppy
Glottis at the C3-4
level
Trachea is small,
mobile, posterior
displacement into
thorax
Pediatric Airway Anatomy
ADULT
INFANT
Pediatric Differences-Physiology
Arrest states are rarely due to cardiac causes
Infants and children maintain cardiac output
via an increase in heart rate
Hypotension occurs late in shock states in
infants and children and should be
considered a pre-morbid state
Bradycardia is a pre-arrest state
Pediatric Cardiopulmonary Arrest
10%
10%
80%
Resp
Shock
Cardiac
Pediatric Cardiopulmonary Arrest
Cardiopulmonary Arrest
Hypoxia and Hypercarbia
Act Here
Bradycardia
Respiratory Arrest
Survival in Respiratory Arrest
Respiratory Arrest Alone –
more than 50% neurologically
intact survival rate
Pediatric EMS
50% of calls are for trauma
Falls
Motor Vehicle Collisions
50% of calls are for medical illnesses
Fever and Infectious Diseases
Respiratory Complaints
Seizures
Intubation
Reported success rates
for intubation in
pediatric patients is
lower than for adult
patients
Intubation
Pediatric calls <10% of total calls
Of these, <20% are ALS runs
60% of EMT-P will see <3 pediatric
pt/month
84% of EMT-I will see <3 pediatric
pt/month
87% of EMT-B will see <3 pediatric
pt/month
Intubation
Problem
Unique knowledge set
Unique skill set
Unique equipment
BUT………
Relatively rare encounters
Rarely require ALS skills which means there is
little change to maintain skills
Intubation
Setting: Large, urban, rapid-transport EMS system
Patients: 830 pediatric patients age <12 years
assigned to either bag-valve-mask or BVM
followed by intubation
Outcomes: Survival to hospital discharge and
neurologic status at discharge
Gausche M. et al. Effect of out-of-hospital pediatric
endotracheal intubation on survival and neurologic outcome: a
controlled clinical trial. JAMA 2000;283:783-90.
Pre-hospital Intubation
30
25
20
BVM
ETI
15
10
5
0
Survival
Neuro Outcome
Tracheal Tube
Age
kg
ETT
Newborn
3 mos
1 yr
2 yrs
3.5
6.0
10
12
3.5
3.5
4.0
4.5
Length
9
10
11
12
Children > 2 years:
ETT size:
(Age+16)/4
ETT depth (lip):
ETTsize x 3
Broselow Tape
Resuscitation tape with
weight based
equipment and
medication doses based
on the length of the
child
Laryngoscope Blades
Better in older
children who
have a stiff
epiglottis
Curved
Laryngoscope Blades
Better in
younger
children with a
floppy
epiglottis
Straight
Acute Deterioration after Intubation
D.O.P.E:
Displacement
Obstruction
Pneumothorax
Equipment failure
Case 1
ALS is dispatched to home where a 2 month
old was found blue and not breathing.
Arrive to find a 2 month old in his basinet
pulseless and apneic. PALS protocols are
instituted and the child is transported with
CPR in progress. He is pronounced dead 40
minutes after arrival at the local Children’s
Hospital.
SIDS
Sudden Infant Death
Syndrome
3rd leading cause of
death for infants
behind congenital
anomalies and
prematurity
Diagnosis of exclusion
SIDS
1992 – Back to Sleep
campaign by the
American Association
of Pediatrics decreased
SIDS rates by 40%
SIDS
Peak incidence at age 3-5 months
90% occurs within the first 6 months of life
Sudden death occurring beyond the first
year of life is unlikely to be SIDS
SIDS-Risk Factors
Male gender
Prematurity
Maternal smoking
Winter months
Low socioeconomic status
Young maternal age
Multiple gestation
Single parenthood
Prone sleeping
Soft bedding
ALTE
Apparent Life-Threatening Event
Formally termed “near miss SIDS” or
“aborted crib death”
ALTE
“an episode that is frightening to the
observer and is characterized by some
combination of apnea, color change, change
in muscle tone, choking or gagging”
ALTE
Frustrating because
the parents may
describe one thing
while you see another
ALTE
Infection: pertussis, respiratory syncytial
virus, sepsis, meningitis
GERD
Seizures
Aspiration
Munchausen’s by Proxy
Prolonged QT syndrome
ALTE
Treatment:
Directed at the underlying cause of the event if
the cause can be uncovered
Vast majority of ALTE cases are admitted to the
hospital for monitoring
More and more children are leaving the
hospital with a diagnosis of reflux after an
ALTE event
Respiratory Emergencies
Respiratory Mechanics
Head Bobbing
Nasal Flaring
Retractions
Grunting
Stridor
Wheezing or Prolonged Exhalation
Upper Airway Obstruction
turbulence
Lower Airway Obstruction
turbulence &
wheezing
Effect Of Edema
Poiseuille’s law
Pediatric Emergencies-Principles
Much of Pediatric
Emergency
Medicine is
infectious diseases
Children are
“cesspools of
disease”
Case 2
1 year old female presents with respiratory
distress. Mother reports that the child has
been ill for 24 hours with fever and
congestion. Tonite, the child awoke with a
harsh cough that seemed to get better when
she took the child outside in the cool air.
Croup
Laryngotracheobronchitis
Viral infection involving the larynx, trachea
and bronchi
Affects children ages 6 months to 3 years
Croup
Etiology:
Parainfluenza 60%
Influenza
Adenovirus
Measles
RSV
Croup
Clinical
Manifestations:
Stridor develops 1-2
days after the onset of
fever and congestion
Characteristic barking
cough
Fever, tachycardia and
tachypnea (rarely more
than 40 breaths/minute)
Croup
Diagnosis is primarily clinical
Lateral and anteroposterior neck radiographs
show subglottic narrowing
The so-called “steeple sign”
May progress to complete upper airway
obstruction
Croup
Croup
Warning signs
Hypotonicity
Noticeable retractions
Decreased air entry
Decreased level of consciousness
Tachycardia
Cyanosis
Croup
Rising End-tidal CO2
may warn of
impending respiratory
failure
Warning!
If you are able to place
an ETCO2 detector on
a child of this age, be
very afraid!
Croup
Management:
Most are managed as outpatients
Hospitalize for dehydration and stridor at rest
Specific therapy:
Mist
Nebulized racemic epinephrine
Dexamethasone
Case 3
EMS is called to the home of a 3 year old
for fever and difficulty breathing. Mother
(pediatric axiom is that father’s are poor
historians) reports that she thought that
“Wendy” had croup but she is concerned
that she is not acting right. She has had
fever and stridor for 4 hours.
Case 3
You note an ill-appearing 3 year old sitting
quietly (Danger Will Robinson, Danger) in
her mothers arms with her chin extended
with labored respirations.
Case 3
A picture is worth a
thousand words
Early on, croup and
epiglottitis can look
very similar
Epiglottitis
Bacterial infection of the epiglottis
Prior to the HIB vaccine, epiglottitis
accounted for 1/1000 pediatric admissions
Now a rare disease in children
Epiglottitis
Hallmark of the disease is that of a rapidly
progressing (6-24 hours) airway obstruction
Fever
Stridor and labored respirations
Drooling
Ill appearance
Epiglottitis
Diagnosis:
Lateral neck xray
showing a swollen
epiglottis
Thumb sign
Thickened
aryepiglottic folds
Obliteration of the
vallecula
Epiglottitis
Direct visualization of
the epiglottis in a
setting where surgical
airway backup is
immediately available
ie. The Operating
Theatre
Epiglottitis
Epiglottis
during direct
laryngoscopy
Epiglottitis
Management:
Respiratory support – most spend time
intubated in the ICU
Intravenous antibiotics targeted at the causative
organism
**Supportive care during rapid transport to
the Emergency Department unless the
patient is in respiratory arrest
Case 4
You are called to the home of a 3 month old
male for respiratory distress. Mother
reports that the baby has been congested for
24 hours, but today he has had trouble
feeding and seems to be breathing fast.
Multiple members of the family are ill with
“colds.”
Case 4
On exam:
RR 80
Oxygen saturation 92%
Wheezes auscultated in all lung fields
Temperature 38.7
Bronchiolitis
Etiology:
Respiratory syncytial virus
Human Metapneumovirus
Parainfluenza
Most occur in winter months in children
aged 2 months to 8 months ofage
Rare in older children
Bronchiolitis
Airway edema and mucous production
Signs and Symptoms:
Fever, cough, congestion
Tachypnea prominent (80-100 breaths/min)
Nasal flaring and retractions
Wheezing
Grunting – “auto-peep”
Poor feeding due to increased work of
breathing
Bronchiolitis
In neonates, apnea is a real concern
*1% of all hospitalizations for children in
the US in the first year of life
$300 million dollars/year in the US
Bronchiolitis and RSV
Bronchiolitis
Diagnosis:
Clinical presentation
Time of year
Nasopharyngeal aspirate
Chest xray – peribronchial cuffing and
hyperinflation
Bronchiolitis
Bronchiolitis
Management:
Supportive
Albuterol or nebulized epinephrine
Controversial
Not all infants respond
Unlike asthma, steroids play NO role
Pertussis
Whooping cough
Caused by infection
with Bordetella
pertussis
Pertussis
3 stages:
URI – “catarrhal stage”
First 1-2 weeks
Paroxysmal – second stage
Prolonged coughing then inflow of air producing
the characteristic whoop
Cyanosis may occur
Convalescent – third stage
Pertussis
Diagnosis:
Increased white blood cell count with
lymphocyte predominance on differential
Nasopharyngeal culture sent to the state lab
Pertussis
Management:
Infants should be hospitalized due to risk of
apnea and cyanosis
Erythromycin for 14 days
Treat household contacts as well
Case 5
EMS is called to a sleepy urgent care facility in
the “burbs.” On arrival, you find a frantic staff
hovering around a mother and her 7 day old son.
She had brought the child to be evaluated due to
lethargy and sweating during feeding. In triage,
the baby was found to have a heart rate of 300.
The urgent care facility does not have appropriate
sized equipment to take a blood pressure.
Case 5
You put the child on your monitor and find:
Pediatric SVT
Paroxysmal supraventricular tachycardia is
the most common significant arrythmia seen
in pediatric practice
Rates are typically 220-320 beats/minute
50% are “idiopathic”
24% are associated with infection, fever, drug
exposure (cocaine, cold preparations with
sympathomimetic amines)
The rest have an identifiable bypass tract
Pediatric SVT
In most adults you can elicit a history of
palpitations or “racing heart”
Signs and symptoms in children are more
protean
Poor feeding
Irritability
Respiratory distress
Shock
CHF after 24 hours of rapid heart rate
Pediatric SVT
Vagal maneuvers
Ice/Cold water to the
child’s face
Don’t turn a cardiac
emergency into a near
drowning
Children have more
vagal tone
Pediatric SVT
Adenosine 0.1 mg/kg IV push followed by
0.2 mg/kg IV push if unsuccessful
Synchronized cardioversion for unstable
patients
Case 6
EMS is dispatched to the home of a 2 year
old male for “seizure.” On arrival, mother
meets you at the door with an unresponsive
but spontaneously breathing toddler. She
reports that he had a fever earlier in the day
and then had a seizure.
Case 6
What are the immediate actions that must be
taken?
What parts of the history are important?
As you assess the scene, what are important
clues to look for?
Febrile Seizure-Immediate Actions
ABC’s
Is the child still
seizing?
Blood glucose
determination if
available.
Febrile Seizure-Historical Points
History of illness (ie. Was there a fever?)
Any history of trauma?
How long did the seizure last?
Was the start of the seizure witnessed?
Febrile Seizure-Scene
Most kids have multiple febrile illnesses a
year.
Seizure and fever may be true, true and
unrelated.
Keep in mind that toxic ingestions can also
cause seizures!
Specifically tricyclic antidepressants, oral
hypoglycemics, isoniazid, cocaine, ecstasy,
aspirin
Febrile Seizures
Simple Febrile Seizures
80% of cases
Single seizures
Brief (<15 minutes)
Generalized tonic clonic
Febrile Seizures
Complex
20% of cases
Multiple seizures
Prolonged
Focal seizures
Febrile Seizures
33% of patients with one febrile seizure will
have another
75% of these recurrent seizures will happen
within 1 year
Febrile seizures are uncommon beyond 2
years of age
Children “grow out” of febrile seizures
Higher index of suspicion for older children
with seizure in the setting of a febrile illness
Febrile Seizures
What parents want to know:
Febrile seizures do increase the risk of future
epilepsy but only slightly
Risk is 1/100 versus 1/200
Family history of non-febrile seizure, complex
febrile seizure and underlying neurologic
abnormality increase risk of subsequent
epilepsy
Febrile Seizures
Management:
Benzodiazepines
Antipyretics
Simple febrile seizures
are not treated with
long term
anticonvulsants
Take Home Points
Children are far more resilient than adults
Failure to recognize the sometime subtle
signs of impending cardiopulmonary
collapse can be catastrophic
Respiratory arrest is the most common
inciting event in pediatric arrest
Crucial to have the right equipment and a
mechanism to “remember” the right sizes
and drug doses by weight
Questions?