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
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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?