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Initial AssessmentRespiratory Emergency In
Children And Its Management
Tatty Ermin Setiati
Diponegoro University
Dr. Kariadi HospitalSemarang
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Introduction (1)
Respiratory diseaseMost frequent medicalemergency, need early intervention to decrease
mortality
Initial assessment is a very important todifferentiate upper or lower respiratory
emergency
Pediatric Assessment Triangle (PAT)an easyand fast initial assessment to measure the severity
of the disease, and begin inflammatory treatment
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Introduction (2)
Specific treatment for airway obstruction after
PAT and ABCDE assessment should be given
Positioning, suctioning, non-invasive and invasiveairway management, and pharmacologic
treatment (Nebulizer, Antibiotics)
Oxygen therapy according to the need
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Initial Assessment
PATDifferentiate Respiratory Distress,
Respiratory Failure, and Respiratory Arrest
APPEARANCE
WORK OF
BREATHINGCIRCULATION
Conciousness
Core-Skin Temp. Different
Capillary refill
Warm or cool skin
Resp. Rate
Retraction
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Appearance (Tickles = TICLS)
Tonus
Interactive ness
Consol ability
Look/Gaze
Speech/Cry
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Characteristic of Circulation to Skin
Pallor
Mottling
Cyanosis
Capillary Refill Time >
Circulation to Skin
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Normal capillary refill is < 2 seconds in a warm environment
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Circulation to Skin
PAT : Potential Respiratory Failure
Normal Increased
Normal
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Circulation to Skin
PAT : Respiratory Failure
AbnormalIncreased
or
decreased
Normal or abnormal
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Rate
Effort / mechanics Air entry
Skin color and temperature
Rapid Cardiopulmonary Assessment
Physical ExaminationBreathing
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Respiratory Rate
In non-critical: RR determine by sitting the child
in his caregivers lap and exposing his chest
RR may be affected by level of activity, fever,anxiety, and metabolic state
RR > 60x / minuteabnormal in any age
RR < 20x / minute in a sick child < 6 years and 94%oxygenation probably good SaO2 < 90% in a child on 100% oxygen NR mask
need assisted ventilation
Interpret SaO2 together with WOB
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Circulation Heart Rate
TachycardiaEarly sign of hypoxia or low
perfusion, but may also caused by : fever, anxiety,
pain, excitement
A trend of increasing or decreasing HR
worsening hypoxia or shock or improvement after
treatment Bradycardiacritical hypoxia and or ischemia
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Circulation Pulse quality
Normally the brachial pulse is palpable inside or
medial to the biceps (weak / strong)if strong
probably not hypotensive
If peripheral pulse not palpated, check the central
pulse (femoral / carotid)
Absent of a central pulseCPR
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Skin Temperature
Capillary Refill Time
The child skin warm near the wrists and ankles -
good perfusion
Decreasing perfusionthe line of separation
from cool to warm advances up the limb
Capillary refill time (N 2-3 seconds), affected by
environmental factorscool room temp
Circulation to the skin (skin temp., capillary refilltime, pulse quality)assessment circulatory
status
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Rapid Cardiopulmonary Assessment
Physical Examination : Breathing
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Respiratory Arrest
Absence of effective breathing
If ventilation and oxygenation are not adequately
support
Cardio respiratoryArrest
a lowprobability of survival
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General Non-invasive
Treatment Positioning
Patient position of comfortSevere upper
airway obstruction may get into sniffing position
Severe lower airway obstructionTripod posture
Infants and Toddlerscaregivers arms or lap
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The sniffing position
The abnormal tripod position
Retractions
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Oxygen
Treatment with High flow O2safe
Give oxygen to any child with clinical signs of
cardiopulmonary distress, or with a historysuggesting possible abnormalities in gas exchange
When treating children, it is better to overuse
oxygen than to underused it
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Management of Respiratory Failure
Initially treat with general noninvasive measures Upper or lower airway obstructionspecific
treatment
Altered level of consciousness and signs of
or
WOB (flaring, grunting, gasping, apnea, cyanosis)
and or SaO2 < 90% on 100% NR O2 mask
Assisted Ventilation or PPV with BVM
ventilation or ET intubation
Placement of OG or NG tube (relieve gastric
distension and improve ventilation)
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BVM Ventilation
The best technique for providing oxygenation and
ventilation during resuscitation and transport
60-95% O2 can be given effectively and safely by
choosing a well-fitted mask, connecting with O2
reservoir to an oxygen source at 15L/ minute
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How To Use
Resuscitation Mask
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Possible Complications
BVM Ventilation Hypoxia
Barotraumas
Gastric Distension
Emesis and Aspiration
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Endotracheal Intubation (ETT)
Potential Advantages: Definitive Airway Control,Decrease Risk of Aspiration, Ease of assisted
ventilation
Potential Complications: Transient hypoxia,hypercarbia (due to prolonged intubation
attempts), elevation if intracranial pressure,
mechanical trauma of the airway, misplacementof the tube (intrabronchial / esophageal
intubation)
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DOPE
Intubated patient fail to respond (improve color,
SaO2, HR, and appearance)
Dislodgment
Extubate, BVM, Reintubate ObstructionSuction, Extubate, BVM,
Reintubate
PneumothoraxNeedle thoracocentesis
EquipmentCheck equipment patient-to-tank
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Specific Treatment
For Respiratory Distress
Determine upper or lower airway obstruction
Snoring or stridorupper airway obstruction
Wheezing
lower airway obstruction Upper airway obstruction due the tounge and
mandible falling back/ partially blocking the
pharynx
head tilt / chin-lift or jaw trust Maintenance of adequate airway: Placement of an
oropharyngeal airway, nasopharyngeal or ETT
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Croup
A viral disease with inflammation, edema,
narrowing of the larynx, trachea, and bronchioles
Affects infants and toddlers Cold symptoms several days followed by the
development of a barking cough, str idor, various
level of respiratory distress
Fever and symptoms are worse at night
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Croup Treatment
Cool mist (humidified oxygen or nebulizedsaline)
Cool water vapor reduced the inflammation and
obstruction
Pharmacologic treatment: Nebulized epinephrine
(stridor, WOB, poor air movement, SaO2 12 months
Appears ill, Toxic, Pain on swallowing, Stridor
may be present, no barking cough
Examples: Epiglotitis ( H. Influenzae), Tracheitis,
Diphtheria, Peritonsillar Abcess, Retropharyngeal
Abcess
Treatment : General noninvasive dgn high flowoxygen and position of comfort. In RF give BVM
consider ETT
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Lower Airway Obstruction
(Bronchiolitis)
Bronchiolitisviral lower respiratory infection,
usually in children < 3 years caused by RSV
Destruction lining of the bronchioles, profusesecretions, bronchoconstriction
Assessment shows variable degrees of WOB,
tachypnea, diffuse wheezing, insp. Crackles,
tachycardia
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Asthma
Asthma is a disease of small airway inflammation
leads to bronchoconstriction, mucosal edema, and
profuse secretions
Severe airway obstruction and V/Q mismatch
ClinicallyDifferent degrees of tachypnea,
tachycardia, WOB, wheezing on exhalation,SaO2 normal or low
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Asthma with RF
Altered appearance
Exhaustion
Inability to recline Interrupted speech
Severe retraction
Decreased Air Movement
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Management
Lower Respiratory Obstruction
General noninvasive treatment with high flow O2
therapy
Nebulized Bronchodilators
In asthma : Assisted VentilationPPV required
very high insp. Pressure may caused
pneumothorax/pneumomediastinum
BVM ventilation or ETTIf RF and failed torespond to high flow O2 and maximal
bronchodilator therapy
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Summary (2)
Specific treatment for croup cool mist and
nebulized epinephrine
If RF occurred begin with assisted ventilation
with BVM at an age-appropriate rate
Add spesific treatment for airway obstructed if
indicated
Performed ETT, and be alert for DOPE in the
intubated child who suddenly worsens / fails torespond
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