Respiratory Emergenciesin the
Pediatric Population
Respiratory Emergenciesin the
Pediatric Population
16 month old boy with wheeze
Initial Vitals: HR 160 RR 60
BP 88/50Temp 38O2sat on RA 89%
CASE 1
You do your pediatric assessment triangle:
Appearance Crying, distressed, lookingaround, 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 VentolinAtroventIV Access established – orders?
CXR done / pending
Blood work Doctor?
Venous Gas pH 7.35pCO2 38pO2 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 petsOtherwise 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 / IMContinue VentolinConsider racemic Epinephrine (0.5 mls)
Repeat Venous Gas about 30 mins laterpH 7.15pCO2 55pO2 120
Eyes rolling back, little crying now …
What do you want to do?
Drugs? Tube Size?
Ketamine 1-2 mg/kg IV Atropine 0.01 mg/kg IV (min 0.1 mg)Succinyl 1 mg/kg IV
4 – 4.5 tube
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 AsthmaBronchiolitis Foreign Body Aspiration
CVS Congestive Heart FailureVascular Rings
CAEP Pediatric Asthma Guidelines
MILD• Nocturnal cough• Exertional SOB• Increased Ventolin use • Good response to Ventolin
O2 sat > 95%PEF > 75% (predicted / personal best)
± O2VentolinConsider po Steroids
Symptoms
Pre - Treat
Treatment
MODERATE• Normal mental status• Abbreviated speech• SOB at rest• Partial relief with Ventolin and required > than q 4h
O2 sat 92%-95%PEF 50-75% (predicted / personal best)
O2 100%VentolinSystemic corticosteroidsConsider anticholinergic
Symptoms
Pre - Treat
Treatment
CAEP Pediatric Asthma Guidelines
CAEP Pediatric Asthma Guidelines SEVERE• Altered mental status• Difficulty speaking• Laboured respirations• Persistant tachycardia• No prehospital relief with usual dose Ventolin
O2 saturation <92%PEF, FEV1 <50%
100% O2Continuous or frequent b-agonistsSystemic corticosteroids & magnesium sulfateConsider anticholinergic & / or methylxanthines
Symptoms
Pre - Treat
Treatment(consider RSI)
CAEP Pediatric Asthma Guidelines
Symptoms
Pre - Treat
Treatment
NEAR DEATH• Exhausted , Confused• Diaphoretic• Cyanotic, Decreased respiratory effort, APNEA• Falling heart rate
O2 saturation <80% (spirometry not indicated)
As above PLUSRSIIV VentolinInhalational anesthetic, aminophyllineEpinephrine
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
CASE 2
T39.1 degrees rectally, P170, R28, BP 100/66
Appearance alert, awake, not toxic, in no acute distressDid not appear to prefer upright or a forward leaning position
EENT Moist MM, slight erythema of oropharynx, nasal crusting, N TMs, no rash / petechiae, no droolingSupple neck
Chest Clear when restingMild inspiratory stridor with crying
Rest of the exam N
Physical Exam
DDx?
• Croup• Epiglottitis• Bacterial tracheitis• RetroPharygeal abcess• Foreign Body aspiration
Other things on DDx of Inspiratory Stridor
Laryngeal WebTEFDiptheriaAirway thermal injurySubglottic stenosisPeritonsillar abcessGERDEsophageal FBLaryngeal fractureLaryngeal cystLymphoma
Soft tissue lateral neck radiograph
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
Retropharyngeal Abscess
ETIOLOGY
Complication of bacterial pharyngitisLess frequently - extension of infection from vertebral osteomyelitis
Group A hemolytic streptococci, oral anaerobes, and S. aureus
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
Typically …
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
On Exam …
Nasopharynx Bulging forward of the soft palate and nasal obstruction
Oropharynx Bulging of posterior phyaryngeal wallor
Not visualized
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
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
CASE 3
VS T36.8, P200 (crying), R28 (crying), O2 sat 99%
Alert with no signs of respiratory distressAble 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 TissueNeck View
CXR (PA)
Next?
ExpiratoryCXR
Inspiratory View Expiratory View
Right DecubView
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 diaphragmon side down
Abnormal Hyperinflation or “normal” volumes indecub 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 significanceShots UTD
Other sibs with similar URTIs
Temp 38.9HR 140O2 sat 98% (drops to 90% when he crys)RR 40 (mild indrawing)
On Exam …
Irritable, crying, good colour
H & N sl erythema of throat, no pusN TMs, small cervical nodes
Chest Barky cough, inspiratory stridorNo wheeze noted
Diagnosis?
Racemic Epinephrine 0.5 ml dose
? Dexamethasone now or later
Re – Assess in 30 minutesNo improvement with 1st dose of epinephrine
What would you like to do now?
IV Cefuroxime PLUS Cloxacillin Consult Pediatric ICU / Pulmonary
for Bronch / Intubation
Re – ExamineOngoing Inspiratory StridorCries when trachea is examined
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
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)
CLINICAL MANIFESTATIONS
Antibiotics (good Staph coverage)
Intubation or tracheostomy is usually necessary
? Decadron
Treatment
Pediatric Pneumonia
Neonate Bacteria more frequentE. coli, Grp B strep, Listeria, Kleb
1 – 3 mo Chlamydia trachomatis (unique)Commonly viral (RSV, etc.)B. Pertussis
1 – 24 mo S. pneumonia, Chlamydia pneumMycoplasma pneumonia
2 – 5 yrs RSVStrep pneumonia, Mycoplasma, Chlam
Severe Pneumonia:
Staph aureusStrep pneumoniaGrp. A strepHIBMycoplasma 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, headacheCough or wheezingChest 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)