Common Pediatric Emergencies - excellence.creighton.edu · pneumothorax FB, severe asthma,...

9/4/2018

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Common Pediatric

EmergenciesAngie Kratochvil-Stava, M.D.

September 7, 2018

[email protected]

Objectives

Evaluate and initiate treatment for critically ill infants

Evaluate and initiate treatment for critically ill children

NO DISCLOSURES

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Physical Exam

Physical Exam – Principles

Early identification is better than cardiorespiratory failure

Primary physiologic problem easier to identify early

Age appropriate responses

Steps in patient survey are same as for adults, but different specific signs of distress or physiologic instability

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Physical Exam – Rapid Assessment Appearance

Tone Moving vigorously? Resisting exam? Good muscle tone?

Interacting Alert? Reach out for objects? Readily distracted by sounds, people?

Consolable Consoled by caregiver?

Look/Gaze Fix on face? Or a “nobody home” stare?

Speech/cry Strong and spontaneous? Or weak, muffled?

Physical Exam – Rapid Assessment Work of Breathing

Abnormal airway sounds

Altered speech, stridor, wheezing, grunting

Abnormal positioning

Head bobbing, tripoding

Retractions Supraclavicular, intercostal, substernal retraction of chest wall

Flaring Nasal flaring

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Physical Exam – Rapid AssessmentPutting it Together

Normal appearance and increased work of breathing = respiratory distress

Abnormal appearance and increased work of breathing = respiratory failure

Abnormal appearance and abnormally decreased work of breathing = late respiratory failure

Physical Exam – Rapid AssessmentCirculation

Pallor White skin indicating lack of peripheral blood flow and an attempt to compensate for shock

Mottling Patchy skin discoloration with patches of cyanosis, due to vascular instability and loss of compensation

Cyanosis Bluish discoloration indicating shock and/or respiratory failure

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Physical Exam – Primary SurveyABCs – Airway and Breathing

Audible sounds – stridor, wheezing Loudness not correlated with severity

Respiratory Rate Caution with fever, anxiety, pain, excitement

Pulse oximetry

Physical Exam – Primary SurveyABCs – Interpreting Breath Sounds

Stridor upper airway obstruction croup, FB

Wheezing lower airway obstruction asthma, FB

Expiratory Grunting

Inadequate oxygenation pneumonia, pulm. contusion

Inspiratory Crackles

fluid/mucus/blood in airway

pneumonia, pulm. contusion

Absent Breath Sounds w/ inc. work of breathing

complete obstruction, pleural fluid, consolidation, pneumothorax

FB, severe asthma, hemothorax, pneumothorax

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Physical Exam – Primary SurveyABCs – Circulation

Color and skin perfusion Shock – compensated or decompensated Hypoxia? Infection? Head Trauma? Drugs?

Heart Rate – varies with age Blood Pressure – challenging in small kids Capillary Refill Pulse Quality End organ perfusion – kidneys, brain

Critical Newborn

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Critical Newborn

10-day-old full term infant presents with poor feeding and decreased alertness

Critical Newborn – Scenario 1

Pale, listless, weak cry

HR 180, RR 60, BP 78/50, Temp 103.5

Irritable with exam, no focal findings

Lungs: CTA, tachypnea, no retractions

Circulation: cap refill 1 second, warm and well-perfused

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Critical Newborn – Scenario 1Sepsis

Febrile newborns less than 28 days CBC, blood culture UA, urine culture LP, CSF culture IV Abxs – Ampicillin & Gentamicin/Cefotaxime

Most common bacteria: E. coli, GBS

Consider CXR HSV – HSV PCR of CSF and IV Acyclovir

ill-appearing, seizures, skin lesions


Febrile newborns 29-90 days: ill-appearing Essentially same as for <29 days old

Most common pathogens: S. pneumo, H. flu, N. meningiditis

IV Antibiotics Consider adding vancomycin

May choose ceftriaxone instead of cefotaxime

Use ampicillin in infants 29-60 days old

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Febrile newborns 29-90 days: well-appearing Minimum evaluation

CBC, blood culture, UA and urine culture

If term, uneventful birth, low-risk labs, and good follow-up, MAY observe as outpatient with 24 hour follow-up Low-risk labs

CBC - I:T <0.2, 5000-1500 WBC

UA - normal

If empiric antibiotics are used, must do LP May empirically use ceftriaxone or cefotaxime after LP

Consider CXR if respiratory symptoms

Critical Newborn – Scenario 1Sepsis – Difficult Situations

Unsuccessful LP Obtain blood and urine cultures

Less than 28 days, begin IV antibiotics at meningitis doses If positive blood or urine, reattempt LP

Treat as if meningitis if CSF pleocytosis

29-90 days, may observe

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Patient on Antibiotics Cannot be considered low-risk for serious

bacterial illness

Must admit for empiric IV antibiotics and obtain blood, urine, and CSF cultures


Concomitant Viral Infections Influenza positive – may omit LP if > 28 days and

low-risk lab results Do CBC, blood culture, UA, urine culture, CXR

Bronchiolitis – same as for Influenza

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Critical Newborn


Critical Newborn – Scenario 2

Pale, lethargic, gray

HR 200, RR 60, BP 70/40, Temp 98.8

Lungs: retractions, grunting, crackles

Circulation: cool, 4-5 sec cap refill

Cardiac: 3/6 systolic ejection murmur

Liver: extends to pelvis

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Critical Newborn – Scenario 2Cardiogenic Shock – Management

ABCs and vascular access

Oxygen saturation (pre/postductal)

Hyperoxia challenge

ABG

Dopamine/Dobutamine if hypotensive

Judicious fluid resuscitation

Prostaglandin E1


Prostaglandin E1 Relaxes smooth muscle of ductus arteriosus

IV infusion: 0.05 mcg/kg/min

Side effects: tachycardia, hypotension, apnea

Must have secondary IV access

Must have intubation materials available

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After initial stabilization, consider CBC

Blood culture

Echocardiogram

EKG

Broad Spectrum IV antibiotics

Intubate and ventilate prior to transfer

Critical Newborn


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Critical Newborn – Other Causes

Inborn Errors of Metabolism Glucose, electrolytes, ammonia, ABG

Non-accidental trauma A shaken baby often presents with poor feeding

as the only sign of abuse

Critical Pediatric Patients

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Pediatric Emergency – Scenario 1

3-year-old male with known asthma presents with sudden onset cough and “wheezing.” He has received albuterol via nebulizer every 3 hours x 3 without improvement.


Sitting, leaning forward, coughing

HR 170, RR 56, BP 92/66, Temp 98.8

Lungs: rare breath sounds on right, left normal

Circulation: normal

CXR: severe atelectasis of right lung

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Pediatric Emergency – Scenario 1Foreign Body

Most common in kids < 3 years

Most common objects: peanuts, grapes, coins, small toys, jewelry, latex balloons, hot dogs

Majority aspirated into right lung

Suspicious when acute respiratory distress and no prodromal illness

Pediatric Emergency – Scenario 1Foreign Body – CXR

About 10% of FBs are radioopaque May see radiolucent objects if severe

obstruction Most common findings in lower airway FBA

Hyperinflated lung Atelectasis Mediastinal shift Pneumonia

Inspiratory/Expiratory Films

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www.radrounds.com/photo/1791588:Photo:16860?c


7-month-old presents with 3 days of low-grade fever, vomiting, and diarrhea. She is limp and very sleepy.

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Pale, limp, doesn’t cry

HR 200, RR 50, BP 80/50, Temp 100.8

Lungs: Rapid breathing, clear lungs

Circulation: cool peripherally, central pulses 1+, peripheral pulses not palpable, cap refill 5 seconds

GI: 3 stools during exam

Pediatric Emergency – Scenario 2Hypovolemic Shock

Shock – failure of the cardiovascular system to provide sufficient oxygen and other substrates to meet the metabolic demands of the tissues

Three Stages Compensated – normal BP, alert

Decompensated – dec. BP, dec. consciousness

Irreversible – bradycardia, apnea, hypotension

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Pediatric Emergency – Scenario 2Hypovolemic Shock – Management

IV/IO access No more than 3 IV attempts before IO

20 ml/kg crystalloid infused in < 20 minutes and reassess

Repeat 20 ml/kg fluid boluses

Use pulses, extremity temp, cap refill, level of alertness to guide therapy


A 15-month-old infant presents with 2 days of rhinorrhea, cough, and low-grade fever. The child became acutely worse after going to bed and the parents now describe a “squeaking” noise and difficulty breathing.

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Sitting on parents lap, suprasternal retractions, tachypnea, stridor

HR 160, RR 62, BP 102/76, Temp 101.2

Chest: Intercostal/suprasternal retractions

Lungs: Inspiratory stridor

Circulation: normal

Pediatric Emergency – Scenario 3Croup (Laryngotracheobronchitis)

Most common cause: parainfluenza virus

Most common ages: 3 months – 3 years

Harsh, barking/seal-like cough, hoarseness, and stridor following a few days of coryza and low-grade fever

Symptoms caused by upper airway edema, which narrows the subglottic region

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Pediatric Emergency – Scenario 3Croup – Management

Cool mist or humidified oxygen

Nebulized racemic epinephrine 0.05 ml/kg of 2.25% solution in 3 ml NS

Risk of rebound edema 30-90 minutes after

Dexamethasone 0.6 mg/kg PO/IM/IV (max 10 mg)

Inhaled Budesonide?

Prednisolone?


5-year-old child presents with dry cough and increasing shortness of breath over the last 24 hours. He has been taking cetirizine for allergic rhinitis for the last two weeks. No fever.

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Pediatric Emergency 4 – Asthma Epidemiology – National

20.3 million asthmatics in U.S.

Morbidity/Mortality 1.8 million ER visits annually

500,000 hospitalizations

5000 deaths

Pediatric Emergency 4 – Asthma Epidemiology – National (Peds)

#1 chronic childhood illness in U.S.

Almost 5 million children with asthma

3rd ranking cause of pediatric hospitalization

4th most common cause for pediatric visits

14 million lost school days annually

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Pediatric Emergency – Scenario 4Asthma

What is asthma? Bronchial muscle spasm

Mucosal edema

Inflammation

Mucus plugging

Severity of wheezing does not always correlate with severity of airway obstruction

Peak flow of limited value in young patients

Pediatric Emergency – Scenario 4 Asthma - Pathophysiology

Sensitive airways that react to irritants that normal lungs can filter out

When irritants are inhaled swelling and inflammation occurs, making it hard

for air to pass in and out of lungs

the muscles around the airways constrict, making the airways even smaller

more thick, sticky mucus is made, making it hard for air to pass through

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Pediatric Emergency – Scenario 4 Asthma - Pathophysiology

The 4 main signs of asthma Dry, hacking cough

Wheezing

Chest tightness

Shortness of breath

Pediatric Emergency – Scenario 4Asthma – Management

Relieve bronchial muscle constriction Rescue/Quick medications

SABA – nebulizer or inhaler w/spacer

Oxygen

Decrease inflammation/swelling/mucus Maintenance/Controller medications

Inhaled steroids

Leukotriene receptor antagonist

Allergy treatments

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Pediatric Emergency – Scenario 4Asthma – Quick Relief

Used in ALL asthma

Also called reliever/rescue medications

Quickly decrease muscle constriction

Medicine is breathed into the lungs using an inhaler (with spacer) or nebulizer Spacer with mask for younger children

Levalbuterol has no proven benefit over albuterol

Pediatric Emergency – Scenario 4Asthma – Management – Spacers

1. Shake the inhaler at least 5 times and take cap off.2. Place the spacer on the end of the inhaler.3. Relax and breathe out. Hold your head looking straight ahead, not

looking down.4. Put the spacer in your mouth, on top of your tongue.

Close your lips around the spacer.5. Press down on the inhaler.

This will put 1 puff of medicine into the spacer.

6. Breathe in slowly and deeply until your lungs are full, five times.

7. Wait at least 1 minute. Then repeat the above steps.

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Pediatric Emergency – Scenario 4Asthma – Controller MedicationsUsed in persistent asthmaDo not stop an asthma episodeShould be taken every day, even when

children are feeling wellAct over a long period of time, taking weeks to

reach effectiveness

Tell families to think of them as vitamins protecting children from serious illnessNot addicitve, rare side effects


Relieve bronchospasm Oxygen (bronchodilator)

Albuterol - 0.15 mg/kg in 3 ml NS (max 5 mg) Short acting beta-2 agonist

May repeat every 20 minutes x 3, then minimum 30 minutes intervals or continuous

Decrease airway inflammation Prednisone 2 mg/kg PO/IM/IV (max 60 mg)

If no improvement after one dose albuterol

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Moderate-Severe, consider adding: Ipratropium with first three albuterol treatments

Anticholinergic – bronchodilation through smooth muscle relaxation

250 mcg/dose if < 20 kg, 500 if > 20 kg

Only proven useful in ER setting

IV magnesium sulfate smooth muscle relaxant

75 mg/kg (max 2.5 grams) over 20 minutes


Moderate-Severe, consider adding: Parenteral beta 2 agonists

Terbutaline SC/IM 0.01 mg/kg dose (max 0.4 mg/dose) May repeat q 20 minutes x 3

Epinephrine SC/IM 0.01 mg/kg dose (max 0.4 mg/dose) May repeat q 20 minutes x 3, then every 2-6 hours

Terbutaline IV Bolus 10 mcg/kg over 10 min, then 0.3-0.5 mcg/kg/min,

inc. by 0.5 mcg/kg/min q 30 min (max 5 mcg/kg/min)

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2-month-old former 35 week premature infant presents with few days of rhinorrhea and mild cough and now having difficulty breathing. Infant has felt warm and is not eating well.


Anxious appearing infant in respiratory distress

HR 180, RR 85, BP 80/40, Temp 101.6

Chest: moderate retractions, occasional grunting

Lungs: scattered wheezes, fine crackles

Circulation: warm, well-perfused

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Pediatric Emergency – Scenario 5Bronchiolitis

Etiologies: RSV, human metapneumovirus

Causes small airway obstruction

Most severe in children < 2 years

Prodrome: cough, coryza, low-grade fever

Apnea in very young infants

CXR: hyperinflation w/patchy infiltrate and atelectasis

Pediatric Emergency – Scenario 5Bronchiolitis – Management

Treatment – What Works Oxygen

IV fluids

Patience and Time

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Treatment – What Might Work Bronchodilators (albuterol)

Trial acutely, small percentage may respond

Racemic Epinephrine More helpful than albuterol, especially in ED

Hypertonic Saline Potentially reduces airway edema and mucus

plugging

Surfactant in ICU patients


Treatment – What Doesn’t Work Chest Physiotherapy

Steroids

Antibiotics

Ribavirin

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A 4-month-old infant who started coughing while sitting in an infant seat. She then had a large emesis, turned “white,” and had a long pause in her breathing.


Well-appearing, alert infant, sitting on mom’s lap

HR 120, RR 32, BP 86/48, Temp 98.9

Chest: Breathing non-labored, symmetric

Lungs: Clear

Circulation: warm, well-perfused

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Pediatric Emergency – Scenario 6ALTE (Apparent/Acute Life-Threatening Event)

An episode that is frightening to the observer and is characterized by some combination of apnea, color change, change in tone, choking, or gagging

No ICD-9 code for ALTE

0.05-1% of infants

Pediatric Emergency – Scenario 6ALTE

Etiology found in half with H & P and focused evaluation Differential diagnosis is LONG

Most common GERD with laryngospasm (30%)

Neuro – breath-holding, seizure (20%)

Infection

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Pediatric Emergency – Scenario 6ALTE

Retrospective study of 471 patients Characterized long and short term risk for death,

child abuse, abnormal neurological outcomes

11% were ultimately victims of child abuse No risk factors identified Other studies, 1-2.5% had abusive head trauma

Risk factors: vomiting, irritability, 911 call

5% with adverse neurologic outcome Risk factors: family history of seizure

Pediatric Emergency – Scenario 6ALTE - Recommendations

No intervention? Monitor at home? Admit? Admit with A/B monitor if more than one episode

or history of physiologic compromise

Focused work-up based on H & P Was it truly life-threatening? Frightening?

If “real” and no clear explanation, consider: CBC, UA, BMP, EKG, CXR, toxicology screen

Inpatient neurologic evaluation low yield Don’t forget child abuse!

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